The I-Human Case Study – Week 2 focuses on a 25-year-old female patient, Daisie Blankenship, presenting with an itchy and tender rash on her upper thighs and left inner forearm. This case study requires a systematic approach to history-taking, diagnosis, and treatment. The following is a detailed SOAP note outlining the assessment and management of the patient’s condition.
I-Human Case Study – Week 2 Subjective
Chief Complaint (CC)
“I have this ugly-looking rash on my upper thighs.”
History of Present Illness (HPI)
Daisie Blankenship is a 25-year-old female presenting with an itchy and tender rash bilaterally on her inner thighs and left inner forearm. The rash began 36 hours ago after a hiking trip in Napa with her boyfriend. The patient reports exposure to various potential allergens, including a new sunscreen, new foods (scallops), a new drink, and time spent in a hot tub. She denies prior similar rashes or treatments for this episode. Her boyfriend does not have similar symptoms.
Past Medical History (PMHx):
- Denies chronic illnesses.
- No history of hospitalizations.
- Allergies: Ceclor (Cefaclor), causing hives as a child.
- Medications: Birth control pills.
Family History (FH):
- Maternal grandfather: Died of cardiovascular disease at age 81.
- Maternal grandmother: Alive, 88, history of heart attack, stent placement, and hypertension.
- Parents: Alive and well; father has hypertension.
- Siblings: Three siblings (35, 32, and 21 years old), all alive and well.
Social History (SHx):
- Occupation: English teacher for 7th and 8th grade.
- Relationship: Sexually active heterosexual female in a monogamous relationship.
- Tobacco: Denies smoking.
- Alcohol: Drinks socially.
- Drug use: Denies illicit drug use.
- Diet: Follows a typical American diet.
Gynecological History:
- Age of menarche: Unknown.
- Menstrual cycle: Regular.
- Last menstrual period (LMP): Unknown.
- Breast screening: Performs self-exams.
- Last Pap smear: 1 year ago, normal.
- Gravida/Para: Nulliparous.
Review of Systems (ROS):
- General: No fever, chills, or weight loss.
- Skin: Reports an itchy, tender rash; denies prior similar episodes.
- HEENT: No swelling, redness, rhinorrhea, vision changes, discharge, discomfort, or itching.
- Pulmonary: No shortness of breath, cough, wheezing, or difficulty breathing.
- Cardiovascular: No palpitations or chest discomfort.
- Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or heartburn.
- Genitourinary: No urinary urgency, frequency, burning, or hematuria.
- Musculoskeletal: No muscle weakness, joint pain, stiffness, or swelling.
- Hematologic: No bruising, bleeding gums, nosebleeds, or anemia.
Objective
Physical Examination:
- General: Well-appearing Caucasian female, alert and oriented ×4.
- Skin:
- Erythematous, pruritic maculopapular rash bilaterally on the inner thighs and left forearm.
- No pustules, vesicles, or signs of infection.
- No systemic signs of anaphylaxis.
- HEENT: Normal, no signs of allergic conjunctivitis or swelling.
- Cardiovascular: Normal heart sounds, no murmurs.
- Pulmonary: Clear breath sounds, no respiratory distress.
- Gastrointestinal: Soft, non-tender abdomen, normal bowel sounds.
- Musculoskeletal: No joint swelling or tenderness.
Assessment
Primary Diagnosis:
- Allergic Contact Dermatitis (ACD)
- Rationale: The rash appeared after hiking, with potential exposure to environmental allergens (new sunscreen, new food, and hot tub chemicals). The distribution of the rash suggests an external allergen rather than systemic pathology. The absence of respiratory symptoms or severe systemic involvement reduces the likelihood of anaphylaxis.
Differential Diagnoses:
- Irritant Contact Dermatitis (ICD) – Possible reaction to sunscreen or chemicals in the hot tub.
- Food Allergy – Less likely as there are no systemic symptoms such as urticaria or anaphylaxis.
- Hot Tub Folliculitis – Less likely due to lack of pustules or systemic symptoms.
Plan
1. Diagnostic Studies:
- Not required for an initial diagnosis of ACD.
- Consider patch testing if the rash recurs or persists beyond expected resolution.
2. Treatment Plan:
- Avoidance: Instruct the patient to discontinue the suspected triggers (sunscreen, hot tub use, or new foods).
- Topical Corticosteroids: Prescribe hydrocortisone 1% cream to reduce inflammation.
- Oral Antihistamines: Recommend cetirizine or diphenhydramine for pruritus relief.
- Skin Care: Advise the patient to keep the area clean and avoid scratching.
- Follow-up: Re-evaluate in 1 week if symptoms persist or worsen.
3. Patient Education:
- Educate on ACD causes and preventive measures.
- Advise discontinuing any suspected allergens and documenting any new exposures.
- Discuss signs of worsening symptoms that require immediate medical attention (e.g., swelling, difficulty breathing, spreading rash).
iHuman Case Study Week 2- Daisie Blankenship’s
Daisie Blankenship’s case of Allergic Contact Dermatitis demonstrates the importance of a thorough history and focused examination in diagnosing dermatological conditions. By identifying potential allergens and implementing appropriate management strategies, the patient can achieve symptom relief and prevent future reactions. Continued education and follow-up are crucial to ensure the best outcomes.
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