COMPREHENSIVEI HUMAN CASE STUDY WEEK #2 6531 A 36 YEAR OLD FEMALE WITH ITCHY RASH MARC, Exams of Nursing

Download COMPREHENSIVEI HUMAN CASE STUDY WEEK #2 6531 A 36 YEAR OLD FEMALE WITH ITCHY RASH MARC and more Exams Nursing in PDF only on Docsity!

• Character: Erythematous, raised, pruritic lesions, some with excoriation
• Aggravating Factors: Hot showers, scratching
• Relieving Factors: Antihistamines provide partial relief
• Associated Symptoms: Mild fatigue but no fever, joint pain, or systemic involvement Past Medical History:
• Atopic dermatitis as a child, resolved in adolescence
• No history of psoriasis, autoimmune disorders, or chronic illnesses Family History:
• Mother has a history of psoriasis
• No known family history of lupus or allergic disorders Social History:
• Works as a kindergarten teacher
• No recent travel, no pets
• No smoking or alcohol use Medications & Allergies:
• Takes a daily multivitamin
• No new medications or known drug allergies 3. Physical Examination:
• General: Well-appearing, no acute distress
• Vitals: BP: 118/76 mmHg, HR: 78 bpm, Temp: 36.8°C, RR: 14/min
• Skin Exam:

o Scattered erythematous papules and plaques with excoriations on forearms, trunk, and lower legs o No vesicles, pustules, or target lesions o No mucosal involvement

• Systemic Exam: No lymphadenopathy, no joint swelling or tenderness 4. Differential Diagnosis:

1. Atopic Dermatitis (Eczema) - History of childhood eczema, flexural involvement, itching
2. Contact Dermatitis - Possible occupational exposure to allergens in the classroom
3. Urticaria (Chronic Idiopathic or Allergic) - Intermittent pruritus, but lacks transient wheals
4. Scabies - Pruritus and excoriations, though no classic burrows were noted
5. Psoriasis - Family history present, but no classic silvery plaques 5. Diagnostic Workup: Laboratory Tests Ordered:

• Complete Blood Count (CBC) - Mild eosinophilia noted
• Erythrocyte Sedimentation Rate (ESR) & C-Reactive Protein (CRP) - Normal
• Skin Scraping & KOH Prep - Negative for fungal elements
• Skin Biopsy (if needed) - Considered if no response to initial treatment 6. Diagnosis:

9. Conclusion: An itchy rash in a 36-year-old female requires a methodical evaluation to rule out allergic, infectious, and autoimmune causes. This case underscores the role of targeted history-taking, physical examination, and judicious use of diagnostic tests in guiding appropriate treatment. 10. References:

1. Williams, H., Stewart, A., & Huth, C. (2023). Clinical Dermatology: A Color

Guide to Diagnosis and Therapy. Elsevier.

2. Silverberg, J. I. (2022). "Atopic Dermatitis in Adults: Recognition and

Management." JAMA Dermatology.

3. Bolognia, J. L., Schaffer, J. V., & Cerroni, L. (2021). Dermatology. Elsevier.

Structured Case Workup Plan

1. History Taking A thorough history is essential for narrowing down differential diagnoses. A. Chief Complaint - Onset : Acute (hours to days) vs. Chronic (weeks to months) - Progression : Spreading, worsening, or improving? - Location : Localized vs. Generalized - Character of Rash : Red, raised, scaly, blistering, weeping, dry, etc.

• Associated Symptoms : Fever, pain, burning, swelling, systemic involvement (e.g., joint pain, fatigue).
• Itch Severity : Mild, moderate, severe B. Triggers & Exposures
• New skincare products, detergents, cosmetics? (Contact Dermatitis)
• Recent outdoor activities? (Plant exposure like poison ivy, insect bites)
• New medications or supplements? (Drug Reaction)
• Recent illness or fever? (Viral exanthem, systemic disease)
• History of allergies, asthma, or eczema? (Atopic Dermatitis)
• Close contact with affected individuals? (Scabies, viral rash)
• Pets or travel history? (Zoonotic or parasitic infections) C. Past Medical History
• Chronic skin conditions? (Eczema, psoriasis, lupus)
• Autoimmune diseases? (Lupus, Dermatitis Herpetiformis, Celiac Disease)
• Immunosuppression? (HIV, Cancer, Organ Transplant, Chemotherapy) D. Family & Social History
• Family history of psoriasis, eczema, or autoimmune disease?
• Smoking, alcohol, or drug use? (Can worsen some conditions)
• Stress levels? (Can exacerbate psoriasis, eczema) 2. Physical Examination A full-body skin exam is crucial. A. General Inspection

