Age: 57.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Chronic spontaneous urticaria, Compression garment application, Differential white blood cell count abnormal, Drainage, Dry skin
Clinical narrative: Started out as a rash on my left torso in early July. Over time it started spreading and I started getting hives. The hives seemed to "travel". They would go away from one spot and then pop up in another. Zyrtec helped some but not completely. The itching seemed to "change shifts". For awhile it would be worse in the morning  other times in the evening. There were several periods where I could not sleep more than 2 to 4 hours without waking up because of the itching. In October and  November the hives began "weeping". It was as if some sort of toxic glue was oozing out of my pores and it was at times painful, especially after getting out of the shower. By the end of November it seemed to have evolved into eczema. Dry itching flaky skin all over my body. I went to Urgent Care on November 27 because the pain and the itching were unbearable. I was prescribed Oral steroids  Antibiotics  and prescription Antihistamines. They fast tracked me an appointment with the dermatologist he he prescribed topical steroids. Since the beginning of December I have been taking Hydroxizine 1 every six hours. Zyrtec 1 every 12 hours. On around Dec 10 I started taking a "mega -dose" of vitamin D3 5000IU one every 12 hours. The healing seemed to accelerate after I started the D3 and it seemed like my histamine levels also continued to lower. ------------------------------------------------------------------------------------------------------------------------- SUMMARY THAT I SENT TO ALLERGIST Symptoms: Symptoms began on approximately July 12 2021. Scaly patch on left and right torso and on shoulders. In a short time progressed and spread with hives on legs and behind the knee. Wound on left leg from scratching in my sleep.  I had already had problems with itching on that leg due to venous stasis dermatitis.  Water and sweat make affected areas itchy red and swollen. On most nights I can only sleep 2 to 4 hours at a time before waking up with itch. Sometimes the affected areas have a burning sensation. On a few other rare occasions the patches on my torso felt as if they tickled. There is nothing consistent about the intensity,frequency, and location of the symptoms. They vary from day to day and hour to hour. I must make note that the patches on my torso disappeared after the first 3 weeks and then returned about 1 week ago.  Triggers: Water  Sweat  Sleep The condition is sometimes (not always) triggered by pressure from sitting or lying down.  Treatment: 1 H1 (Alternate Zyrtec and Allegra every other week) + 1 H2 (Tagamet)  2X per day (every 12 hrs.) Tylenol  for occasional pain flares in wound on leg. Relieve itches by applying hair dryer to affected area. Elevate legs against the wall with pillows behind back. Walking to increase  blood flow and distract from itching.   Supplements: 2 Adult Multivitamin 2 D3 1 B3 1 Zinc 1 E  ¼ tsp. C crystals dissolved in 100% Cranberry juice 3 drops nascent iodine + 1 Selenium B12 supplement 1 to 2 times weekly  Herbals: 1 Ginkgo Biloba 2 Echinacea/Goldenseal 1 eyedropper of Echinacea tincture Ginseng supplement  1 to 2 times weekly NOTE: I have been drinking Green Tea w/lemon juice (NO SUGAR) nearly every day for approximately the last 4 years. I use several brands but I have not changed them or the source from where I buy them.    Have had bad reaction to:  Benadryl ( both Oral and topical) VERY bad reaction to Zzzquil. I am allergic to it. Hydocortizone  -  Swelling on leg after scratching which led to cellulitis. Calamine Lotion  intense itching  had to rinse off immediately. Cetaphil - intense itching  had to rinse off immediately. Aloe Vera Gel - intense burning  had to rinse off immediately. Coconut Oil  was very irritating. Neosporin greatly irritated leg wound. NOTE: During the first few weeks I tried several "home remedies" by washing up with water and a very small amount of   *Tea Tree Oil   - minimal to zero effext  *Apple Cider Vinegar burns if not diluted properly. *Bleach  initially cleared up patches on torso but is too dangerous for any areas of broken skin. *Baking Soda (initially soothes but does not last) *Gold Bond Lotion  initially soothes but wears off fairly quickly. Comments: *Sometimes hair dryer brings relief for as long as 12 hours. Other times it does not help at all. *Hair dryer works more often than it doesn't. *Hair dryer satisfies the urge to scratch