WEEK #4 COMPREHESIVE CASE STUDY ,,, (CLASS 6512) REASON FOR ENCOUNTER ; NEW RASH 25 YEARS, Exams of Health sciences

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WEEK #4 COMPREHESIVE CASE STUDY ,,, (CLASS 6512)

REASON FOR ENCOUNTER ; NEW RASH FOR 25 YEARS OLD

FEMALE PATIENT ACTUAL SCREENSHOT FOR THE CASE

…..INCLUDING ALL CLINICAL CASE REPORT/ "Clinical

Documentation"

Case: 25 years

Case: 25 years Patient Information

• Age: 25 years old
• Height: 5'5" (165 cm)
• Weight: 120 lbs (54.5 kg)
• Reason for Encounter: New rash CC: 25 y/o F “I have this ugly looking rash on my upper thighs” HPI: .is a 25 y/o female presenting with an itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash.

Case: 25 years PMHx: Child: “usual coughs and tummy ache nothing remarkable.” Adult Illness: Denies SurgHx Medical: None Surgical: None Obstetric: None Hospitalizations: None FamHx Maternal grandfather died of CVD at age

Grandmother (age 88) has prior heart attack, stent and HTN. Mother alive and well. Father alive and well, treated for HTN. Brothers - 35 and 32 both alive and well. Sister - 21 alive and well. SHx Tobacco: Denies ETOH: Socially Illicit Drugs: Denies Occupation: English teacher for 7th^ and 8th^ grade Relationship: Sexually active heterosexual female in a monogamous relationship Diet: Normal American Diet

Case: 25 years Reproductive Hx Age of menarche: “doesn’t remember.” Menstruation cycle duration: “seems fine to me,” regular periods Sexual hx and concerns: Denies concerns LMP: unknown Breast screening: Conducts self- breast exams Last Pap Smear: 1 year ago, with no signs of abnormalities Gravida para status/Childbirth hx: Nulliparous Allergies Ceclor (Cefaclor) second generation cephalosporin – Patient developed hives as child when taking this antibiotic for otitis media List of Current Medications/supplements: Birth control pill Supplements: None

Case: 25 years Review of Systems: (ROS) Use this column to document the ROS below. General: Denies unintentional weight loss or gain, chills, fever, and night sweats Eyes: Denies any vision changes, discharge, discomfort, dryness, or itching ENT: Denies any swelling, redness, rhinorrhea, or pain Pulmonary: Denies SOB at night or at rest or when lying down, denies cough, wheezing or difficulty catching breath CV: Denies palpitations denies heavy feeling or From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below:

Case: 25 years sensation of a “pounding heart GI: Denies NVD, constipation, or heartburn. States normal bowel movements GU: Denies pain, burning, blood in urine, denies difficulty starting or stopping urinating, dribbling, incontinence, urgency during night or day, or any changes in the frequency of urination MS: Denies muscle weakness, joint pain, stiffness, or swelling Heme: Denies bruising, bleeding gums, nose bleeds, abnormal bleeding, or history of anemia Endocrine: Denies heat and cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite Derm: Patient states” Ugly looking rash on my upper thighs, now it’s on my left inner forearm too”, rash is “itchy Derm: Patient states ” Ugly looking rash on my upper thighs, now it’s on my left inner forearm too”, rash is “itchy and getting more tender”

Case: 25 years and getting more tender” Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness Psych: Denies anxiety, depression, loss of energy or changes in interests

Case: 25 years Physical Exam: (PE) Use this column to document the PE below. Vitals: Height: 5' 5" (165.0 cm) Weight: 120 lb (55.0 kg) (BMI 20.0) Temperature: 98.6 F (oral) Pulse: 76 bpm - regular Blood pressure: 116/62 mmHg - supine/sitting From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below:

Case: 25 years

Case: 25 years Blood pressure: 106/60 mmHg - upon standing Respiratory rate: 12 bpm SpO2: 94% on room air General: Thin, pleasant, cooperative female, alert and oriented x Skin: Skin on head, neck, back, chest, abdomen, right arm: warm, dry, intact, no redness, itching or swelling. Left inner forearm is noted with itchy erythematous papules in linear configuration with vesicles. Bilateral inner thighs noted with raised confluent erythematous papules with vesicles in various stages Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness ENT: Deferred Neck: Deferred Skin: Skin on head, neck, back, chest, abdomen, right arm: warm, dry, intact, no redness, itching or swelling. Left inner forearm is noted with itchy erythematous papules in linear configuration with vesicles. Bilateral inner thighs noted with raised confluent erythematous papules 10x12cm with vesicles in various stages

