Subjective SCC Chief Complaint: This Rash Is Getting 619718

Subjective Scc Chief Complaint This Rash Is Getting Worse Even

Subjective (S): CC: chief complaint – “This rash is getting worse, even with the creams you gave me”. HPI: history of present illness – Patient is an 11-year-old black female who presents with complaint of worsening rash on bilateral arms and increased itching and flakiness on her scalp. PMH: past medical history – She has a past medical history of mild eczema with no prior treatment needed before this fall. There is no reported history of asthma. Allergies: None. Medications: Hydrocortisone topical cream 2.5% to be applied twice daily to affected area.

Social history: She lives at home with her mother, father, and younger brother. She is currently attending online schooling due to the pandemic. She has two cats as well in the home. Family history: Mother reports that the patient’s younger brother also suffers from eczema and asthma, both are controlled. She reports they have never had to treat her brother’s eczema and he uses a rescue inhaler for his asthma.

Health Maintenance/Promotion – A screening of blood pressure is necessary yearly and was normal for this visit. She received her influenza vaccine in October 2020. The family has declined the HPV vaccine while they review education materials. She is up to date on all other vaccinations. Depression screening was performed at her last physical in October and she scored a zero.

She last saw her dentist about six months ago and goes twice a year. She does not receive regular vision exams and does not report any vision concerns. She denies any concerns of interpersonal violence or safety concerns in the home (this was asked while the mother was outside of the exam room). ROS: review of systems – General: She reports having a rash on her arms for the last month that is worsening. She reports trying “the cream that was prescribed” with little to no improvement.

She also states that her scalp is itchy and flaking over the last month. Her mother reports she has always had a flaky scalp in the colder months, but the itching is new. Skin: She denies any new skin lesions, growths and hair or nail changes. She reports that the “rash” that she has in the inside of her upper arm and some new “flaking” on her scalp. She denies noticing any skin changes to the skin on her neck.

HEENT : She denies any vision changes. She denies any headaches. She denies eye pain, ringing in ears, vertigo, dizziness, nosebleeds, or balance concerns. She denies any ear pain, tinnitus, or drainage from ears. She reports that she always has dry scalp but now she is having increased flaking and itchiness on her head.

Neck: She denies any swollen glands or throat, difficulty swallowing or changes with range of motion in neck. CV: She denies any palpitations, chest pain or feeling any abnormal heart beats. Lungs: She denies any shortness of breath, congestion, or hemoptysis nor wheezing. She denies any coughing at night or coughing that awakens her at night. Endo: She denies any heat or cold intolerances noticed.

She and her mother deny any polyuria, polydipsia, or polyphagia. She denies any history of any autoimmune disorders. Diet: She reports that she eats almost anything. She does drink “flavored water”, but it is zero calorie sweetener such as sucralose, according to her mother. She reports drinking about 10 glasses of water a day.

She loves chips and eats a lot of “fast food”. McDonald’s is her favorite. Pain: She reports that the area of her arms is very itchy, they are also painful most of the time. She reports the pain as a 7/10 and a burning feeling along with the severe itching. She reports that nothing makes the pain better and the only things that feel better are when she itches. She reports that right after she itches then it starts to burn worse and itch more. She reports this itching and burning starting “sometime in October”. She reports that nothing makes it better. She reports that scratching makes it worse, it burns more. She says that putting on the cream makes it hurt worse (burn).

Objective (O): Gen: Patient appears calm, focused, and a little tired. She is dressed appropriately for the environment and responds appropriately to questions. She is alert and oriented to person, place, and time. She is well nourished and in no acute distress. VS: Weight 97 lbs. Height 4 ft. 7 in. BMI 22.5 Temperature 100.7 Heart rate 92 Respiratory rate 16 Blood pressure 101/68 Pulse Oximeter 100% Skin: Signs of excoriations on bilateral antecubital region. Scaling on bilateral antecubital regions with erythema about 3 inches in diameter. Arms appear xerotic bilaterally. Medium brown skin with no signs of cyanosis or pallor. Nails intact, long, no clubbing. Neck: Acanthosis nigricans circumferentially. HEENT: No erythema or edema in the nose. Nasal turbinates pink and without edema. Symmetric external nose. Septum midline, no deviation or perforation. Mouth normal, tonsils 2+, no edema or exudate. Uvula midline. No oral lesions. No sinus tenderness. Tongue symmetric, no lesions. Conjunctiva clear, sclera normal. Ears normal with no effusions or ear canal abnormalities. No palpable lymph nodes. Neck: No palpable lymph nodes, no edema, no tenderness. Full ROM. Cardiac: Normal S1 and S2, no murmurs. Lungs: Clear bilaterally, normal expansion. Psych: Happy, talkative, good eye contact, appropriate responses.

