ALBANY STATE UNIVERSITY

COLLEGE OF SCIENCE AND HEALTH PROFESSIONS

FAMILY NURSE PRACTITIONER PROGRAM
Episodic Care Information Sheet
STUDENT NAME: Alexander Warren
PT. J.T.

RRACE: Black

A AGE: 62

DATE: 02/19/2015
SEX: Male

ENCOUNTER DATE: 02/17/2015

SUBJECTIVE
Chief complaint/concern: I have a rash all over my body and blisters on my hands.
HPI: 60 year old African American widowed male presents today for an evaluation of a rash
that, he states, began three days ago. Patient states that it began on his chest and was very
pruritic. Yesterday, per the patient, the blisters began forming on the palms of his hands and the
soles of his feet. He has taken OTC Benadryl for the itching with no relief.
Past Medical History:
CAD.
HTN.
DM type II.
Hyperlipidemia.
Status post CABG X 4 in 2010.
Allergies: NKDA
Current Medications: Simvastatin 40 mg daily, Amlodipine 5 mg daily, Bydureon 2 mg
weekly, Metformin 500 mg twice a day
Immunizations: Up to date.
Family Health Hx: Mother and father are obese. Mother had CVA in her 50s. Father with CHF
and died from MI in his 60s.
Social History: Widower since wife passed away last year. Lives with his son who is single.
Has three children, all live in the Valdosta area. Denies use of alcohol or drugs. The patient is a
smoker, states he smokes about a pack a day X 8 years.
Review of Systems:
General: Denies fever, chills, difficulty sleeping, unintentional weight loss/gain, or fatigue.

EENT: Denies any visual disturbances, headaches, dizziness, ear pain/drainage. Denies any
nose bleeds or other nasal discharge. Denies sore throat, swelling/pain of the tongue, or bleeding
of the gums.
Respiratory System: Denies any wheezing, shortness of breath, cough, or mucous production.
Cardiovascular: Denies any palpitations, chest pain, swelling of extremities, coldness in
extremities, or exertional dyspnea.
Gastrointestinal system: Denies any pain of the abdomen, nausea, vomiting, change in appetite,
indigestions, constipation, or diarrhea. Denies any blood in his stools.
Genitourinary system: Denies nocturia, urinary frequency/urgency, incontinence, or urinary
retention.
Skin: Complains of pruritic rash that first appeared on his trunk 3 days ago. He states vesicles
began to form on the palms of his hands and sole of his feet 1 day ago. The rash that began on
his trunk has now spread almost completely across his entire body but has spared his face. He
denies changing detergents or coming into contact with any foreign chemical. He denies any
drainage from the lesions but states that vesicles are very painful. He denies any bruising or hair
changes.
Endocrine: Denies any heat or cold intolerance. Denies any hair changes. Denies any dry skin
or excessive thrist.
Musculoskeletal System: Denies any joint pain, swelling, or stiffness. Denies any difficulty
walking, muscle pain, or cramps.
Neurologic System: Denies any change in mental status, increase forgetfulness, or nervousness.
Pscyh: Denies insomnia, anxiety, or depression.
Objective
BP: 128/86

O2 sat: 95%

P: 82

R: 18 Temp: 97.2

HT: 70 inches Wt: 218 pounds

Physical Examination.
A. General: Healthy appearing 60 year old African American male who is well developed
and well nourished in appearance. No distress or anxiety noted.
B. Head: Normocephalic. Normal male pattern baldness noted. Negative TMJ. No
lymphadenopathy or sinus tenderness noted.
C. Eyes: PERRLA.
D. Ears: Tympanic membranes intact and pearly gray in color. No fluid or irritation noted.
No masses or lesions.