and  feels as though I am actually scratching *Sometimes taking NyQuil allows me  to sleep as long a 8 hours. Other times I wake up itching 2hours after taking it. * Prednisone helped only on the 1st day I took it. After that there was not much difference. * Hydroxyzine  helped only on the 1st day I took it. After that there was not much difference. * I do not like the way Prednisone and Hydroyzine affected me mentally and physically. *Gabapentin literally makes me intoxicated. On day two I woke up itching 2 hours after taking it. *Tested my well water with a kit that checks 13 conditions. PH reads 9 to 10. Alkalinity 240ppm. All others good,. *I cleaned and flushed both the water softener and water heater. Hardness level was dramatically    improved,however my symptoms are still aggravated when my skin gets wet. PH still at 9. Alkalinity reduced to 180ppm.  Reliability of home water test is questionable. We no longer have white powdery residue on topsoil of houseplants.    * I stopped drinking the tap water about two weeks into this however there was never any effect either way. *THERE HAVE BEEN NO  CHANGES IN MY DIET, ENVIRONMENT, OR THE CLEANING PRODUCTS THAT I USE OR THE CLOTHES THAT I WEAR. It is still however possible that the manufacturers may have added ingredients. It is also possible the airborne allergens may have been introduced into my environment.  * We have no pets in  our household nor do I have frequent encounters with animals. * We have numerous houseplants that we have had for 10+ years. We have not purchased any new plants in the past year. *Aside from intermittent clutter on desks and tables, our house is clean. My wife regularly sweeps ,mops ,vacuums and dusts. *We run an air purifier most of the time to help my wife with her allergies (filter changed routinely) *I do yard work  mowing and weeding  weekly and sometimes daily. I usually bathe and change clothes immediately afterward. * Aside from my symptoms and lack of sleep there have been no other excessive stressors in my life. *NOTE: On two occasions last year (2020) , I had a minor unexplained rash on both wrists that lasted for about 3 weeks. Both of these incidents seemed to coincide with a peak of Covid cases in the local region as reported in the news. I had no other Covid symptoms and I never got tested. During both periods there were a few employees at work who had tested positive and had to quarantine. --------------------------------------------------------------------------------------------------------------------    It was in mid December that I discovered perhaps a dozen threads on a web forum discussing similar experiences after receiving the covid vaccine. Threads that were posted on the forum discussing skin disorders that were similar to mine. Most of these occurred after receiving a Moderna or Pfizer vaccine. Although there is no actual proof that the MRNA vaccines are the root cause of these disorders, there seems to be too many people with a similar experience to just simply ignore this. It is not my intention to make negative and aggressive accusations, but to make the medical community aware of  this problem and to hopefully prevent other people from going through months of extreme discomfort as I have.  As a side note I must also mention that these posts cannot be found using the usual search engine. I found them using a different search engine.   Below are Doctor's notes from my appointments.  Progress Notes 7/21/2021 11:30 AM Patient is a 58 y.o. male who presents for rash.    Left leg rash x 2 weeks with previously known chronic varicose veins. Rash is red, itchy, spreading up to his back and armpits. He was seen on a telehealth visit 2 days ago, was given a prescription for prednisone and hydroxyzine which has been helpful since then. Suspicion is for poison ivy due history of outdoor work. After two doses of prednisone he reports improvement in rash and itching mainly on his back.    Left groin lump which appeared last year summer. Non painful.          Past Medical History: Diagnosis Date o Hepatitis 1982   Hepatitis A    History reviewed. No pertinent family history.      