IHUMAN Case Study 5 Krista Hampton-Grades A+-2022-2023

Case: Krista Hampton IHUMAN Case Study #5 Krista Hampton NURS 5308 Instructions: Type patient encounter information directly into each box of the template similarly to your case studies.

CC: 25 y/o F

HPI: Ms. Hampton is a 25 y/o female presenting with an itchy and tender

“I have this ugly looking rash on my upper thighs”

rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend.

She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash.

PMHx: Child: “usual coughs and tummy ache nothing remarkable.”

Adult Illness: Denies

SurgHx Medical: None Surgical: None Obstetric: None Hospitalizations: None

FamHx

SHx

Maternal grandfather died of CVD at age 81.

Grandmother (age 88) has prior heart attack, stent and HTN. Mother alive and well.

Father alive and well, treated for HTN. Brothers - 35 and 32 both alive and well.

Sister - 21 alive and well.

Tobacco: Denies ETOH: Socially Illicit Drugs: Denies Occupation: English teacher for 7th and 8th grade

Relationship: Sexually active heterosexual female in a monogamous relationship Diet: Normal American Diet Reproductive Hx

Allergies

Age of menarche: “doesn’t remember.”

Ceclor (Cefaclor) second generation cephalosporin – Patient developed hives

Menstruation cycle duration: “seems fine to me,”

as child when taking this antibiotic for otitis media

regular periods Sexual hx and concerns: Denies concerns

List of Current Medications/supplements: Birth control

LMP: unknown

pill Supplements: None

Breast screening: Conducts self-breast exams Last Pap Smear: 1 year ago, with no signs of abnormalities Gravida para status/Childbirth hx: Nulliparous

Review of Systems: (ROS) Use this column

From the ROS: list/highlight the current symptoms/complaints to

to document the ROS below.

generate a list of pertinent “reported or denied” symptoms

General: Denies unintentional weight loss or gain,

below:

chills, fever, and night sweats Eyes: Denies any vision changes, discharge, discomfort, dryness, or itching ENT: Denies any swelling, redness, rhinorrhea, or pain Pulmonary: Denies SOB at night or at rest or when lying down, denies cough, wheezing or difficulty catching breath CV: Denies palpitations denies heavy feeling or

sensation of a “pounding heart GI: Denies NVD, constipation, or heartburn.

States normal bowel movements GU: Denies pain, burning, blood in urine, denies difficulty starting or stopping urinating, dribbling, incontinence, urgency during night or day, or any changes in the frequency of urination MS: Denies muscle weakness, joint pain, stiffness, or swelling Heme: Denies bruising, bleeding gums, nose bleeds, abnormal bleeding, or history of anemia Endocrine: Denies heat and cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite Derm: Patient states” Ugly looking rash on my upper thighs, now it’s on my left inner forearm too”, rash is “itchy and getting more tender”

wDneloramde:d Pbya: tTioepnmtossttSactheosl”ar U| nggulyra8lo9@okgminagil.croamsh

on my upper thighs, now it’s on my

left inner forearm too”, rash is “itchy and getting more tender”

Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness Psych: Denies anxiety, depression, loss of energy or changes in interests

Physical Exam: (PE) Use this column

From the PE: list/highlight the presence or absence of objective findings

to document the PE below.

to generate a list of pertinent “(+) or (-)” symptoms below:

Vitals: Height: 5' 5" (165.0 cm) Weight: 120 lb (55.0 kg) (BMI 20.0) Temperature: 98.6 F (oral) Pulse: 76 bpm - regular Blood pressure: 116/62 mmHg - supine/sitting

D

l

Case: Krista Hampton

Blood pressure: 106/60 mmHg - upon standing Respiratory rate: 12 bpm SpO2: 94% on room air

General: Thin, pleasant, cooperative female, alert and oriented x4 Skin: Skin on head, neck, back, chest, abdomen, Skin: Skin on head, neck, back, chest, abdomen, right arm: warm, dry, right arm: warm, dry, intact, no redness, itching intact, no redness, itching or swelling. Left inner forearm is noted with or swelling. Left inner forearm is noted with itchy erythematous papules in linear configuration with vesicles. Bilateral itchy erythematous papules in linear inner thighs noted with raised confluent erythematous papules 10x12cm configuration with vesicles. Bilateral inner with vesicles in various stages thighs noted with raised confluent erythematous papules with vesicles in various stages Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge.

