Diagnosis of Ms. Krista Hampton- 25 year old with Sensitive skin PDF

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Summary

HPI: Ms. Krista Hampton 25-year-old female with a history of sensitive skin presented to the office complaining of an itchy and tender erythematous rash on her left inner arm, and bilateral inner thighs. She started experiencing her symptoms with itchiness followed by rashes. She reports “We sort of...

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Diagnosis of Ms. Krista Hampton- 25 year old with Sensitive skin HPI: Ms. Krista Hampton 25-year-old female with a history of sensitive skin presented to the office complaining of an itchy and tender erythematous rash on her left inner arm, and bilateral inner thighs. She started experiencing her symptoms with itchiness followed by rashes. She reports “We sort of lost the trail a bit and wound up bushwhacking through some woods and brush to get back.” The patient reports wearing inappropriate clothing for hiking in the woods such as “wearing shorts and a tank top.” The patient also reports using a hot tub bath on that day. All the symptoms accrued 24 hours after hiking in the woods, after eating new food, using new sunscreen lotion, and hot tub bath. The rashes started in her inner thighs and spread to her left inner forearm. She reports, she noticed worsening and changes in rashes over time.

Ms.

Hampton denies any similar rashes in the past. The patient reports severe childhood rashes related to Ceclor allergic reaction. The patient denies fever, night sweat, unwanted weight loss. Primary Diagnosis and ICD -10 code: Including any procedural codes L24.7 Irritant contact dermatitis due to plants L24.9 Irritant contact dermatitis (unspecified cause) (AAAAI, 2020) 3- 5 Differential Diagnoses 1. Contact dermatitis 2. Cellulitis 3. Hot tub folliculitis 4. Bullous insect bites 5. Bacterial infections 6. Dyshidrotic eczema Additional Laboratory and Diagnostic tests: The serum IgE will be examined, because there is possibility that it could increase to 80% to 90% of pts with AD (Maldonado & Z=>iga, 2019). Additionally, if primary or secondary infections are suspected a viral culture or skin bacterial will be performed.

Consults: When diagnosis cannot be determined the patient will be referred to dermatology provider including refractory cases (Terry Mahan Buttaro et al., 2017). The dermatologist or an allergist will perform patch testing and determine the actual diagnosis of the causative agent (s). Health promotion: The patient will be recommended to wash her exposed clothes, including other items, such as towels, bathing linens, and pets using a special soap that eliminate the poison oak, or poison ivy. The patient will be reminded to follow safety cautions labeled on harmful chemical (Terry Mahan Buttaro et al., 2017). After using the chemical, the patient will be advised to wash their immediate will soap and clean water incase the harmful chemical comes to contact with their skin. Avoiding of the offending agent Patient will be recommend to use petrolatum products, which have low potential for allergic and irritation (Terry Mahan Buttaro et al., 2017). However, for a surface that is crusting lesion, the patient will recommended to use domeboro solution for relief. It is important use warm water and cleanser to wash your hand to a minimum (Terry Mahan Buttaro et al., 2017). Alcohol based cleanser is preferred because they are likely to cause less irritant hand dermatitis in comparison to water and soap. Educate patient The patient will be informed to reduce the number to time she baths per week and also reduce usage of soap (Maldonado & Z=>iga, 2019). It is also essential to inform the patient to consume more fluid per day, and keep off irritants that may aggravate their symptoms. The patient will also be educated on thorough application of the steroid and inform them of po benefits and risks (Maldonado & Z=>iga, 2019). In case patient shows signs of emotional

triggers, she will be advised to utilize stress management and relaxation technique, and reassure the patients. Disposition/follow-up instructions The patient will be informed to come back for checkup after two week (Maldonado & Z=>iga, 2019). If symptom exacerbate, the patient is recommended to seek assistance from their provider and immediately report back for examination. It is important to seek immediate medical care in case their skin patient believe their skin is infected, particularly if the patient experience increased bodily temperature, and release of puss from wounds. In case of inflamed or painful nasal passage, which can arise from inhaling an allergen, the patient is advised to call 911 or visit the nearest emergency department (Maldonado & Z=>iga, 2019). The same is recommend for difficulty breathing.

References AAAAI. (2020). American Academy of Allergy Asthma and Immunology. Maldonado, D. C., & Z=>iga, C. (2019). SOAP for family medicine. Wolters Kluwer. Terry Mahan Buttaro, Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care : a collaborative practice. Elsevier....