Paper For Above instruction

This case involves a young girl presenting with a worsening rash on her arms and increasing scalp flaking and itching. The clinical impression and management plan include diagnosing atopic dermatitis (eczema), evaluating for secondary infection, and addressing potential contributing factors, including environmental and allergic components.

The primary diagnosis in this case is atopic dermatitis, also known as eczema. The patient’s history of a chronic, relapsing itchy rash with exacerbations during colder months, along with her personal history of mild eczema, strongly supports this diagnosis (Leung & Bieber, 2020). The physical findings of xerotic, erythematous, and excoriated skin on her arms further reinforce this diagnosis. The scalp flaking and itching, especially with no similar recent changes in other skin areas, are characteristic of seborrheic dermatitis, which frequently coexists with eczema (Kraft & Bowen, 2019). Her history of eczema in her brother and house pets suggest environmental and genetic factors contributing to her skin condition (Mogulkoc et al., 2017).

Secondary bacterial infection is a concern given the presence of excoriations and intense itching, which compromise the skin barrier and predispose to bacterial colonization. Signs such as crusting, increased erythema, or pustules would suggest infection, but no such signs are evident in this case. Still, empirical antibacterial treatment or a topical antibiotic may be warranted if clinical suspicion increases (Heng et al., 2018).

Management of atopic dermatitis focuses on skin hydration, barrier repair, and reducing inflammation. Regular use of emollients, such as ceramide-containing moisturizers, is essential to restore the skin barrier and prevent flare-ups (Liu et al., 2020). The patient is currently using hydrocortisone 2.5%, which can be continued or adjusted depending on response. Given her persistent symptoms despite initial treatment, a topical calcineurin inhibitor (e.g., tacrolimus) could be considered to minimize steroid use (Schmidt et al., 2019).

Addressing her scalp symptoms involves considering seborrheic dermatitis, which responds well to anti-dandruff shampoos containing ketoconazole or selenium sulfide, and managing the increased itch and flaking (Kraft & Bowen, 2019). Education on proper scalp hygiene and avoiding harsh shampoos or irritants is advisable.

The patient's environmental factors, including living with pets and attending online school, may contribute to her eczema and dermatitis. It is advisable to assess for potential allergens, such as animals, dust mites, or fragrances, and advise minimizing exposure when possible. Education on allergy avoidance and skin care routines emphasizing hydration and barrier repair is critical for long-term management (Mogulkoc et al., 2017).

Follow-up should be scheduled in 4 to 6 weeks to assess the response to management, educate on skin care routines, and consider referral to a dermatologist for further evaluation if symptoms persist or worsen. Continuous monitoring for signs of secondary infection or complications is essential.

References

• Leung, D. Y., & Bieber, T. (2020). Atopic dermatitis. The New England Journal of Medicine, 383(7), 655-663.
• Kraft, J. K., & Bowen, A. (2019). Seborrheic dermatitis in children. Seminars in Pediatric Infectious Diseases, 30(3), 179-185.
• Mogulkoc, N., et al. (2017). Environmental and genetic factors in atopic dermatitis. Journal of Clinical & Diagnostic Research, 11(6), QE01-QE04.
• Heng, J. F., et al. (2018). Bacterial superinfection in atopic dermatitis. Clinical Pediatrics, 57(5), 607-612.
• Liu, Y., et al. (2020). Emollients and skin barrier repair in atopic dermatitis. Journal of Dermatological Treatment, 31(4), 395-404.
• Schmidt, J., et al. (2019). Topical calcineurin inhibitors in atopic dermatitis management. British Journal of Dermatology, 180(4), 743-749.