Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions

Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions

PATIENT INFORMATION

Name: Kaylee Hales

Age: 25 years

Gender Identity: Male

Sources: Patient

Allergies: NKA

Current Medication: Contraceptive Pills

PMA: N/A

IMMUNIZATION: Up to Date

PREVENTIVE CARE: N/A

Surgical HISTORY: None

FAMILY HISTORY: The patient is single with one boyfriend. Both parents are healthy and alive.

SOCIAL HISTORY: In a relationship, drink alcohol occasionally. Denies smoking tobacco.

SEXUAL ORIENTATION: Straight, sexually active

NUTRITION HISTORY: Balanced Diet

SUBJECTIVE DATA:

Chief Complaint: Itchy, tender rash at the inner thigh and inner forearm.

Symptoms analysis/HPI: Kaylee Hales, a 25-year-old woman in otherwise good condition, appeared with an extremely itchy, erythematous rash over her inner thighs and left forearm that had been present for two days. Physical examination reveals a 10×12 cm scattered contiguous erythematous papular rash with surrounding superficial excoriation on the inner thighs, along with erythematous blisters on the left inner forearm and a 6 cm pair of linear circumscribes Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions. Recent exposures include using a hot tub, a new lotion, and scallops for the first time in her life. She has also gone on a nature hike and used a hot tub.

CONSTITUTIONAL: She denied weight gain or loss.

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NEUROLOGIC: No memory loss or seizures, or tremors experience.

HEENT: No headache or head injuries. No vision problem. He denied hearing lost. PT denied nose bleeding and changes in smelling senses. No presence of sore hoarseness or throat. Denies difficulty with swallowing. She denied mouth sore and bleeding gums.

RESPIRATORY: Denied wheezing or cough.

CARDIOVASCULAR: Pt denied palpitation, edema, and chest pain. She also denied difficulty breathing and rapid heart rate.

GASTROINTESTINAL: Denied having constipation and diarrhea symptoms.

GENITOURINARY: Denied polyuria and dysuria.

MUSCULOSKELETAL: Denied joint swelling, myalgia, and back pain.

SKIN: Has skin rash at inner thigh and inner forearm.

OBJECTIVE DATA:

VITAL SIGNS: BP 116/62, HR 70, Temp. 98.3, Spo2 95% room air, RR 20.

GENERAL APPEARANCE: Pt is health, neatly dressed and alert

NEUROLOGIC: Pt is focused and denied memory loss history.

MAIN DIAGNOSIS:

• Contact Dermatitis (ICD-10 Code- 9)

Skin inflammation known as contact dermatitis is brought on by coming into proximity to an allergen or irritant. The two subtypes of CD are allergy and irritating dermatitis. Pruritus, an erythematous rash, vesicular and linear, rough, redden patches, weepy lesions with numerous small vesicles on an erythematous base, and a burning or stinging sensation are all common cardinal symptoms of CD (Bains & Fonacier, 2019). According to the patient’s activity history, she recently went hiking; she was wearing shorts and a tank top, and it’s probable that she came into contact with hazardous plants on her extremities and upper arms. Contact with poison ivy, oak, or sumac causes the skin condition known as poison ivy (Toxicodendron) dermatitis (TD) Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions. Millions of Americans suffer from this frequent type of allergic contact dermatitis (ACD) each year (Buttaro et al., 2019). Blisters, intense itching, and discomfort are possible symptoms of toxicodendron dermatitis (Shenoy et al., 2021). The patient’s inner arms and thighs are covered in an itchy, blistering, and erythematous papular rash. The main diagnosis is contact dermatitis based on these symptoms.

DIFFERENT DIAGNOSIS

• Folliculitis

An infection of the hair follicles known as folliculitis causes yellow-white papules and pustules to form on the erythematous base (Buttaro et al., 2019). The folliculitis patient has non-pruritic pustules on the erythematous base of the body-wide hair rash. Folliculitis, an infection of the hair follicles, can appear as a red papule (which may be sensitive) or a pustule can have a number of different causes (Shenoy et al., 2021). The patient may suffer from hot tub folliculitis in this situation. Hot tub folliculitis, on the other hand, must cause the rash to spread to every part of the body that has been submerged in the hot tub, not only the upper thighs and left upper arms.

