Case Study For Patient With Cluster Of Rashes With Blisters

Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

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Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this weekâ€™s Learning Resources.

*As far as the SOAP notes, you do not have enough information. I advise them to make up the information that is not there (ie. Health Hx, social Hx, etc). This will allow you to critically think as you develop the notes. * Case Study For Patient With Cluster Of Rashes With Blisters

Skin Condition 4 seems like it is cellulitis.

Differential Diagnosis for Skin Condition

Focused soap note:

Picture 5#

Patient information

Patient initials: K.M Age: 59 Gender: Male Race: Caucasian

Subjective

CC: “Rash with some blisters and scab on my back and chest.”

HPI: K.M, a 59-year-old Caucasian male, presented to the clinic unaccompanied with a chief complaint new cluster of rashes with blisters on his anterior right flank and posterior chest. He reported that these symptoms began 7 days ago but four days before then, the affected area were itchy and he could feel some pain which he rated 8/10. He also reported significant pain in his right ear, a minor headache, fatigue, and a burning feeling that intensified when exposed to light. The patient reported that the discomfort is sometimes so intense that he cannot sleep. He reported taking over-the-counter pain relievers, particularly ibuprofen 200mg, but this had little benefit. Denies experiencing nausea, vomiting, or diarrhea. Case Study For Patient With Cluster Of Rashes With Blisters

Current Medication: Ibuprofen 200mg 2tabs PO TID for pain and Flomax 0.4 mg PO qDay, 30 minutes after meal for BPH.

Allergies: NKDFA

Immunization: up-to-date. He received his last influenza vaccine 23/7/22, Tdap 12/5/2018. Moderna Covid-19 Vaccine 23/4/2021.

PMH: Benign prostatic hyperplasia (BPH), well managed. Chicken pox at 12 years old. Case Study For Patient With Cluster Of Rashes With Blisters

PSHx: TURP in 2021.

Family history: no significant family history reported.

Sexual Hx: Heterosexual.

Social history: The patient is a retired teacher at a neighboring college. He has never smoked or consumed alcohol. He is married with 5 children. Do not exercise. Reported consuming healthy diet rich in fruits and vegetables.

ROS

General: reported fever, headache and general fatigue. Denies any significant changes in weight

HEENT: Reported intense pain in the right ear. Denies vision or hearing problem.

Cardiovascular: denies chest pain, and palpitation

Respiratory: Denies SOB, cough and history of pneumonia.

GI: Denies nausea and vomiting.

GU: Denies dysuria or polyuria. No history of STDs reported

Psych: denies anxiety and depression. No suicidal ideation reported.

Msk: Denies joint or muscle pain.

Neurologic: Denies dizziness and gait disturbances.

Skin: reported a cluster of painful rashes with blisters on the anterior and posterior part of the chest. Denies changes in skin color Case Study For Patient With Cluster Of Rashes With Blisters

Endocrine: Denies issue with heat or cold intolerances.

Vts.: T.37.1 oc. BP 124/80. P 84. R 20 Wt.: 56 Height: 5’4

General: A&Ox3, well-groomed, no acute distress noted.

HEENT; normocephalic and atraumatic., PERRLA, and EOMI

Cardiovascular: RRR, S1, S2 intensity are of normal, no murmur, nor gallops noted

Lungs: chest is symmetrical. Lung sounds equal and clear on auscultation.

MSK: muscle strength 5/5 bilaterally. No history of trauma or fractures.

Skin: Appropriate color to ethnicity. Cluster with fluid-filled blister noted on the posterior chest and back.

Abdomen: Soft and non-tender. Bowel sounds are normoactive.

Neuro: Memory and thought process intact. No abnormal sensory and stable gait noted.

Genital: normal rectal sphincter tone. Guac is negative.

Psychiatric: Appropriate mood and affect. Insight and judgement are good. Case Study For Patient With Cluster Of Rashes With Blisters

Lab test and result

CBC: WBC 7,000, RBC 4.8 mcL

Polymerase chain reaction (PCR): result pending

ELISA: positive IgM

Covid PCR-neg

Differential diagnoses

Shingles

This is a viral infection that affects a single sensory nerve ganglion and the skin regions it supplies. Shingles is characterized by discomfort, which is accompanied by a rash which evolves onto blisters that dries out to form scabs (Fritz et al.,2020)Case Study For Patient With Cluster Of Rashes With Blisters. As demonstrated in the case presentation, it is also defined by headache, discomfort in the affected area, fever, and general fatigue. Furthermore, this illness affects specific parts of the body and does not cross the midline, making it a likely diagnosis.

Eczema

This is a skin infection that produces dryness, redness, itching, and bumpiness. Muscle tension, constipation, difficulty focusing, continual concern, pains, and dizziness are among symptoms of eczema (Szari et al.,2019).

Contact Dermatitis

This is an inflammatory skin illness induced by chemicals or metal ions that are noxious without triggering a T-cell response. It is distinguished by an itchy rash, rough skin, and blisters (Aquino et al.,2019). It also shows signs of hyperpigmented skin, which were not seen in the case presentation.

Primary diagnoses: Shingles

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.] Case Study For Patient With Cluster Of Rashes With Blisters

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References

Aquino, M., & Rosner, G. (2019). Systemic contact dermatitis. Clinical reviews in allergy & immunology, 56(1), 9-18. https://link.springer.com/article/10.1007/s12016-018-8686-z

Fritz, D. J., Curtis, M. P., & Kratzer, A. (2020). Shingles. Home Healthcare Now, 38(5), 282-283. https://journals.lww.com/homehealthcarenurseonline/Citation/2020/09000/Shingles.13.aspx

Szari, S., & Quinn, J. A. (2019). Supporting a healthy microbiome for the primary prevention of eczema. Clinical Reviews in Allergy & Immunology, 57(2), 286-293. https://link.springer.com/article/10.1007/s12016-019-08758-5 Case Study For Patient With Cluster Of Rashes With Blisters