Current Outpatient Medications Medication Sig Dispense Refill o predniSONE (DELTASONE) 50 mg Oral tablet Take 1 tablet by mouth daily 5 tablet 0 o hydrOXYzine (ATARAX) 25 mg Oral tablet Take 1 tablet by mouth 4 (four) times daily as needed for Itching     Review of Systems As per HPI   Objective:   BP 114/72 (BP Site: Left Arm, Patient Position: Sitting, Cuff Size: Regular) | Pulse 78 | Resp 20 | Ht 5' 8" (1.727 m) | Wt 175 lb 8 oz (79.6 kg) | BMI 26.68 kg/m²    General:  alert, appears stated age, cooperative and no distress Skin:  Right ankle venous stasis changes and varicose veins are noted with erythematous MP rash spreading up the leg HEENT:  ENT exam normal, no neck nodes or sinus tenderness Lungs:  No respiratory distress, no retractions, no stridor Heart:  No edema, no pallor, normal heart rate Abdomen: Left inguinal hernia on exam Nondistended Extremities:  Extremities normal, atraumatic, no cyanosis or edema Neurologic:  AOx3. Gait normal. Reflexes and motor strength normal and symmetric. Cranial nerves 2-12 and sensation grossly intact. Psychiatric:  non focal     Assessment:      Encounter Diagnoses Name Primary? o Rash Yes o Colon cancer screening   o Left inguinal hernia     Patient was seen today for rash and lymph node.   Diagnoses and all orders for this visit:   Rash - LYME SERUM IGG IGM WREFLEX; Future - predniSONE (DELTASONE) 50 mg Oral tablet; Take 1 tablet by mouth daily - hydrOXYzine (ATARAX) 25 mg Oral tablet; Take 1 tablet by mouth 4 (four) times daily as needed for Itching   Colon cancer screening - COLOGUARD   Left inguinal hernia         Plan: Continue prednisone since it is helping so far. Call back if not improving in the next 5-7 days. He mentions a history of tick exposure about a month prior to the rash so it's reasonable to test for lyme   Agrees reluctantly to cologuard testing. He has not seen a physician in about 20 years, but reports blood testing done through his work that has not found any problems.    He has a left inguinal hernia on exam which can be monitored for now. Advised him of red flags symptoms for which to seek care.   ED Provider Notes 8/23/2021  4:52 PM   History   No chief complaint on file.     HPI 58-year-old male presenting with left leg redness swelling past medical history of remote hepatitis. Patient reports that since early July he has had rash urticaria he believes he is allergic to diphenhydramine states that he he will scratch his legs while he sleeps, states he has had more scratches to his left leg that he has had increased redness and swelling with some drainage from it called his primary care doctor recommended evaluation here denies any fevers states that he has been taking Zyrtec for rash. He is concerned that he may need an antibiotic denies any immobility or injury otherwise states his left leg is more swollen than the right he tried compression stockings but they were too tight and he did not like them. No history of blood clots in his legs.        Past Medical History: Diagnosis Date o Hepatitis 1982   Hepatitis A          Past Surgical History: Procedure Laterality Date o VARICOSE VEIN SURGERY   2000     No family history on file.   Social History       Tobacco Use o Smoking status: Current Every Day Smoker     Packs/day: 0.50     Years: 20.00     Pack years: 10.00     Types: Cigarettes o Smokeless tobacco: Never Used Vaping Use o Vaping Use: Never used Substance Use Topics o Alcohol use: Never o Drug use: Never     Review of Systems   Review of Systems  All other systems reviewed and are negative.     Physical Exam   ED Vitals [08/23/21 1543] Temp: 97.8 °F (36.6 °C) Heart Rate: 81 SpO2 Heart Rate: n/a Resp: 18 BP: 132/70 SpO2: 97 % Height: 5' 8" (1.727 m) Weight: 170 lb (77.1 kg) Weight Source: n/a   Physical Exam Vitals and nursing note reviewed.  Constitutional:  General: He is not in acute distress. Appearance: He is not diaphoretic.  HENT:  Head: Normocephalic and atraumatic.  Eyes:  General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:  Rate and Rhythm: Normal rate.  Heart sounds: Normal heart sounds.  Comments: Strong DP PT pulse the left lower extremity is greater in size than the right no induration though there is calf tenderness Pulmonary:  Effort: Pulmonary effort is normal. No respiratory distress.  Breath sounds: Normal breath sounds. No stridor.  Abdominal:  Palpations: Abdomen is soft.  Tenderness: There is no abdominal tenderness.  Musculoskeletal:  General: No tenderness or deformity.  Cervical back: Neck supple.  Skin: General: Skin is warm and dry.    Comments: Numerous excoriations with blanchable erythema and violaceous color  Neurological:  Mental Status: He is alert.  Comments: No facial droop  Psychiatric:  Behavior: Behavior normal.        