E. Nose: Septum midline. Nasal turbinates not swollen and nasal passages are clear.
Mucosa pink and moist. No polyps noted
F. Mouth: Dentition in good repair. Mucosa pink and moist. Tongue midlines with no
lesions or swelling noted. Gums pink with no disease or bleeding noted.
G. Neck: No lymphadenopathy noted. Thyroid reveals no enlargement or masses. Trachea
midline. Symmetrical and supple.
H. Skin: Fine macular popular rash noted that covers almost the entire body. Rash only
spares the face, palms of hands, and soles of feet. The patients skin is otherwise irritated
and inflamed from the patient scratching. There appears to be a secondary infection on
the patients ear from where he has scratched a lesion. There are small vesicles noted on
the patients palms of hands and soles of his feet. They all measure around 1 cm x 1 cm
in size and are filled with clear fluid. The patient walks with a limp, stating that it hurts
to stand on the lesions.
I. Respiratory: Chest rise and fall is symmetrical. Respirations are unlabored. Breath
sounds are clear.
J. Cardiovascular: S1 and S2 heard. No murmurs, rubs, or gallops noted. Rhythm regular.
K. GI: Abdomen reveals no distention. No pulsations noted. Bowel sounds noted in all 4
quadrants. No tenderness to palpation.
L. Gu: Deferred.
M. Lymphatic: No lymphadenopathy or tenderness noted.
N. Musculoskeletal: Normal gait. Full range of motion and denies pain with movement. No
crepitus noted.
O. Neuro: Cranial nerves II-XII intact. Patient alert and oriented. Full strength noted in
upper and lower body.
Lab Findings/Diagnostics: CMP normal, CBC revealed only slightly elevated eosinophils at
500, ESR slightly elevated at 28
DIFFERENTIAL DIAGNOSIS;
1. Contact dermatitis.
2. Medication reaction. Patient started on Bydureon a week ago.
3. Atopic dermatitis.
Assessment/Final Diagnosis: Medication reaction due to Bydureon.
Plan:
1. Given Depo Medrol shot IM in office 80 mg.
2. Referred immediately to dermatology. Called and sent patient there immediately. The
dermatologist made the final diagnosis.
3. Stop Bydureon.
4. Take lukewarm baths to soothe skin.
5. Keep skin infection on ear clean and dry. Should clear up on its own but follow up in 3
days if no improvement.

6. Follow up in one week to consider new options to replace Bydureon.

Health Promotion Issues and Education
Use sunscreen when working outside to reduce the risk of skin cancer. If you notice any
side effects from new medications call the office or come in immediately. Do not scratch lesions
as this can cause secondary infections which could lead to serious problems. Keep current
infected area clean and dry. Avoid abrasive chemicals that could irritate the skin, use detergents
that are free from colors and scents. Encouraged smoking cessation. Risks of continued
smoking discusses and benefits of cessation discussed. Discussed ADA diet and handouts were
given. Encouraged to keep a food diary and a blood sugar log.
Discussion: My preceptor and I were very concerned upon visualizing the patient. The rash was
very severe and the patient was in obvious discomfort. He initially did not complain about
the vesicles on the palms of his hands or the soles of his feet so it appeared to be just a diffuse
rash across his body. With that presentation only, and because the rash spared his face,
it appeared to be contact dermatitis. It was not until he stood and began walking that we saw him
limping. When asked why he was limping, he showed us the vesicles. This made it very clear
that it was a systemic problem. We were aware that the patient had recently been started on
Bydureon but this was not a reported side effect. Bill (my preceptor) happened to have the
number for the representative for this medication. Once called, the representative stated this had
never been reported as a symptom. I did some researching myself on reactions to Bydureon and
found the most common reactions are hypoglycemia 8%, injection site reactions 17.1%,
pancreatitis, thyroid tumors, and drug interactions (Painter, 2013). Adverse drug events (ADE)
are more common than I thought, depending on the patients age, adults have a 5.27% chance of

having and ADE while the elderly have a 16.1% (Tache, 2011). The patient was given a Depo
shot 80 mg IM in the office in an attempt to decrease the inflammatory process. Bill then
called a dermatologist and sent the patient directly to his office. The dermatologist diagnosed the
patient with a drug reaction that was probably due to the Bydureon. I feel this was the
appropriate treatment. It was very concerning that the patient did not inform us about the
vesicles on the bottom of his feet as this symptom is what alerted us to the problem being
systemic. I also feel that Bill was correct in sending the patient to a specialist instead of
treating the patient himself.

Painter, N. A., Morello, C. M., Singh, R. F., & Mcbane, S. E. (2013). An Evidence-Based and
Practical Approach to Using Bydureon in Patients With Type 2 Diabetes. The Journal of the
American Board of Family Medicine, 26(2), 203-210. doi: 10.3122/jabfm.2013.02.120174

Tache, S. V., Sonnichsen, A., & Ashcroft, D. M. (2011). Prevalence of Adverse Drug Events in
Ambulatory Care: A Systematic Review. Annals of Pharmacotherapy, 45(7-8), 977-989. doi:
10.1345/aph.1P627

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