Kaylee Hales I-HUMAN CASE STUDY SOAP NOTE: EVALUATING AND MANAGING INTEGUMENTARY CONDITIONS

Kaylee Hales I-HUMAN CASE STUDY SOAP NOTE: EVALUATING AND MANAGING INTEGUMENTARY CONDITIONS

PATIENT INFORMATION

• Name: Kaylee Hales
• Age: 25 years
• Gender Identity: Female
• Sources: Patient
• Allergies: NKA
• Current Medication: Contraceptive Pills
• PMA: N/A
• IMMUNIZATION: Up to Date
• PREVENTIVE CARE: N/A
• Surgical HISTORY: None
• FAMILY HISTORY: Single with one boyfriend; both parents healthy and alive.
• SOCIAL HISTORY: In a relationship, occasional alcohol consumption, denies smoking.
• SEXUAL ORIENTATION: Straight, sexually active
• NUTRITION HISTORY: Balanced Diet

SUBJECTIVE DATA:

• Chief Complaint: Itchy, tender rash at the inner thigh and inner forearm.
• Symptoms analysis/HPI: Kaylee Hales, a 25-year-old woman, presented with an extremely itchy, erythematous rash over her inner thighs and left forearm persisting for two days. Recent exposures include hot tub use, new lotion, and trying scallops for the first time. She also went on a nature hike.
• CONSTITUTIONAL: Denied weight gain or loss.
• NEUROLOGIC: No memory loss, seizures, or tremors.
• HEENT: No headache, vision problems, or hearing loss. No sore throat or difficulty swallowing.
• RESPIRATORY: Denied wheezing or cough.
• CARDIOVASCULAR: Denied palpitation, edema, chest pain, and difficulty breathing.
• GASTROINTESTINAL: Denied constipation and diarrhea.
• GENITOURINARY: Denied polyuria and dysuria.
• MUSCULOSKELETAL: Denied joint swelling, myalgia, and back pain.
• SKIN: Presents with a rash at inner thigh and inner forearm.

OBJECTIVE DATA:

• VITAL SIGNS: BP 116/62, HR 70, Temp. 98.3, Spo2 95% room air, RR 20.
• GENERAL APPEARANCE: Healthy, neatly dressed, and alert.

MAIN DIAGNOSIS:

Contact Dermatitis (ICD-10 Code- 9)

Skin inflammation known as contact dermatitis, caused by exposure to allergens or irritants, presents with pruritus, erythematous rash, vesicles, and burning sensation. Considering the patient’s recent activities, contact with hazardous plants during hiking may have caused poison ivy dermatitis. The main diagnosis is contact dermatitis.

DIFFERENTIAL DIAGNOSES:

1. Folliculitis:
   • Infection of hair follicles causing pustules on an erythematous base.
   • Unlikely as the rash is not body-wide and consistent with hot tub folliculitis.
2. Urticaria:
   • Sudden, widespread eruption of wheals with itching.
   • Possible, but vesicles and erythematous base differ from typical urticaria.
3. Pruritus:
   • Characterized by itching with or without a rash.
   • Inadequate as the patient presents with vesicles and pinpointed causes.

PLAN:

• Advise avoiding identified allergens.
• Prescribe topical corticosteroids for symptomatic relief.
• Educate on preventive measures.
• Follow up to monitor improvement.

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