Ideal body weight: 68.4 kg (150 lb 12.7 oz) Adjusted ideal body weight: 71.9 kg (158 lb 7.6 oz)    ED Course   Procedures   MDM Patient with intermittent urticaria believes he has chronic urticaria he has been taking antihistamines, states scratching behavior and there are excoriations wounds to left lower extremity combination of this in addition to venous stasis raise concern for cellulitis recommend ultrasonography to rule out deep venous thrombosis, related to urticaria recommend avoidance of diphenhydramine you could also be allergic to them excipients such as the dye used in the manufacturing of the medication, regardless he has no evidence of deep vein thrombosis I will place him on an antibiotic to cover for cellulitis and recommend follow-up with his primary care doctor to discuss management, given the report of drainage from it I see no evidence of active purulence to culture will place him on clindamycin    Lab Results     Labs Reviewed BASIC CHEM PANEL - Abnormal; Notable for the following components: Result Value    Glucose 117 (*)     All other components within normal limits CBC W/ DIFFERENTIAL - Abnormal; Notable for the following components:   RDW 11.7 (*)     All other components within normal limits PARTIAL THROMBOPLASTIN TIME - Normal   Narrative:    PTT therapeutic range for unfractionated heparin: 38.0-58.2 seconds. Heparin response studies performed in our lab show that, in general, a PTT of 38.0-58.2 seconds corresponds to an unfractionated heparin level of 0.3 - 0.7 IU/mL for this reagent lot. PROTHROMBIN TIME - Normal   Narrative:    The therapeutic range is dictated by the clinical situation being treated.   CBC WITH DIFFERENTIAL   Narrative:    The following orders were created for panel order CBC WITH DIFFERENTIAL. Procedure Abnormality Status  --------- ----------- ------  CBC W/ DIFFERENTIAL[134086061] Abnormal Final result    Please view results for these tests on the individual orders. HOLD TUBE SST GOLD HOLD TUBE PST GREEN   US UNILATERAL VENOUS DUPLEX Final Result     Impression No evidence of a left lower extremity deep venous thrombosis. <Electronic Signature> 08/23/2021 04:44 PM _____________________________________ Clinical Impression as of Aug 23 1658 Left leg cellulitis Multiple excoriations     ED New Prescriptions      New Prescriptions   CLINDAMYCIN (CLEOCIN) 150 MG ORAL CAPSULE Take 3 capsules by mouth 3 (three) times daily for 10 days   08/23/21 1719    ED Notes Nurse at 8/23/2021  5:12 PM Provided discharge instructions / verbalized understand fully   ED Triage Notes Nurse at 8/23/2021  3:43 PM Left lower leg redness swelling for few months    Progress Notes 9/2/2021  3:00 PM Patient is a 58 y.o. male who presents for ER follow up.    F/u ER visit. Was seen 8/23 for celluilitis to the left leg thought to be caused by itching and venous stasis. Tested negative for dvt. He has completed his clindamicin. Overall feels better but still having itching all over mainly legs and trunk with some rash.    Currently taking allegra and pepcid he is not sure it is helping. He has an upcoming dermatology appointment next week.       Past Medical History: Diagnosis Date o Hepatitis 1982   Hepatitis A    History reviewed. No pertinent family history.      Current Outpatient Medications Medication Sig Dispense Refill o clindamycin (CLEOCIN) 150 mg Oral capsule Take 3 capsules by mouth 3 (three) times daily for 10 days 90 capsule 0 o gabapentin (NEURONTIN) 300 mg Oral capsule Take 1 capsule by mouth 3 (three) times daily 20 capsule 0 o hydrOXYzine (ATARAX) 25 mg Oral tablet Take 1 tablet by mouth 4 (four) times daily as needed for Itching (Patient not taking: Reported on 9/2/2021     Progress Notes MA at 9/7/2021 11:30 AM Patient is a 58 y.o. male who presents for evaluation of rash.  Patient states the rash has been present for 1 month.  Patient states they are breaking out with the rash on the right torso, left torso, shoulders, posterior legs.  Patient states the rash started on the right torso. Patient states the rash does itch.  Patient states the rash does not hurt.  Patient states that heat does makes the rash worse. Patient states that stress does not makes the rash worse.   Patient states hair dryer improves the rash. Patient states they have tried the following over the counter medications: zytec, allegra, tagamet, tylenol.  Patient states this does not improve the rash. Patient states they has not started any new medication or supplements prior to the onset of the rash. Patient states they has nothad any flu like symptoms prior to or during the rash.  Patient states they has not traveled out of the state recently and have not stayed in a hotel recently.  Patient states they has not been in a hot tub recently.  Patient states there is not anyone else in the home with a rash.  