You read online about a 26-year-old African American male Gold Medal Olympic bicyclist training for his second Olympic trial, who has been hospitalized due to an accident. You remember that about a week ago he came into the pharmacy with his wife. He stated that he was experiencing a lot of itching, a burning sensation, and redness in his groin area. Symptoms started 3 days earlier and had gotten worse. He noticed that the skin was starting to flake and peel. He stated that he has had this problem before and used an over-the-counter product, but could not remember the name of the product.
After asking several questions you obtained the following information from the patient: he had no known medical conditions or allergies; father has high blood pressure controlled by medication and his mother had breast cancer. He stated that he does not drink alcohol or use tobacco. The only supplements he was taking were a multivitamin daily, calcium twice a day, and vitamin D once a day. He did not remember the strength but was able to point out the specific products on the shelf. You note that he is using calcium carbonate 500 mg and vitamin D 1000 IU. Patient estimated that his height is 5 ft 10 in and weight is 142 lb. Blood pressure and heart rate were measured at 118/74 mm Hg and 62 bpm, respectively.
The following is what you have last documented in your pharmacy charts. Example SOAP Note:
Subject: 26 y/o AA male athlete presents to pharmacy with a chief complaint of itching, redness, and burning in the groin area for the last 3 days. He also states that the skin is starting to flake and peel. He said that he has had this problem before and used an over-the-counter product but could not remember the name of the product.
PMH: Tinea cruris
FH: Father has hypertension, mother had breast cancer
Soc Hx: Married, Denies tobacco and ETOH use, Olympic athlete
Medications: Multivitamin daily, Calcium carbonate 500 mg orally twice daily; Vitamin D 1000 IU orally once daily
VS: Ht: 5'10”, Wt: 142 lb, BP: 118/74, HR: 62
Assessment: Suspected Tinea cruris as evidenced by patient reports of burning, itching, flaking, peeling and redness in the groin area.
Plan: Recommend terbinafine (Lamisil AT) 1% cream. Apply once daily to affected and surrounding areas for 7 days. Educate on preventative measures. If signs/symptoms not resolved after 7 days, follow-up with your primary care physician.