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 tolerated
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