• Thyroid Panel (TSH, T4) : If chronic pruritus without rash (hypothyroidism).
• Autoimmune Panel (if lupus, vasculitis suspected): ANA, dsDNA, Anti-Smith.
• Celiac Serology (if Dermatitis Herpetiformis suspected) : Anti-tTG, IgA. B. Skin-Specific Tests
• Skin Scraping & KOH Test : If fungal infection suspected (e.g., Tinea, Candidiasis).
• Dermoscopy : Helpful for scabies, melanoma, or certain inflammatory conditions.
• Skin Biopsy (Punch or Shave Biopsy) : If unclear diagnosis or suspected autoimmune disease.
• Patch Testing : If contact dermatitis suspected but allergen unknown. C. Microbiology Tests
• Bacterial Culture : If bacterial infection suspected (Impetigo, Cellulitis).
• Viral PCR or Tzanck Smear : If viral etiology suspected (Herpes, Varicella, Measles).
• Scabies Test (Burrow Ink Test, Microscopy) : If suspected. 4. Diagnosis & Management Once the diagnosis is established, treatment is tailored accordingly: A. Empiric Treatment (While Awaiting Tests)
• Mild Cases : Topical steroids, antihistamines, emollients.
• Suspected Infection : Antifungals, antibiotics, or antivirals as needed.

• Severe/Systemic Symptoms : Referral to dermatology, immunology, or rheumatology. **Differential Diagnoses for Itchy Rash

1. Allergic & Hypersensitivity Reactions**

• Atopic Dermatitis (Eczema) – Chronic, relapsing itchy rash, often on flexural surfaces.
• Contact Dermatitis – Localized rash due to irritants/allergens (e.g., soaps, metals, cosmetics).
• Urticaria (Hives) – Raised, red, itchy welts; often from allergies, infections, or idiopathic.
• Drug Reaction (e.g., Stevens-Johnson Syndrome, DRESS) – Rash following medication use. 2. Infectious Causes
• Fungal Infections (Tinea Corporis, Tinea Versicolor, Candidiasis) – Scaling, erythema, central clearing.
• Scabies – Intensely itchy rash, worse at night, burrows in web spaces, wrists, and axillae.
• Viral Exanthems (e.g., Varicella, Measles, Herpes Zoster) – Rash associated with fever, systemic symptoms.
• Bacterial Infections (e.g., Impetigo, Erythrasma, Cellulitis) – Pustules, honey-colored crusting, warmth. 3. Autoimmune & Inflammatory Disorders
• Psoriasis – Silvery scales on extensor surfaces, often with nail pitting.

• Fungal Infections → Topical antifungals (e.g., Clotrimazole) or oral antifungals for widespread disease.
• Scabies → Permethrin 5% cream (apply overnight, repeat in 1 week), treat household contacts.
• Urticaria → Antihistamines, epinephrine if anaphylaxis is suspected.
• Psoriasis → Topical steroids, vitamin D analogs, phototherapy, systemic agents if severe.
• Lupus Rash → Sunscreen, hydroxychloroquine, steroids if severe.
• Drug Reaction → Stop offending drug, steroids if severe, supportive care. When to Refer to a Specialist
• Severe or Persistent Rash → Dermatology referral.
• Systemic Symptoms (fever, weight loss, joint pain, organ involvement) → Rheumatology, Infectious Disease consult.
• Suspected Anaphylaxis → Emergency management with epinephrine. Here's a detailed workup plan for your case study of a 36 - year-old female with an itchy rash , including history, physical exam, diagnostic tests, and structured case documentation. B. Follow-Up Plan
• Mild Cases : Reassess in 1-2 weeks if symptoms persist.
• Unclear Cases : Consider biopsy or referral if no improvement.
• Systemic Symptoms : Urgent referral if suspected autoimmune or serious infection.

