NR 576 Week 2 iHuman Virtual Patient Encounter - Kaylee Hales - Dermatology Assessment

History Notecard by Suzy Hanah on case Kaylee Hales Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = Sx = Sx = Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity Attempt: 3197453 Report generated on 7/12/2024, 5:55:03 PM America/Los_Angeles Management Plan by Suzy Hanah on case Kaylee Hales Diagnostic tests: None Rationale: This diagnosis is clinical, which means it is based solely on clues discoverable in the history and physical examination. Testing at this visit is not needed. Medications: Hydrocortisone butyrate 0.1% cream. Apply thin film BID to affected area for no more than 3 weeks Rationale: Low-potency steroids decrease inflammation and relieve itching. Topical corticosteroids are frequently used to treat contact dermatitis (Cohen, 2020) Education: Steer clear of the harmful substance. When there is a chance of coming into touch with an allergen, wear protective clothing (gloves, long sleeves). If skin comes into touch with the substance, wash it off right away (within 15 minutes) using soap and water, then rinse well. Use cold water to soak irritated areas. Taking a warm bath could ease itching. Before using, read the product labels. If patients test positive for allergens such nickel, cobalt, balsam of Peru, chromium, or gallates that may cause reactions when consumed, systemic contact dermatitis should also be considered. If systemic reaction occurs, follow up within 24hrs (Mowan et al., 2021). Rational: Avoiding contact with known substance prevents reaction (Hollier, 2021). Referral: Dermatologist or allergist Rationale: Dermatologist for slow-to-respond lesions. Allergist if offending substance cannot be identified or condition is recurrent (Hollier, 2021). Follow up: Follow up in office 2 weeks for rash Rationale: atopic dermatitis is usually relieved within 1-2 weeks (Hollier, 2021). References: Cohen, D. E., & Heidary, N. (2020). Treatment of irritant and allergic contact dermatitis. Dermatologic therapy, 17(4), 334– 340. https://doi.org/10.1111/j.1396-0296.2020.04031.x Hollier, A. (2021). Clinical Guidelines in Primary Care (4th ed.) [Print]. Advanced Practice Education Associates. Mowad, C. M., Anderson, B., Scheinman, P., Pootongkam, S., Nedorost, S., & Brod, B. (2019). Allergic contact dermatitis: Patient diagnosis and evaluation. Journal of the American Academy of Dermatology, 74(6), 1029–1040. https://doi.org/10.1016/j.jaad.2019.02.1139 Attempt: 3197453 Report generated on 7/12/2024, 5:55:03 PM America/Los_Angeles Family History Category Data entered by Suzy Hanah Family History Mother (age 58): alive and well Father (age 59): hypertension Sister (age 21): alive and well Brothers (ages 35 and 32): both alive and well Maternal grandfather (died at age 81): history of cardiovascular disease Maternal grandmother (age