No orbital edema, redness, tenderness ENT: Deferred D

l

Case: Krista Hampton Neck: Deferred Pulm: Respirations even and unlabored bilaterally, good chest wall expansion, lung sounds clear to auscultation bilaterally both anterior and posterior CV: Heart rate and rhythm normal, no significant change while standing, squatting and during Valsalva maneuver, no JVD. 2+ peripheral pulses x4 extremities, PMI in the 5th intercostal (ICS) at the midclavicular line (MCL) GI: Lean, non-distended, no scars noted, bowel sounds audible in all 4 quadrants, no hepatosplenomegaly, mass or herniation

GU: Deferred Neuro: Deferred MSK: Deferred Psych: Deferred Lab/Radiology or other Diagnostic data

Problem Statement: Ms. Hampton is a 25 y/o female presenting with an

reviewed today during virtual visit

itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her

No tests ordered or recommended at this

boyfriend. She states she spent time hiking, tried a new sunscreen, tried new

time. History and physical assessment only.

foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash. Upon examination, the left inner forearm is noted with itchy erythematous papules in a linear configuration with vesicles. The bilateral inner thighs were noted with raised confluent erythematous papules 10x12 cm with vesicles in various stages.

List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding – total of

1. MNM/Leading/Concluding: Allergic Contact Dermatitis L23.9 2. MNM: Cellulitis L03. 90

3 3. MNM: Herpes Zoster (Shingles) B02.9 *Include ICD 10 codes after each Plan Treatment: •

Steroid creams or ointments. These

Case: Krista Hampton

topically applied creams or ointments help soothe the rash of contact dermatitis.

A topical steroid may be applied one or two times a day for two to four weeks.

•

Oral medications. In severe cases, your doctor may prescribe oral corticosteroids to reduce inflammation, antihistamines to relieve itching or antibiotics to fight a bacterial infection.

Mild cases: •

Domeboro to dry the vesicles and minimize spreading

•

Clobetasol propionate

cream Severe cases: •

Prednisone (20mg tabs) 3 tabs QDx3 days; D

Case: Krista Hampton 2 tabs QD x 3 days; 1 tab 3-5 days •

Domeboro to dry the vesicles and minimize spreading

•

Clobetasol propionate cream

•

Acute severe allergic contact dermatitis, such as from poison ivy, often needs to be treated with a 2-week course of systemic corticosteroids.

•

Most adults require an initial dose of 40- 60 mg.

•

The oral corticosteroid is tapered over a 2- week period, but a complicated tapering regimen probably is not necessary given the short duration of systemic corticosteroid use.

•

The systemic corticosteroids must be administered for 2 weeks, because shorter courses are notorious for allowing poison ivy dermatitis to relapse.

•

Long-acting intramuscular triamcinolone acetonide (Kenalog) 40-60 mg may be used in place of oral prednisone.

To help reduce itching and soothe inflamed skin,

try these self-care approaches and education:

•

Avoid the irritant or allergen.

•

The key to this is identifying what's causing your rash and staying away from it.

•

Your doctor may give you a list of products that typically contain the substance that affects you.

•

Also ask for a list of products that are free of the substance that affects you.

Case: Krista Hampton

•

Apply an anti-itch cream or lotion to the affected area.

•

A nonprescription cream containing at least 1 percent hydrocortisone can temporarily relieve your itch.

•

A steroid ointment may be applied one or two times a day for two to four weeks.

•

Or try calamine lotion.

•

Take an oral anti-itch drug.

•

A nonprescription oral corticosteroid or antihistamine, such as diphenhydramine (Benadryl), may be helpful if your itching is severe.

•

Apply cool, wet compresses.

D

Case: Krista Hampton •

Moisten soft washcloths and hold them against the rash to soothe your skin for 15 to 30 minutes.

•

Repeat several times a day.

•

Avoid scratching.

•

Trim your nails.

•

If you can't keep from scratching an itchy area, cover it with a dressing.

•

Topical soaks with cool tap water.

