What is the History of Present Illness (HPI) for a patient presenting with a rash?

From the Guidelines

The patient's emergency room history of present illness (HPI) for a rash should include a detailed description of the rash, its progression, and any associated symptoms, as well as a thorough medical history and medication list, as outlined in the UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016 1. When generating the ER HPI for a rash, it is essential to consider the following key points:

• A detailed description of the rash, including its location, onset, and progression
• Associated symptoms, such as fever, malaise, upper respiratory tract symptoms, and mucosal involvement
• Respiratory and bowel symptoms, including cough, dyspnea, bronchial hypersecretion, hemoptysis, diarrhea, and abdominal distension
• Medical history, including previous or ongoing medical problems, history of recurrent HSV infections, and chest infections
• Medication list, including all medicines taken over the previous 2 months, including over-the-counter and complementary/alternative therapies The HPI should also include the index date, which is the date of onset of the adverse reaction, and any symptoms indicating involvement of other systems, such as the eyes, mouth, nose, and genitalia, as recommended by the UK guidelines 1. Some key questions to ask the patient include:
• Can you describe the rash and when it first appeared?
• Have you experienced any symptoms such as fever, malaise, or upper respiratory tract symptoms?
• Have you noticed any involvement of mucosal sites, such as the eyes, mouth, nose, or genitalia?
• Have you experienced any respiratory or bowel symptoms?
• What medications have you taken in the past 2 months? By including these details in the ER HPI, healthcare providers can quickly identify potential causes of the rash and develop an appropriate treatment plan, as suggested by the UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016 1.

From the FDA Drug Label

Treatment was begun within 72 hours of rash onset and was most effective if started within the first 48 hours. The ER HPI for rash should include the onset of rash and the duration of symptoms.

• The patient should be asked about the time of rash onset to determine if treatment can be started within the most effective time frame (within 48 hours).
• The severity of symptoms and any associated symptoms such as pain, fever, or lethargy should also be assessed. 2

From the Research

ER HPI for Rash

The following elements should be included in the ER HPI for a patient presenting with a rash:

• Chief complaint: rash
• History of present illness:
  • Onset and duration of the rash
  • Description of the rash, including its location, size, shape, color, and any changes over time
  • Associated symptoms, such as fever, itching, or pain
  • Recent travel history or exposure to new medications or substances
• Red flags to consider:
  • Hemodynamic instability
  • Erythroderma
  • Desquamation
  • Petechiae/purpura
  • Mucous membrane involvement
  • Severe pain As noted in the study 3, a thorough history and physical examination are essential in evaluating a patient with a rash, and consideration of red flags can help identify potentially life-threatening conditions. The study 4 also emphasizes the importance of a detailed medical history and physical examination in evaluating fever and rash in adult patients.

Categorization of Rashes

Rashes can be categorized into four broad groups based on their visual and tactile characteristics:

• Petechial/purpuric
• Erythematous
• Maculopapular
• Vesiculobullous As discussed in the study 3, this categorization can help emergency providers rapidly diagnose and manage potentially life-threatening rashes. The study 5 also reviews characteristics of common rashes and rarer, potentially life-threatening rashes in pediatric patients.

Associated Symptoms and Conditions

Associated symptoms and conditions that should be considered in the ER HPI for a patient with a rash include:

• Fever
• Systemic signs of illness
• Recent travel history
• Exposure to new medications or substances
• History of drug hypersensitivity reactions, as discussed in the study 6 The study 7 notes that empiric antimicrobial therapy may be considered in patients presenting with fever, and an organized approach to prescribing antimicrobials can help ensure prompt and appropriate treatment.