NR 511 Week 2 iHuman Virtual Patient Encounter - Kaylee Hales
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Family Hx: father has HTN. maternal grandfather died of heart disease. grandmother has had a heart attack, a stent, and HTN PHYSICAL EXAM: General: Vitals reviewed, healthy appearing, well-developed, NAD HEENT/Neck: Normocephalic, atraumatic, no deformities, facial features symmetric, temporal arteries non-tender to palpation, maxillary and frontal sinuses non-tender both sides, PERRL, no ptosis, conjunctiva pink, sclera anicteric, TM translucent and pinkish/grey in color, no nasal discharge or polyps, no swelling at lips or tongue, pharynx without erythema or edema, trachea midline and freely mobile Cardio: S1 S2, RRR Respiratory: Lungs clear bilaterally, no use of accessory muscle Abdomen: No scars, moles masses, rashes, erythema, ecchymosis GU: not assessed MSKL: not assessed Neuro: AXO4 Skin: Inner forearm: rash measuring 6 cm, linear, multiple erythematous vesicles. Thigh: bilateral areas of urticaria on inner thighs measuring 10X12 cm Lymphatic: Cervical lymph nodes non-tender Psych: not assessed ASSESSMENT: • Itching progressing to tenderness • Erythematous itchy plaques on inner thighs • left inner arm rash with vesicles in linear streaks • exposure to brush plants while hiking • use of new lotion • use of hot tub • exposure to scallop PROBLEM STATEMENT: K.H. is a 25-year-old female with no pertinent health history, presenting with a rash that started 2 days ago after walking through wild brush plants and new exposure to hot tubs, lotions, and scallops. Primary rash appears on the patient's legs as raised, confluent, erythematous papules References Chan, C. X., & Zug, K. A. (2021). Diagnosis and management of dermatitis, including atopic, contact, and hand eczemas. Medical Clinics, 105(4), 611-626. Dickel, H. (2023). Management of contact dermatitis. Allergo Journal International, 32(3), 57- 76.
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