Case Study Documentation Format Use this format for structured case reporting: Patient Profile

• Name/ID : (If applicable)
• Age/Sex : 36-year-old Female
• Chief Complaint : "Itchy rash for X days/weeks"
• History of Present Illness : Include onset, progression, triggers, and treatments tried.
• Past Medical History : Relevant conditions (eczema, lupus, etc.).
• Family History : Any hereditary skin conditions.
• Social History : Occupation, stress, habits, environmental exposures. Physical Exam Findings
• Vitals : Normal or abnormal?
• Skin Examination : Rash description, distribution, systemic signs. Differential Diagnosis Considered

1. Atopic Dermatitis
2. Tinea Corporis
3. Psoriasis
4. Drug Reaction
5. Scabies Diagnostic Tests Ordered

• Blood Work : CBC, ESR, CRP, ANA, etc.

Nits on the shaft of hair: Head, body, and/or pubic Pruritis, excoriation Arthropod bites Localized areas of pruritis, urticarial, papules caused by mosquitos, biting flies, bedbugs, ticks (infectious disease), chiggers, etc Atopic Dermatitis (Eczema) Itchy dry skin commonly in the Antecubital, popliteal area with small, raised bumps (can leak fluid when scratched, will then crust over) Acute Flares: Mild/moderate: erythematous, scaly patches with crusting or excoriation Severe: diffuse, exfoliative erythroderma (>30% of body surface area) Pompholyx (dyshidrotic eczema)

Pruritic rash with “tapioca” vesicles 1-2 mm in size commonly on the palms, soles, and sides of fingers; can have scaling and fissuring Keratosis Pilaris itchy dry skin with 1-2 mm papules center on small hair follicles most commonly found on upper arms and front of thighs-- feels rough and dry like sandpaper seborrheic dermatitis (Cradle cap in infants, dandruff in adults) greasy, fine, dry, white adherent scale overlying red, inflamed skin on the vertex of the scalp with minor itching Allergic contact dermatitis Intense pruritis, tiny vesicles, weeping, & crusting that extends beyond the area of direct contact irritant contact dermatitis Itchy erythematous/scaly rash (vesicles rare) contact dermatitis (general) Acute lesions: edema, papules, vesicles, bullae, serous discharge, or crusting

Koebner phenomenon when lesions occur in areas trauma, which can be seen with Lichen Planus and Psoriasis atopic dermatitis what is the most common type of Ezcema or chronic inflammatory disease? •Pruritus and chronic relapsing course starting in infancy how does atopic dermatitis presents? •Ig E associated or allergic form of dermatitis •Non IgE associated form what are the 2 types of atopic dermatitis? •Must have- an itchy skin condition •Plus 3 or more of the following: h/o involvement of skin creases Personal history of atopy h/o dry skin Visible flexural eczema Onset under 2 years of age what are the diagnostic guideline of atopic dermatitis? •Early-onset - first 2 years •Late onset - after puberty

•Senile onset - after 60 what are the 3 subsets of atopic dermatitis based on age of onset? Genetic susceptibility to allergic contact dermatitis. What is the filaggrin gene associated with? Loss of function mutation What type of mutation in the filaggrin gene is linked to allergic contact dermatitis? •Mutations in filaggrin gene epidermal barrier function •Family history •Gene-gene and gene-environment interactions •epidermal barrier dysfunction •Transepidermal water loss •Pruritus - 1L 13 •Epicutaneous sensitisation what are the factors that contribute to the pathogenesis of atopic dermatitis? •Acute stage - erythema, oedema , papules and plaques vesiculation, oozing , crusting •Subacute - erythema, scaling and variable crusting •Chronic - thickened plaques with lichenification •Pruritus(Itching) is the main symptom •Perifollicular accentuation , hyper /hypo pigmentation