• Urticaria

A sudden, widespread eruption of pale, transient wheals or papules accompanied by excruciating itching is known as urticaria (Buttaro et al., 2019). Drugs, food, food preservatives, insect bites, and bacterial, fungal, viral, or parasitic diseases are some of the things that might cause urticaria. Hives or wheals that occur at a specific time of day, disappear, and then return the following day are its primary symptoms (Shenoy et al., 2021). Due to a potential allergy to scallops, the patient may develop urticaria. The patient’s rash started two days ago, but instead of wheals and papules, there are vesicles on the erythematous base.

• Pruritus

The condition known as pruritus is characterized by itching and a desire to scratch (Bains & Fonacier, 2019). With or without a rash, pruritus can be present. Internal illnesses such renal, liver, the illusion of parasitosis, hyperparathyroidism, Hodgkin’s lymphoma, and polycythemia vera do not create a rash or pruritus. External skin conditions, bug bites, fungus, topical medications, scabies, dry skin, or drug reactions can all induce pruritus with a rash. The patient also has other symptoms in addition to pruritis, including vesicles with an erythematous base and a rash that extends from her thighs to her left arm, and she is able to pinpoint the causes. As a result, the diagnosis of pruritus is insufficient for this patient.

PLAN

Labs and Diagnostic Tests:

• Patch Testing

Patch testing will assist discover allergens not detected by blood testing or skin prick testing and helps determine which compounds may be causing a delayed-type allergic reaction in a patient Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions

Case: Management Plan

Pharmacological Care

• Apply Clobetasol propionate 0.05% cream topical 2X daily to the afflicted region for two weeks, avoid applying to your face and the groin area.
• Cetirizine 10mg tablet PO daily as needed for itching

Supportive Care

• Bathe in oatmeal
• To treat the region, use cool, moist compresses.
• Apply aluminum acetate or topical calamine lotion to the afflicted area
• Aloe vera gel should be applied at the region with rash

Patient Education

• Apply the betamethasone cream as prescribed
• If a rash develops on the face, avoid applying clobetasol cream.
• Return to the office if a face rash appears.
• Adequate hand washing
• Throw away any exposed clothing, trim your fingernails to avoid infection and itching.
• When hiking or gardening, protect yourself from further exposure by dressing in long pants and long sleeve t-shirts, socks, and closed-toe shoes.
• If blisters appear, leave the skin there because it can shield the open wound below and ward off infection.
• After washing, gently pat the skin dry with a soft cloth rather than rubbing it.
• Wear breathable clothing

 

Follow Up/Disposition

• Follow up with your PCP if not improve in two weeks.
• No restriction, may return to work at tolerate

References

Bains, S. N., & Fonacier, L. (2019). Irritant contact dermatitis. Clinical Reviews in Allergy &            Immunology, 56(1), 99-109.

Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2021). Primary care:             Interprofessional collaborative practice (6th ed.). Elsevier.

Shenoy, E. S., Macy, E., Rowe, T., & Blumenthal, K. G. (2019). Evaluation and management of          penicillin allergy: a review. Jama, 321(2), 188-199. Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions

Kaylee Hales i-human case study soap note: assessing and treating skin problems

Patient Information

Name: Kaylee Hales

Age: 25 years

Gender Identity: Male

Sources: Patient

Allergies: No Known Allergies

Current Medication: Birth Control Pills

PMA: Not Applicable

Immunization: Up to Date

Preventive Care: Not Applicable

Surgical History: None

Family History: The patient is unmarried and has a boyfriend. Both parents are healthy and alive.

Social History: In a relationship, occasionally drinks alcohol. Doesn’t smoke.

Sexual Orientation: Heterosexual, sexually active

Nutrition History: Balanced Diet

Subjective Data:

Chief Complaint: Itchy, tender rash on inner thighs and inner forearms.

Symptoms Description/HPI: Kaylee Hales, a 25-year-old woman in generally good health, presented with a severely itchy, red rash on her inner thighs and left forearm that has been bothering her for two days. Upon physical examination, a scattered, contiguous rash of red bumps with superficial sores was found on her inner thighs, along with red blisters on her left forearm and two parallel linear rash marks measuring 6 cm each. Recent activities include using a hot tub, trying a new lotion, and eating scallops for the first time. She also went hiking and used a hot tub.