Patient states they has not been exposed to new soaps, lotions, plants, laundry detergent, cleaning chemicals, chemicals at work, perfume, cologne, makeup.      PA at 9/7/2021 11:30 AM Subjective:   Patient is a 58 y.o. male who presents for evaluation of rash.  Patient states the rash has been present for 1 month.  Patient states they are breaking out with the rash on the right torso, left torso, shoulders, posterior legs.  Patient states the rash started on the right torso. Patient states the rash does itch.  Patient states the rash does not hurt.  Patient states that heat does makes the rash worse. Patient states that stress does not makes the rash worse.   Patient states hair dryer improves the rash. Patient states they have tried the following over the counter medications: zytec, allegra, tagamet, tylenol.  Patient states this does not improve the rash. Patient states they has not started any new medication or supplements prior to the onset of the rash. Patient states they has nothad any flu like symptoms prior to or during the rash.  Patient states they has not traveled out of the state recently and have not stayed in a hotel recently.  Patient states they has not been in a hot tub recently.  Patient states there is not anyone else in the home with a rash.  Patient states they has not been exposed to new soaps, lotions, plants, laundry detergent, cleaning chemicals, chemicals at work, perfume, cologne, makeup.     For social, family, surgical, medications, allergy and past medical history see EMR.   Review of Systems: Pertinent items are noted in HPI. Patient denies fever, weight loss and fatigue.   Objective:   Alert and oriented to person, place and time and in a good mood. Well developed, well nourished, healthy appearing in no acute distress.  Primary findings: macules, plaques Color of lesions:  erythematous Blanching: no Configuration: eczematoid Secondary Features:  scale Distribution:  Bilateral flanks, abdomen, thighs and lower legs. Dusky brown postinflammatory hyperpigmentation on the right lower leg without heat or signs of infection.   Assessment:   Patient was seen today for rash and new patient.   Diagnoses and all orders for this visit:   Neoplasm of uncertain behavior of skin of trunk - DERMPATH PATHOLOGY TISSUE(ROUTINE INTERPRETATION); Future   Dermatitis - clobetasoL (TEMOVATE) 0.05 % Topical cream; Apply to affected areas of torso and extremities as directed BID for 2 weeks   Itching - clobetasoL (TEMOVATE) 0.05 % Topical cream; Apply to affected areas of torso and extremities as directed BID for 2 weeks     Increase Zyrtec 10 mg to 3 tabs daily   Verbal and written consent obtained for a 4 mm punch biopsy on the right flank. The risks of bleeding, infection, and scar formation were discussed. The area was cleansed with Betadine solution and draped in a sterile fashion. Sterile technique was carried out. The area was infiltrated with 1% lidocaine with epinephrine intradermally for local anesthesia. A 4 mm punch biopsy was performed through fat and the tissue was sent to the pathologist. Two 4-0 Ethilon sutures were placed intradermally. Mupirocin ointment and a Band-Aid were applied. Wound care instructions were given. We will contact the patient with the biopsy reports over the next few weeks. The patient was educated on the plan and verbalized understanding.    Plan:   The patient was given written information in regards to dermatitis. Sensitive skin care sheet given to patient. Follow up: 2 weeks The patient was educated on the plan and verbalized understanding.   Progress Notes MA at 9/21/2021 10:15 AM Patient is a 58 y.o. male who presents for followup of rash involving the: right flank.  He is on clobetasol cream for their rash, and overall reports good improvement.       Patient presents for suture removal right flank. The wound is well healed without signs of infection. The sutures are removed. Wound care and activity instructions given. Return prn.    PA at 9/21/2021 10:15 AM Subjective: Patient is a 58 y.o. male who presents for followup of rash involving the: torso and legs. He is on clobetasol cream for their rash, and overall reports excellent improvement.    For social, family, surgical, medications, allergy and past medical history see EMR.   Review of Systems: Pertinent items are noted in HPI.   Objective:   Alert and oriented to person, place and time and in a good mood. Well developed, well nourished, healthy appearing in no acute distress.  Primary findings: macules, plaques Color of lesions:  pink, hyperpigmented Blanching: no. Configuration: eczematoid. Secondary Features:  scale. Distribution:  Bilateral thighs.   