Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Peripheral swelling, Rash, Rash erythematous, Rash papular, Rash pruritic
Clinical narrative: Additional History:. 61 yo M with a PMH HTN and HLD presents to the office with a mod-severe red itchy bumpy blistering rash that has persisted x 1 wk. Pt states he first noticed the rash on his right insole of his foot on 3/17 and over the course of the next few days the rash spread to both feet and got more red with large blisters forming and opening up. He went to the ER 3/20 where he was diagnosed with folliculitis and cellulitis and placed on PO doxycycline and topical Mupirocin. He has been using the meds as prescribed since 3/20. Pt presents to the clinic because the rash has persisted and the medications prescribed have not helped. Pt reports the blisters are now opening up and he's worried about them becoming infected. His feet are also swelling. Pt states that there are no relieving factors identified yet, but notes that water/sweating seems to make the rash worse.He does have a PCP but has not been seen anywhere other that the ER over the weekend. Of note, Pt states that he received his last Moderna vaccination 1/28/21 and had some rashes and swelling of his eyelid, then received his shingles vaccine "a few weeks later" and then the rash on his feet started about a month after receiving the shingles vaccine.1 . Toe rash location details: (all toes involved anterior/posteriorly B feet) Patient presents with rash, described as red, pale, tender, bumpy, itchy and weeping. The rash is located in skin folds, on the dorsum of both feet, on the soles, on the sun-exposed areas, on the extensor surfaces, on the flexural surfaces and in an asymmetric distribution on the toe(s).  Associated symptoms include no abdominal pain, no arthralgias, no cough, no diarrhea, no fatigue, no fever, no headache, no lightheadedness, no malaise, no myalgias, no nail changes, no nausea, no neck stiffness, no shortness of breath, no sore throat, no swollen glands, no urethral discharge and no vaginal discharge. Onset was sudden 1 week(s) ago. The rash is spreading, becoming more red and becoming more pruritic. Changes have occurred over the last 7 day(s). Symptoms are moderate in severity. Precipitating and/or exacerbating factors include 2nd COVID 19 vaccine end of January, Shingles vaccine mid-February, but not carpeting, not exacerbated by chemical exposure, not exacerbated by cold exposure, not exacerbated by food triggers, not exacerbated by heat exposure, not exacerbated by humidity, not exacerbated by exposure to illness, not exacerbated by insect bite, not exacerbated by medication, not exacerbated by personal care products, no contact with pets, not soaps/detergents, not exacerbated by stress, not exacerbated by sun exposure and not exacerbated by tick bite. no recent contact with poison plants No relieving factors are noted.   PE normal except for: Skin:  (diffuse vesicular rash in various stages of eruption on B feet, not following dermatomal distribution. Rash is fluid filled vesicles with scattered bullae on bilateral anterior/posterior foot, extending onto soles, covering all parts of B toes, and spreading onto L calf area. There are several open bullae to R sole without evidence of active infection present. Sensation is intact to bilateral feet without current hypersensitivity or tenderness. Diffuse excoriation present without evidence of infection. NV intact) On exam, the skin was warm, has rash and was not diaphoresis. has drainage Rash(s): vesicular rash that was erythematous, that was becoming confluent, that blanched with pressure, that was excoriated, that did not have fine scales, that did not have thick scales, that had sharply demarcated borders and that was weeping on the lower extremities.   Assessment 1. Dyshidrotic eczema (L30.1)  Plan Calamine lotion may be used for itching.;    Dermatology Referral Physician Referral  See Referral Comment!  Done: 24Mar2021 Ordered;  For: Dyshidrotic eczema;  Ordered By: Dr.  Performed:   Due: 07Apr2021 Laterality 1 : Bilateral Body Part 1 : Foot Reason for referral : Evaluate and Treat Plan: take otc antihistamine during the day, may start otc benadryl at night as needed. 4 packets Loratadine provided in office. Start otc barrier cream such as aquapor or eucerin cream. May use otc calamine lotion for itching as needed. 6 packets Calagel (topical diphenhydramine) provided to patient and applied in office. Ed on emergent s/s, pt verbalized understanding. If you experience and difficulty breathing or swelling of the face/lips please go to te ER. Please follow up with PCP for further eval/management of potential post-vaccine immune mediated reaction. Pt educated on reporting reaction to VAERS.hhs.gov website in order to help identify potential side effects with current COVID 19 vaccines. Referred to dermatology for new onset eczema to rule out alternate diagnoses and determine potential contributing factors.