Primary Care of the Family
Type: SOAP NOTE
Subject: Primary Care Nurse Practitioner
Subject area: Nursing
Education Level: Masters
Length: 2 pages
Referencing style: APA
Preferred English: US English
Spacing Option: Double
Title: Dermatology case study
Instructions: here is the information on case kaylee hales is a 25 year old female who presents to the clinic complaining of a new rash. patient just returned from a trip and was exposed to plants while hiking, tan lotion from boyfriend, a hot tub and ate scallops for first time. it started 24 hours ago after returning from her trip, and rash persists after that. the rash is located on her tights and left inner arm. the rash is itchy, tender, swollen, "nasty looking" according to patient. patient had a simular rash in childhood. she have not attempted to treat. she does not take any daily medication vitals-temp 98.6, bp 116/62, rr 12, ht 5'10", wt 1230 lbs physical examination shows a 6 cm set of linear, circumscribed, erythematous blisters on the left inner forearm and a 10x12 cm scattered contiguous erythematous papular rash with surrounding superficial excoriations on the inner tight
Focus: please refer to case under instructions, use the attached paper for this assignment. on the attached paper i just need help finishing it. please follow the instructions in red font. the work that is already there, i've completed, please use that and just add where the instructions are asking to. i won't have time to finish, and need help. please use references within the last 5 years, reliable such as journals, peer reviewed , or guidelines. please let me know if any questions
Kaylee- Hales I-Human Case Study
Jaqueline DaS
Online Department of Nursing, Regis College
NU664: Primary Care of the Family I
Dr. Robinson
11/14/2022
Assessment
Differentials
- Contact Dermatitis (No need to edit or add anything here)
When an allergy or irritant comes into direct touch with the skin, it can induce inflammation. However, while this inflammation may be irritating and painful, it poses no serious health risks and is not communicable. Rashes, itching, swelling, burning, and discomfort are all symptoms seen in a clinical setting (Dunphy et al., 2019).This diagnosis should be considered for this patient because she presents with 2 days of pruritic, erythematous popular rash on the inner tight and left inner forearm. She had recent exposures such as ingesting scallops for the first time in her life, hiking in the woods, new lotion, and hot tube use, which are all possible triggers of irritation or allergy when in contact to the skin. Furthermore, while examining the patient was noted a 6cm set of linear, circumscribes, erythematous blister on the left inner forearm and a 10x 12 cm scattered contiguous erythematous popular rash with surrounding superficial excoriations on the inner tights, which supports the diagnosis of contact dermatitis.
Also Read: Best Nursing Soap Notes Writing Service
- Folliculitis (PLEASE DO THE SAME AS ABOVE FOR EACH DIFFERENTIAL (3 MORE- FOLLICUTIS, URTICARIA, AND HERPES ZOSTER), CHRACTERICTS OF THE DIAGNOSES, CLINICAL MANIFESTATIO, WHY SHOULD I CONSIDER THIS AS A HYPOTHESIS WHEN RELATING TO CASE, PATIENT PRESENTATION, WHY THIS WAS RULED OUT)
- Urticaria
- Herpes Zoster
Final Diagnosis: Contact Dermatitis
Plan
Pharmacology (No need to edit or add anything to this part)
- Clobetasol propionate 0.05% cream twice a day in affected area until clear (Dunphy et al., 2019)
- Cetirizine 10 mg tab PO daily as needed for itching (Dunphy et al., 2019)
Non-Pharmacology (What else can I add here?)
-
Apply cool, wet compresses to affected areas (Hollier, 2021)
-
Apply topical calamine lotion or aluminum acetate to affected areas (Hollier, 2021)
-
Take oatmeal baths (Hollier, 2021)
Diagnostics (no need to edit or add anything here)
No needed at this time
Consults / Referrals (No need to edit or add anything here)
-
Allergist- a patch test is useful if trigger is not found by inspection, diary, or diligent observation (Dunphy et al., 2021).
-
May consider dermatology referral in the future if rash recurs and patient is not responding to therapy (Dunphy et al., 2021)
Patient Education
PLEASE ADD PATIENT EDUCATION AS YOU ARE TELLING THE PATIENT, SHOULD INCLUDE AT LEAST 11 BULLETS (TEACH ABOUT DIAGNOSIS, TREATMENT, MEDICATION SIDE EFFECTS, WHAT TO AVOID, SUPPORTIVE CARE, COMPLICATIONS, WHEN TO SEEK ADDITIONAL HELP/ OR ANY OTHER ADVICE)
PLEASE USE RELIABLE RESOUCES SUCH AS JOURNALS, GUIDELINES WITHIN THE LAST 5 YEARS
Follow Up (No need to add or edit anything here)
- If symptoms do not improve within 48-72 hours, contact the clinic (Hollier, 2021)
- We talked about warning signs to call the clinic or go to the ER right away, such as difficulty breathing, increased swelling, vomiting, fever, purulent skin discharge, or other concerning symptoms (Hollier, 2021)
References
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: Art and Science of Advanced Practice Nursing. F. A. Davis Company.
Hollier, A. (2021). Clinical guidelines in primary care. Advanced Practice Education Associates.
.