Assessment:   Patient was seen today for follow up and suture removal.   Diagnoses and all orders for this visit:   Spongiotic dermatitis         Plan:   Sensitive skin care precautions once again discussed with the patient. Follow up: as needed The patient was educated on the plan and verbalized understanding.      Progress Notes 10/29/2021  3:30 PM History of Present Illness: See both today's allergy questionnaire and dictation for complete HPI elements including location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms. Allergy questionnaire also compliments PFSH.      The patient is a 58-year-old who I am seeing at the request of Dr. for my opinion on his urticaria.  According to the patient, since July he has had urticaria on a pretty much daily basis.  There have been a few days and he has done better and he has tried everything under the sun to help him with his symptoms.  High-dose antihistamines, namely both 4 a day of Allegra and Zyrtec, did not help.  Prednisone did not help, at least more than a day, and he has tried all sorts of lotions and creams and avoiding things.  What seems to work the best for him is if he heats up in a hot shower or a hair dryer, I think he de-granulates his mast cells and then they do not release the histamine again for 6-8 hours, but that is certainly not a quick fix.  He has had a lot of allergy testing and food testing.  He has definitely a lot of positive ImmunoCAPs, but he has done elimination diet and that has not revealed any results either, that no specific food is causing any problems, at least at this time.  He has had a normal CBC and chemistry profile and he does not have any other symptoms.   Review of Systems:  Including constitutional, eyes, ears, nose, throat, neck, respiratory, cardiovascular and GI are all negative except as noted.   Physical Examination:  Revealed a well-developed, well-nourished 58-year-old in no acute distress.   Impression/Plan:  My impression is that patient has chronic idiopathic urticaria, unresponsive to high-dose antihistamines and unresponsive to prednisone, and at this point we will prior authorize him for Zyrtec since he has failed these prior treatments.  He is not committed to doing the Xolair.  He has read a lot about it and is reluctant to start it, but I said we will prior authorize him and at least offer it to him, and we can take it from there.  He will call with any questions or problems and he will call me if he would like to proceed.   ED Provider Notes PA at 11/27/2021 12:36 PM   History     Chief Complaint Patient presents with o Rash     HPI    Patient is a 58-year-old male presenting to the emergency room for evaluation of a rash. Patient has had a pruritic rash over the last several months. Patient was seen by dermatology back in September had a biopsy done which showed eczema. Patient was also evaluated by allergy, was offered infusion medication however patient declined due to cost. Patient also went back to dermatology and has been given clobetasol cream. Patient reports he has not seen dermatology since the end of September. Patient was on a regimen of clobetasol, Zyrtec, and Tagamet. Patient reports that he decided to stop all of his medications in November. Was doing this to see if he could control it with over-the-counter neuropathic medications to include honey extract and a sulfur extract. Patient has been without his antihistamines over the last 27 days. Patient is also been using extremely hot water in the shower and a bath. Reports he will get the water as hot as he can and stepped into the shower or bath. Patient reports he did sustain a burn to his left lower leg several months ago due to doing this. Patient reports that his left lower leg is slightly more warm and red today. He has had no fevers or chills. He has not seen anybody for this burn. Patient does have an area to his left lower leg that he keeps itching. Patient has not been back to dermatology after his follow-up with allergy. Patient presents today as he feels that his left lower leg is starting to get more red, and the rash is spreading. Patient reports no wheezing denies any throat itching or lesions inside his mouth or groin.      Past Medical History: Diagnosis Date o Environmental allergies   o Hepatitis 1982   Hepatitis A  o Urticaria           Past Surgical History: Procedure Laterality Date o VARICOSE VEIN SURGERY   2000     No family history on file.   