Case 2: Chief Complaint - 45-Year-Old Female Presents With A

Case 2chief Complaintcca 45 Year Old Female Presents With A Complain

Chief Complaint (CC) A 45-year-old female presents with a complaint of an itchy red rash on her arms and legs for about two weeks. She reports that the rash is pruritic, and she has noticed increasing discomfort over the past few days. She has been attending a local YMCA with children for summer camp daily, which has increased her exposure to potential environmental allergens or infectious agents. The patient has no prior history of skin conditions or allergic reactions. She denies fever, chills, or systemic symptoms such as malaise or weight loss.

Subjectively, the patient reports that her rash appeared approximately two weeks ago and has gradually worsened. She mentions that the rash is intensely itchy, causing significant discomfort, especially during the night, which affects her sleep. She also reports occasional scratching, which has led to secondary skin excoriations. She does not recall any recent new medications, soaps, or detergents and denies any recent travel or exposure to new animals. There is no history of similar episodes in the past. Her medical history is otherwise unremarkable, and she takes no regular medications. She reports no known allergies but mentions occasional seasonal allergic rhinitis.

On physical examination, vital signs are within normal limits: temperature 98.3°F, respiratory rate 18 breaths per minute, heart rate 70 beats per minute, blood pressure 118/74 mmHg. The patient appears healthy and alert, in no acute distress. General examination is unremarkable. Examination of the head, ears, eyes, nose, and throat (HEENT) reveals no abnormalities. The ears show no signs of infection; the eyes have no injection, no conjunctival injection or increased lacrimation, and no purulent discharge.

Skin examination reveals a maculopapular rash characterized by erythematous, flat, and raised lesions distributed primarily on the forearms, upper arms, chest wall, thighs, and knees. The lesions are accompanied by secondary linear excoriations resulting from scratching. The rash is pruritic, with evidence of inflammation, including mild edema and erythema. No pustules or vesicles are observed. The surrounding skin appears normal without signs of ulceration or secondary infection. Examination of the neck and throat shows mild edema and inflammation but no lymphadenopathy. There are no signs of systemic illness, such as fever, lymphadenopathy, or hepatosplenomegaly.

Assessment of this patient's presentation points towards a dermatological condition characterized by an itchy, erythematous, maculopapular exanthem with secondary excoriations, likely precipitated by environmental exposure or an allergic response. The absence of systemic symptoms suggests a localized dermatological process rather than an infectious etiology. Differential diagnoses include atopic dermatitis, allergic contact dermatitis, insect bites, and other hypersensitivity reactions. Consideration should also be given to potential irritant dermatitis or infectious causes like scabies, although the distribution and appearance support an allergic or irritant origin.

In cases like this, allergic contact dermatitis is a common cause, particularly considering the recent increase in outdoor activity and exposure to potential allergens at the YMCA environment, such as plants, chemicals, or insects. Contact dermatitis often presents with pruritus, erythema, and secondary excoriations, matching this patient's presentation. Further assessment should include detailed history on recent exposures and potential allergens, with possible patch testing to identify specific contact allergens.

Management involves allergen avoidance, symptomatic relief with topical corticosteroids to reduce inflammation and pruritus, and antihistamines to control itching. Patient education about skin care, such as avoiding scratching and using emollients, is essential to promote healing and prevent secondary infection. If the rash persists or worsens, or if signs of secondary infection develop, additional interventions including antibiotics or further allergy testing may be warranted.

This case underscores the importance of thorough history-taking and physical examination in diagnosing dermatologic conditions. Environmental exposures, especially in settings like summer camps, can precipitate allergic reactions requiring targeted management. Recognizing the common features of contact dermatitis allows for prompt treatment and symptom relief, improving patient quality of life.

References

• Fitzpatrick's Dermatology in General Medicine. (2018). Wolff K., Goldsmith L.A., Katz S.I., et al. (Eds.). McGraw-Hill Education.
• Rietschel R.L., Farmer E. R. (2018). Fisher's Contact Dermatitis. CRC Press.
• Verma, S., & Taylor, S. (2017). Environmental and Occupational Dermatitis. Journal of Clinical & Aesthetic Dermatology, 10(11), 22-27.
• International Contact Dermatitis Research Group. (2020). Guidelines for Contact Dermatitis Management. Skin Pharmacology and Physiology, 33(3), 125-133.