•

Burrow solution (1:40 dilution), saline (1

tsp/pint) can be soothing.

•

Cool compresses with saline or aluminum acetate solution are helpful for acute vesicular dermatitis (eg, poison ivy).

Some

individuals

with

widespread

vesicular dermatitis may obtain relief from lukewarm oatmeal baths.

•

Soak in a comfortably cool bath.

•

Sprinkle the water with baking soda or an oatmeal-based bath product.

Protect your hands.

•

Rinse and dry hands well and gently after washing.

•

Use moisturizers throughout the day.

Case: Krista Hampton •

And choose gloves based on what you're protecting your hands from. For example, plastic gloves lined with cotton are good if your hands are often wet

Consultation and/or referral: N/A Follow up: If symptoms do not improve or worsen after treatment

IHUMAN TOTAL CASE SCORES: #1: 100

Based on patient’s age/risk factors, what preventive screening would be recommended at today’s or a future visit: STI screening Flu vaccine if necessary Well woman’s exam with pap smear every 3 years per guidelines

Reflective Thinking Exercises Instructions: Review the Case summary of your IHUMAN case, noting strengths and areas of needed improvement. Answer the following questions below in brief essay format. Essay should be no longer than 1-1.5 pages in APA format in length. Points will be assigned as to the quality/depth of the student’s reflection.

1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went well?

Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis.

The history portion of this case was very straightforward and short. The number of questions required by the expert were not that many in number and were easily discovered by using OLDCARTS. While going through the ROS the patient had denied

Case: Krista Hampton

all the symptoms, but they were not considered “Good Questions” according to iHuman. That concept threw me off because I always go through the ROS in order to rule out any other accompanying symptoms/and systems.

2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent exam items identified in the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis.

The physical exam the expert was looking for was a very focused exam with focus on the eyes and skin. I did a more extensive exam, examining the heart, lungs, and abdomen, as well as the lymphatic system looking for any other inflammation or allergic reaction. The patient had a rash that was on her thighs bilaterally, I thought it was appropriate to check the GU system, at least externally to make sure there was no spreading to the vaginal/labia area. In the future, I will focus on the specific complaint the patient comes in for. I am still leaning towards being more thorough than missing something yet staying within a short time frame.

3. Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be your

Case: Krista Hampton course readings/IHUMAN lessons/other course info as well as any external articles or supporting literature to help you gain a better understanding of categorizing possibleDdowianglonadoesdebsyi: nToypomuosrtSccahsoela.r H| noguwra8d9i@d gymoauil.caormrive at the potential diagnoses?

Case: Krista Hampton Referring to websites such as WebMD, Mayo Clinic, Medline, and UpToDate I was able to rule in and rule out diagnosis based on presentation and patient symptoms.

4. What specific feedback from previous case studies has your faculty identified that you plan to incorporate on future cases to avoid pitfalls in data gathering or decision making? What will you do differently to improve? *Make sure any references are also listed on a separate page in your references.

I am still working on conducting a focused exam versus being nervous to miss anything. My skills on developing a differential diagnosis are slowly improving. The suggested system was only integumentary in this case. I was confused because I thought the immune system is involved causing an allergic reaction in the body. It is still a challenge for me to select the appropriate diagnostic tests for each individual diagnosis. With time and practice I am learning and developing a system.

References

Cellulitis | Cellulitis treatment | MedlinePlus. (n.d.). MedlinePlus - Health Information from the National Library of Medicine. https://medlineplus.gov/cellulitis.html Contact dermatitis - Symptoms and causes. (2020, June 19). Mayo Clinic. https://www.mayoclinic.org/diseases-

conditions/contact-dermatitis/symptoms-causes/syc-20352742

Contact dermatitis. (2007, January 1). WebMD. https://www.webmd.com/skin-problems-and-treatments/contactdermatitis

Shingles. (2016, October 12). WebMD. https://www.webmd.com/skin-problems-and-treatments/shingles/shingles-skin

Shingles. (n.d.). WebMD. https://www.webmd.com/skin-problems-and-treatments/shingles/default.htm

UpToDate. (n.d.). https://www.uptodate.com/contents/cellulitis-and-skin-abscess-in-adults-treatment