Social History       Tobacco Use o Smoking status: Current Every Day Smoker     Packs/day: 0.50     Years: 20.00     Pack years: 10.00     Types: Cigarettes o Smokeless tobacco: Never Used Vaping Use o Vaping Use: Never used Substance Use Topics o Alcohol use: Never o Drug use: Never     Review of Systems   Review of Systems  Constitutional: Negative for chills and fever.  Respiratory: Negative for cough, chest tightness, shortness of breath and wheezing.  Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Negative for abdominal pain, constipation, nausea and vomiting.  Musculoskeletal: Negative for arthralgias, myalgias, neck pain and neck stiffness.  Skin: Positive for rash. Negative for wound.  Allergic/Immunologic: Negative for immunocompromised state.      Physical Exam   ED Vitals [11/27/21 1208] Temp: 98.5 °F (36.9 °C) Heart Rate: 85 SpO2 Heart Rate: n/a Resp: 20 BP: 118/65 SpO2: 100 % Height: 5' 8" (1.727 m) Weight: 170 lb (77.1 kg) Weight Source: Standing   Physical Exam Skin: Comments: Patient has an erythematous, raised, plaque-like rash noted to his upper extremities bilaterally, and to his lower extremities. There is no lesions inside the mouth area does blanch. There is lichenification noted and excoriation. There is some bleeding noted from the lesions due to chronic itching.  On patient's left lower leg, patient has obvious venous stasis, patient does appear to have a healing granulated thermal burn is circumferential to the left lower extremity appears months old and chronic. There is overlying erythema and warmth, this extends circumferentially from about 2 inches below the knee to about 1 inch below the ankle. They do not extend over the joints. Patient also has a open area to the anterior medial mid shin from itching. Patient has full active range of motion of the knee and ankle without any pain.      Ideal body weight: 68.4 kg (150 lb 12.7 oz) Adjusted ideal body weight: 71.9 kg (158 lb 7.6 oz)    Vital Signs: The heart rate is 85. The blood pressure is 118/65. The respiration rate is 20. Oxygen saturation is 100 % Ra. The body temperature is 98.5 f.   General: The patient is awake, alert, verbal, and interactive. There is NO pain distress. There is NO respiratory distress. The patient appears WELL hydrated. Patient is nontoxic, not ill-appearing, in no acute distress. Patient appears anxious and is pacing in the room. Skin: Warm and dry Head: Normocephalic, atraumatic.  Neck: Trachea midline, no JVD.  Eye: Extraocular movements are intact, normal conjunctiva.  Respiratory: Respirations are even and non-labored.  Psychiatric: Cooperative, appropriate mood and affect.     ED Course     -Patient is afebrile stable vital signs. -Patient appears to have worsening of his chronic eczema, it is becoming significantly diffuse and worse. Patient has also been off of his antihistamines for what he calls" no pill November." Patient is also been taking multiple homeopathic oral therapies for this. Patient appears significantly anxious, and miserable due to the itching and is pacing in the room. Patient also has sustained a chronic thermal burn to his left lower leg in the setting of chronic venous stasis. This again is chronic over last several months. Patient also has an open area to his anterior left lower leg. This appears to have a mild cellulitis along the left lower leg. Patient is afebrile. Encourage patient to stop his homeopathic medication. Patient becomes upset when asked about his medication recommended by allergy. Reports he could not afford the medication. I do recommend that patient follow-up with his dermatologist, appointment was made for this week to discuss next line of treatment as his rash is now significantly more diffuse and worsening. Patient was given a prescription for her oxazine, prednisone, and clindamycin. Patient was given first dose here. Advised on risk of prednisone in this setting, advised elevation. Did give prednisone to stop the scratch itch cycle as this appears to be the setting and cause of his cellulitis. Patient was also instructed not to bathe and hot scalding water as he is now subjecting himself to skin burns. Patient was advised to restart his Zyrtec. Patient was advised on all symptomatic management, he was advised to start a photo log as our full capabilities were not working today. Patient was advised to return for any worsening or concerning symptoms. Patient discharged home in stable condition.   Patient was screened for an emergent medical condition, in my medical opinion, no emergent condition is present and patient is stable for discharge.      The patient was advised of diagnosis, all care instructions, plan for discharge and follow up, as well as signs and symptoms that would warrant r