Annie Chambers ihuman Case Study
General – patient denies productive/non-productive cough, chills, fever, sore throat, night sweats, changes in appetite, intentional/unintentional weight loss/gain.
HEENT/Neck – patient denies neck pain with movement, denies neck swelling, dizziness, visual disturbances, hearing loss, abnormal ear discharge, ear pain, oral ulcerations, pain/difficulty swallowing, or nasal discharge.
Cardiovascular – patient denies lower extremity, facial, or upper extremity swelling, she denies palpitations, chest pain, or history of murmurs.
Respiratory – patient denies productive/unproductive cough, exposure to influenza/TB, shortness of breath (SOB), or exposure to secondhand smoke.
Gastrointestinal – patient denies vomiting, nausea, abdominal pain/cramping.
Genitourinary – patient denies urinary frequency, urgency, pain with urination, foul smelling odor, abnormal vaginal discharge, vaginal sores, or lower back pain.
Musculoskeletal – patient denies difficulty/pain with range of motion (ROM), back, lower extremity, neck, or upper extremity swelling.
Neurologic – patient denies dizziness, lower or upper extremity tingling or numbness, memory loss, headaches, or loss of consciousness.
Integumentary/breast – patient reports a new, itchy, erythematous, and tender rash on bilateral inner thighs and left inner forearm. She denies flaky/dry skin, or excess sweating.
Psychiatric – patient denies suicidal or homicidal ideations, auditory or visual hallucinations, feeling sad/anxious, or mood changes.
Endocrine – patient denies excess growth of facial hair or hair on legs and arms, denies increased urination, excessive thirst, intentional/unintentional weight loss/gain.
Hematologic – patient denies lack of energy, fatigue, familial/self-history of anemia, delayed wound healing, spontaneous bleeding/bruising, cold/blue fingers
Allergic/Immunologic – patient reports getting hives as a reaction to a drug (Cefaclor) during childhood but denies known/unknown allergies to food, environment, or drugs in adulthood
PMH – patient denies history of acute/chronic illnesses
Hospitalizations/surgeries – patient denies hospitalization for acute/chronic illnesses, or major/minor surgeries
Preventive Health – patient is up-to-date with all screenings and immunizations.
Medications – patient denies use of prescription, OTC or herbal medications other than her contraceptive pills.
Allergies –patient reports getting hives as a reaction to a drug (Cefaclor) during childhood but denies known/unknown allergies to food, environment, or drugs in adulthood
Social History – patient informs that she’s only a social drinker, denies recreational/illicit drug use or tobacco use.
Family History – both mother and father are alive and healthy. Father has hypertension that’s well controlled with drugs. Maternal grandfather died of heart disease. Maternal grandmother has hypertension, stent placement and also had a heart attack.
Management Plan
Diagnostic tests
No additional diagnostic tests are needed in this visit
Medications:
Med #1
Med: clobetasol propionate 0.05%cream (Johnston et al., 2017).
Sign: Apply clobetasol propionate 0.05% cream 12 hourly every day.
Disp: 1
Refills: none
Rationale: clobetasol is a steroid primarily used to relieve inflammation of the skin as a result of skin conditions such as ACDs, and psoriasis (Brar, 2021). Patients should not use the drug for more than two weeks and expected side effects to look out for include; dry skin, heat rash, skin color change, itching/burning, and thin skin.
Med #2
Med: OTC cetirizine 10 mg (Johnston et al., 2017).
Sign: take OTC cetirizine 10mg PO daily for pruritus for 3 days
Disp: 3
Refills: none
Rationale: cetirizine is an antihistamine that provides relief to symptoms such as pruritus and inflammation that can be distressing following an allergic reaction (Corsico et al., 2019). Besides, it contains anti-inflammatory properties to reduce inflammation and tenderness.
Suggested consults/referrals
No consults/referrals are needed in this visit
Patient education
- Allergic contact dermatitis (ACD) is a delayed-type IV hypersensitivity reaction that follows re-exposure to an allergen. When an individual’s skin gets re-exposed to a substance such as urushiol, cosmetics, soap, foods, or medications, an inflammatory response initiated by cytokines and T-cells causes irritation, inflammation, among other symptoms within 48 hours post-exposure (Johnston et al., 2017). Patients are later more likely to present with an erythematous rash characteristic of swollen vesicles similar to the rash that you presented with.
- Use hot water to wash and clean all the towels, clothes, and bedding that you used during the hike to do away with irritants.
- Always wear protective/safety gears/clothing during outdoor activities.
- You can also use cool compresses on the affected areas of your skin to reduce itching and pain.
- Alternatively, embrace oatmeal baths as they help to decrease inflammation and act as protective skin barrier (Johnston et al., 2017).
- Recommend cervical cancer screening (every 3 years), monthly self-breast exams, and STIs screening.
- Discuss alcohol and drug abuse, depression and mental health, heathy nutrition and physical activity
Follow up
- If within 48-72 hours there is no improvement in symptoms, return immediately/visit the nearest health center
- Should you develop worsening symptoms such as fevers, breathing difficulty, vomiting, or worsening pruritus, seek emergency care (Johnston et al., 2017).
References
Brar, K. K. (2021). A review of contact dermatitis. Annals of Allergy, Asthma & Immunology, 126(1), 32-39. https://doi.org/10.1016/j.anai.2020.10.003
Corsico, A. G., Leonardi, S., Licari, A., Marseglia, G., Miraglia del Giudice, M., Peroni, D. G., & Ciprandi, G. (2019). Focus on the cetirizine use in clinical practice: a reappraisal 30 years later. Multidisciplinary Respiratory Medicine, 14, 1-7. https://doi.org/10.1186%2Fs40248-019-0203-6
Johnston, G. A., Exton, L. S., Mohd Mustapa, M. F., Slack, J. A., Coulson, I. H., English, J. S. C., … & Exton, L. S. (2017). British Association of Dermatologists’ guidelines for the management of contact dermatitis 2017. British Journal of Dermatology, 176(2), 317-329.
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