Constitutional: No weight changes reported.
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Neurologic: No memory loss, seizures, or tremors reported.

HEENT: No headaches or head injuries. No vision problems. No hearing loss. No nosebleeds or changes in smell. No sore throat or hoarseness. No difficulty swallowing. No mouth sores or bleeding gums.

Respiratory: No wheezing or coughing.

Cardiovascular: No palpitations, swelling, or chest pain. No breathing difficulties or rapid heartbeat.

Gastrointestinal: No constipation or diarrhea.

Genitourinary: No frequent urination or painful urination.

Musculoskeletal: No swollen joints, muscle pain, or back pain.

Skin: Rash on inner thighs and inner forearms.

Objective Data:

Vital Signs: Blood Pressure 116/62, Heart Rate 70, Temperature 98.3°F, Oxygen Saturation 95% on room air, Respiratory Rate 20.

General Appearance: Patient appears healthy, well-dressed, and alert.

Neurologic: Patient is focused and has no history of memory loss.

Main Diagnosis:

Contact Dermatitis (ICD-10 Code: 9)

Contact dermatitis is skin inflammation caused by exposure to an allergen or irritant. It can be allergy-related or irritant-related. Itchy rash, redness, blisters, weepy lesions with small vesicles, and a burning sensation are common symptoms (Bains & Fonacier, 2019). Considering the patient’s recent activities, she likely encountered irritating plants during her nature hike, causing the rash on her extremities. Poison ivy dermatitis is a possibility if she came into contact with poison ivy, oak, or sumac during her outdoor activities (Buttaro et al., 2019). Toxicodendron dermatitis (TD) is a type of allergic contact dermatitis (ACD) caused by these plants and is characterized by blisters, intense itching, and discomfort (Shenoy et al., 2021). Based on her symptoms and history, the primary diagnosis is contact dermatitis.

Other Possible Diagnoses

Folliculitis

Folliculitis is an infection of hair follicles resulting in yellow-white papules and pustules on a red base (Buttaro et al., 2019). Patients with folliculitis have non-itchy pustules on red skin. In this case, hot tub folliculitis might be the cause. However, hot tub folliculitis typically affects all submerged body parts, not just the upper thighs and left forearm.

Urticaria

Urticaria is a sudden outbreak of transient wheals or papules accompanied by severe itching (Buttaro et al., 2019). It can be triggered by drugs, food, insect bites, or infections. Urticaria wheals disappear and reappear within a day (Shenoy et al., 2021). If the patient is allergic to scallops, urticaria could be considered. However, the vesicles on her rash do not match typical urticaria symptoms.

Pruritus

Pruritus is characterized by itching and a desire to scratch (Bains & Fonacier, 2019). Pruritus can occur with or without a rash and might be caused by internal or external factors. While the patient has itching and vesicles on her rash, pruritus alone isn’t a sufficient diagnosis.

Plan

Labs and Diagnostic Tests:

Patch Testing

Patch testing helps identify allergens that blood tests or skin prick tests might miss and can pinpoint delayed allergic reactions in patients.

Case: Management Plan

Pharmacological Care

Apply Clobetasol propionate 0.05% cream topically twice daily to the affected area for two weeks, avoiding the face and groin.
Take Cetirizine 10mg tablet orally daily as needed for itching.

Supportive Care

Use oatmeal baths.
Apply cool, moist compresses to the affected area.
Apply aluminum acetate or calamine lotion.
Apply aloe vera gel to the rash.

Patient Education

Follow prescribed treatment with betamethasone cream.
Avoid applying clobetasol cream on the face if a rash develops.
Return if a face rash occurs.
Practice proper hand hygiene.
Dispose of exposed clothing and trim fingernails to prevent infection and itching.
Wear protective clothing during outdoor activities.
Leave blisters intact to protect against infection.
Gently pat skin dry after washing.

Follow Up/Disposition

Follow up with primary care provider if no improvement in two weeks.
No work restrictions; patient