Kaylee Hales iHuman Case Study SOAP Note: Evaluating and Managing Integumentary Conditions
Patient Information
- Name: Kaylee Hales
- Age: 25 years
- Gender Identity: Female
- Sources: Patient
- Allergies: NKA
- Current Medication: Contraceptive pills
- Past Medical History: N/A
- Immunizations: Up to date
- Preventive Care: N/A
- Surgical History: None
- Family History: Both parents are healthy and alive.
- Social History: In a relationship, drinks alcohol occasionally, denies smoking tobacco.
- Sexual Orientation: Straight, sexually active
- Nutrition History: Balanced diet
Subjective Data
Chief Complaint: Itchy, tender rash on the inner thigh and left forearm.
HPI: Kaylee Hales, a 25-year-old woman, presented with an extremely itchy, erythematous rash on her inner thighs and left forearm. The rash has been present for two days. She reports recent exposure to a hot tub, new lotion, and scallops, all for the first time. Additionally, she went on a nature hike.
Constitutional: Denied weight loss or gain.
Neurologic: Denies memory loss, seizures, or tremors.
HEENT: No headaches, vision problems, hearing loss, nosebleeds, sore throat, or difficulty swallowing.
Respiratory: No wheezing or coughing.
Cardiovascular: Denies chest pain, palpitations, or edema.
Gastrointestinal: No diarrhea or constipation.
Genitourinary: No polyuria or dysuria.
Musculoskeletal: No joint swelling or myalgia.
Skin: Rash on the inner thigh and left forearm.
Objective Data
Vital Signs:
- BP: 116/62 mmHg
- HR: 70 bpm
- Temperature: 98.3°F
- SpO2: 95% on room air
- RR: 20 breaths per minute
General Appearance: Patient appears healthy, neatly dressed, and alert.
Neurologic: Patient is focused, no history of memory loss.
Skin: A 10×12 cm scattered erythematous papular rash with superficial excoriation on the inner thighs and erythematous blisters on the left inner forearm.
Assessment
Main Diagnosis:
Contact Dermatitis (ICD-10 Code: L23)
Contact dermatitis is a skin inflammation caused by direct contact with an allergen or irritant. Symptoms include erythematous, pruritic, vesicular, or linear rashes. Given Kaylee’s recent exposure to a hot tub, new lotion, and hiking, she may have come into contact with an allergen like poison ivy, oak, or sumac, which causes allergic contact dermatitis. Symptoms such as an itchy, blistering rash align with the diagnosis (Bains & Fonacier, 2019).
Differential Diagnoses:
- Folliculitis
Folliculitis is an infection of the hair follicles that causes pustules on an erythematous base. Hot tub folliculitis occurs when the body is submerged in contaminated water. However, in Kaylee’s case, the rash is localized, suggesting a less likely diagnosis (Buttaro et al., 2021). - Urticaria
Urticaria presents as a sudden eruption of pale, transient wheals accompanied by severe itching, often caused by allergens. Although Kaylee ate scallops for the first time, her symptoms do not include the characteristic wheals of urticaria (Shenoy et al., 2019). - Pruritus
Pruritus refers to the sensation of itching, which may or may not involve a rash. Although Kaylee experiences itching, the presence of vesicles and an erythematous rash suggests a more specific diagnosis like contact dermatitis (Shenoy et al., 2019).
Plan
Labs and Diagnostic Tests:
- Patch Testing: To identify allergens not detected by blood or skin prick tests, particularly for potential allergens from her hike or exposure to new lotion and scallops.
Management Plan:
Pharmacological Treatment:
- Clobetasol propionate 0.05% cream: Apply topically 2x daily to the affected areas for two weeks. Avoid using it on the face and groin.
- Cetirizine 10 mg tablet: Take orally once daily as needed for itching.
Supportive Care:
- Bathe in oatmeal to soothe the skin.
- Apply cool, moist compresses to the affected areas.
- Use aluminum acetate or topical calamine lotion for symptomatic relief.
- Apply aloe vera gel to the rash for additional soothing effects.
Patient Education:
- Apply the prescribed clobetasol cream as directed.
- Avoid using the cream on the face if a rash develops.
- Perform adequate handwashing and avoid scratching to prevent infection.
- Discard any clothing that may have come in contact with allergens.
- Wear long pants, long sleeves, socks, and closed-toe shoes during outdoor activities to avoid future contact with potential allergens.
- If blisters form, do not puncture them, as the skin acts as a natural barrier to infection.
Follow-up:
- Return to the clinic if symptoms persist or worsen after two weeks.
- No work restrictions are necessary; resume activities as 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.
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