Case: 25 years Pulm: Respirations even and unlabored bilaterally, good chest wall expansion, lung sounds clear to auscultation bilaterally both anterior and posterior CV: Heart rate and rhythm normal, no significant change while standing, squatting and during Valsalva maneuver, no JVD. 2+ peripheral pulses x extremities, PMI in the 5th intercostal (ICS) at the midclavicular line (MCL) GI: Lean, non-distended, no scars noted, bowel sounds audible in all 4 quadrants, no hepatosplenomegaly, mass or herniation

Case: 25 years GU: Deferred Neuro: Deferred MSK: Deferred Psych: Deferred Lab/Radiology or other Diagnostic data reviewed today during virtual visit No tests ordered or recommended at this time. History and physical assessment only. Problem Statement: .is a 25 y/o female presenting with an itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash. Upon examination, the left inner forearm is noted with itchy erythematous papules in a linear configuration with vesicles. The bilateral inner thighs were noted with raised confluent erythematous papules 10x12 cm with vesicles in various stages. List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding – total of 3 *Include ICD 10 codes after each

1. MNM/Leading/Concluding: Allergic Contact Dermatitis **L23.

2. MNM: Cellulitis L03. 90
3. MNM: Herpes Zoster (Shingles) B02.**

Case: Krista Hampton Plan Treatment:

- Steroid creams or ointments. These

topically applied creams or ointments help soothe the rash of contact dermatitis. A topical steroid may be applied one or two times a day for two to four weeks.

- Oral medications. In severe cases, your doctor may prescribe oral corticosteroids to reduce inflammation, antihistamines to relieve itching or antibiotics to fight a bacterial infection. Mild cases: - Domeboro to dry the vesicles and minimize spreading - Clobetasol propionate cream Severe cases: - Prednisone (20mg tabs) 3 tabs QDx3 days; 2 tabs QD x 3 days; 1 tab 3-5 days

- Domeboro to dry the vesicles and minimize spreading - Clobetasol propionate cream - Acute severe allergic contact dermatitis, such as from poison ivy, often needs to be treated with a 2 - week course of systemic corticosteroids. - Most adults require an initial dose of 40- 60 mg.

Case: Krista Hampton

- The oral corticosteroid is tapered over a 2- week period, but a complicated tapering regimen probably is not necessary given the short duration of systemic corticosteroid use. - The systemic corticosteroids must be administered for 2 weeks, because shorter courses are notorious for allowing poison ivy dermatitis to relapse. - Long-acting intramuscular triamcinolone acetonide (Kenalog) 40 - 60 mg may be used in place of oral prednisone. To help reduce itching and soothe inflamed skin, try these self-care approaches and education:

- Avoid the irritant or allergen. - The key to this is identifying what's causing your rash and staying away from it. - Your doctor may give you a list of products that typically contain the substance that affects you. - Also ask for a list of products that are free of the substance that affects you.

Case: Krista Hampton

- Apply an anti-itch cream or lotion to the affected area. - A nonprescription cream containing at least 1 percent hydrocortisone can temporarily relieve your itch. - A steroid ointment may be applied one or two times a day for two to four weeks. - Or try calamine lotion. - Take an oral anti-itch drug. - A nonprescription oral corticosteroid or antihistamine, such as diphenhydramine (Benadryl), may be helpful if your itching is severe.

Case: Krista Hampton

- Apply cool, wet compresses. - Moisten soft washcloths and hold them against the rash to soothe your skin for 15 to 30 minutes. - Repeat several times a day. - Avoid scratching. - Trim your nails. Case: Krista Hampton

Case: Krista Hampton

- If you can't keep from scratching an itchy area, cover it with a dressing. - Topical soaks with cool tap water. - Burrow solution (1:40 dilution), saline (1

Case: Krista Hampton tsp/pint) can be soothing.

- Cool compresses with saline or aluminum acetate solution are helpful for acute vesicular dermatitis (eg, poison ivy). Some individuals with widespread vesicular dermatitis may obtain relief from lukewarm oatmeal baths. - Soak in a comfortably cool bath. - Sprinkle the water with baking soda or an oatmeal-based bath product. Protect your hands. - Rinse and dry hands well and gently after washing.

Case: Krista Hampton

- Use moisturizers throughout the day. - And choose gloves based on what you're protecting your hands from. For example, plastic gloves lined with cotton are good if your hands are often wet Consultation and/or referral: N/A Follow up: If symptoms do not improve or worsen after treatment