Krista Hampton Ihuman Allergic Contact Dermatitis
Patient Case Studies help to identify and diagnose any underlying issues in a patient. Ihuman case studies help to show a full evaluation of a patient and they help to prepare to deal and eliminate any health complications. Below is an Ihuman Case sample of Krista Hampton:
Patient Complain: "Ihave this ugly looking rash on my upper thighs"
HPI: Patient 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 boyfrienddoes not have similar symptoms,and that she has not tried any treatments for the rash.
PMHx: Denies
SurgHx Medical: None Surgical: None Obstetric: None
Hospitalizations: None
FamHx:
Maternal grandfather died of CVD at age 81. Grandmother (age 88) has prior heart attack, stent
and HTN.
Mother alive and well.
Father alive and well, treatedfor HTN.
Brothers - 35 and 32 both alive and well. Sister - 21 alive and well.
SHx
Tobacco: Denies ETOH: Socially Illicit Drugs: Denies
Occupation: English teacherfor 7th and 8th grade
Relationship: Sexually active heterosexual female in a monogamous relationship
Diet: Normal American Diet
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) secondgeneration cephalosporin - Patient developedhives as child when taking this antibiotic for otitis media
List of CurrentMedications: Birth controlpill
Review of Systems: (ROS)
General: Denies unintentional weightloss or gain, chills, fever,and night sweatsEyes: 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, deniescough, wheezing or difficulty catching breath
CV: Denies palpitations denies heavy feelingor 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, urgencyduring night or day, or any changesin the frequency of urination
MS: Denies muscle weakness,joint pain, stiffness, or swelling
Heme: Denies bruising,bleeding gums, nose bleeds, abnormalbleeding, or historyof 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 forearmtoo", rash is "itchy and getting more tender"
Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures,or weakness Psych: Deniesanxiety, depression, loss of energy or changesin interests
Physical Exam: (PE)
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
Blood pressure: 106/60mmHg - upon standing Respiratory rate: 12 bpm SpO2: 94% on room air
General: Thin,pleasant, cooperative female,alert and orientedx4
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 withoutcrusting, eyelids withoutedema, erythema. Conjunctivae pink, no discharge. No orbital edema,redness, tenderness
ENT: Deferred Neck:Deferred
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 x4 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 orherniation
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
GU: Deferred
Neuro: Deferred
MSK: Deferred
Psych: Deferred
Assessment:
- Rash on bilateral upper thighs & left inner forearm- started3 days ago
-Went hiking& bush whackingthrough woods
- Went in a publicbath tub
- Sensitive skin
-Rash itchy and tender
Differential Diagnosis:
-Allergic Contact Dermatitis (L23.9)
-Hot tub folliculitis (L66.2)
Diagnostic Testing:
Lab/Radiology or other Diagnostic data reviewed today during virtualvisit
No tests ordered or recommended at this time. History and physical assessment only.
Plan:Allergic Contact Dermatitis
-Betamethasone 0.05% topically to affected area BID
-Cetirizine 50 mg PO every 4-6 hr PRN
Patient Education:
-Luke warm baths with oatmealpreparation
- Do not scratch rash
-Cool compress to relieve itch and pain
-Wash skin with warm soapy water
Are your grades plumeting? Is that Online class making you struggle?. At acemyhomework.com we are available 24/7 and guarantee quality. timely and professional work. Contact us or email us to place your order.
