Episodic Visit: A Dermatology Focused Note

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Episodic Visit: A Dermatology Focused Note

Patient Information: Graphic 2

Patient Initials: __M. K ___ Age: ____13___ Gender: __Female_____

S.

CC “There are a lot of rashes all over my body. I also uncomfortably warm.” Episodic Visit: A Dermatology Focused Note.

HPI: M.K. is a 13-year-old African American female who presents to the clinic with her mother with multiple rashes on her skin. She explains that the rashes are concentrated in clusters around the waist line even though they are distributed in the entire body. The first lesion developed 3 days ago following a rapid increase in their volume in the consecutive days. The lesions are reddish, fluid filled and itchy and burst to form crusty appearance. The client’s mother notes that she has a headache and fever that has severed with the increase of lesions. She has also lost her appetite and appears fatigued all the time. The patient rates her pain at 5 on a scale of 1 to 10. However, the mother says that she has not had any medication to relieve the pain and the presenting symptoms.

 

Current Medications:

Calamine Lotion 8%. Topically applied frequently to alleviate itching and skin irritation on the affected areas.

Colloidal Oatmeal Baths two times daily to eliminate pain and itching

Allergies:  NKA

PMHx: Last chickenpox immunization at 6 years. Other vaccinations are up to date. Mother denies any major surgeries and acne.

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Soc Hx:  Patient is a grade 8 pupil living with both of her parents and siblings in their home in the rural area. She denies any drug abuse. Episodic Visit: A Dermatology Focused Note.Spends leisure time practicing in the church choir. Both parents work in their farm and are married for 15 years.

Fam Hx: Mother had acne at 18 years. Sister has completely treated chicken pox 10 days ago. No other member has had a skin disease in the past.

ROS:

GENERAL:  +loss of weight, chills and fever, tiredness and weakness since the onset.

HEENT:  +mouth ulcers and sore throat

SKIN:  + papules, pustules, crusts and vesicles; +itching skin; pruritic macules on the abdomen, scalp, extremities, face, back and chest.

CARDIOVASCULAR: Normal S1 and S2 are heard. -chest pain, palpitations or edema; -chest discomfort.

RESPIRATORY:  Normal breathing sounds; -sputum, cough or shortness of breath

GASTROINTESTINAL:  -organomegaly; -abdominal tenderness; symmetrical abdomen without distention; normal abdominal sounds heard

GENITOURINARY: + lesions and itching

NEUROLOGICAL: -headache and focal neurological deficits

MUSCULOSKELETAL: + fatigue, joint pain, stiffness and muscle pain.

HEMATOLOGIC: + fluid filled lesions and bruising; -bleeding

LYMPHATICS:  +Enlarged lymph nodes.

PSYCHIATRIC:  +Anxiety

ENDOCRINOLOGIC: + sweating, cold and heat intolerance.

ALLERGIES:  – asthma, hives, eczema. Episodic Visit: A Dermatology Focused Note.

O.

Physical exam: Vital signs: RR. 17, P 83, low grade fever of 102°F, B/P 110/75, Wt: 105 lbs; Ht: 5’1; BMI 19.7

Mental: discomfort due to fever and headache

Heart: pulses+2 bilat pedal and +2 radia

Skin: clustered rashes, lesions, papules, crust, vesicles

Genital: + reddish and itchy external genitalia, -genitalia tenderness

Diagnostic results:

  1. Antibody testing: rules out the presence of underlying infection shown by IgG and IgM antibodies
  2. Medical history and physical examination
  3. Microscopic examination:  observes for intranuclear inclusions secreted by varicella virus Ahmad et al. (2018).

A.

Differential Diagnoses

Chicken pox (ICD-10-CM B01.9): presented through itchy red rashes on the scalp, face, back, chest and the entire body. It is characterized by red, itchy rash that breaks out on the chest, back, scalp and face with fluid. Lesions burst to form clusters of rashes.

  1. Disseminated herpes simplex virus (ICD-10-CM B00.7): indicated by multiple lesions on skin regions or internal viscera. Symptoms are pustules erosions on the skin.
  2. Measles (ICD-10-CM B05.2): symptoms include cough, fever, running nose and sore throat (Shaw, 2019).

The most appropriate diagnosis is chickenpox since the patient’s symptoms largely relate to those of the illness.

P

Primary diagnostics of the client is chickenpox arrived at through physical examination of the lesions and antibody testing that revealed the presence of varicella virus. this was able to rule out the presence of disseminated herpes simplex and measles. The treatment plan entails application of 8% calamine lotion as often as need be to relieve itchiness. Non-pharmacological approach entailed the bathing twice daily in a Colloidal Oatmeal Bath (Go et al., 2017). Episodic Visit: A Dermatology Focused Note. The client will also drink plenty of fluids to remain hydrated. Headache and pain management will be attained via use of paracetamol. The client is advised not to scratch the itchy rashes to prevent the spread of the virus and secondary infections. No referrals were made. However, the client was to return to the clinic after two weeks for monitoring of the progress.

Reflection

Following the client’s symptoms, it is evident that suffer from chickenpox as diagnosed by the preceptor. As such, I agree with the preceptor’s interventions because they present the best evidence-based approaches towards the illness. This case taught me the importance of differential diagnosis in arriving at the correct diagnosis in situations of overlapping symptoms. Therefore, I wouldn’t do anything differently. It is important to note that health promotion involved family awareness of infections disorders such as chicken pox and the for isolation to prevent spread (Hizon & Zamora, 2019).

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References

Go, N. G., Choi, H. M., Lee, Y. H., Jung, J. H., & Ha, J. (2017). A Clinical Report on Chicken Pox Scars Treatment with Sae-ssack Therapy. The Journal of Korean Medicine Ophthalmology and Otolaryngology and Dermatology, 30(2), 146-154.

Hizon, C. F., & Zamora, G. M. (2019). Knowledge and practices of the residents in larion alto, Tuguegarao city towards chicken pox. International Journal of Advanced Research in Management and Social Sciences, 8(4), 393-401. Episodic Visit: A Dermatology Focused Note.

Shaw, G. (2019). The Measles Are Spreading… Again: What the Experts Advise on Vaccines for Patients with Neuroimmune Disorders. Neurology Today, 19(12), 1-42.

Wk 6, Assignment 2:

Episodic Visit: A Dermatology Focused Note

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will work with an adolescent patient and complete a Focused Note Template (see attached template) in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.

Assignment

Select an adolescent patient. With this patient in mind, address the following in a Focused Note.

  1. Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
  2. Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. Episodic Visit: A Dermatology Focused Note.
  3. Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
  4. Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  5. Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? Episodic Visit: A Dermatology Focused Note.