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AcuteDermatitisSOAPNote.ppt.pptxAcute Dermatitis. Students Name: professors Name: date.
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Atopic Dermatitis.
Introduction.
Acute Dermatitis also known as Atopic dermatitis (eczema) is a condition that affects both young and old people regardless of age and sex. Studies have shown that causes of acute dermatitis can be attributed to a wide range of factors. Among these factors include a combination of immune system activation along with genetic related defects, stress as well as environmental factors. This causes the immune system of the affected people to overreact to allergens causing inflammation of the skin. What should be known is that acute dermatitis is a chronic disease and currently no effective cure has been found but when appropriate healthcare guidelines are followed along with the provision of patient education, this condition can be managed (Stoner, Ophaug, Simpson, & Hanifin, 2020). Some of the key symptoms of atopic dermatitis include the development of dry skin that is itchy with its severity increasing to the extreme end during the night.
The disease may also manifest itself and lead to signs such as red to brownish-gray patches on the affected parts of the body. Based on the question, this SOAP document will focus on providing subjective and objective data of an 18-month-old male patient to help develop a deferential diagnosis for atopic dermatitis. The document will also provide more insights into the most appropriate treatment plan for the patient’s condition.
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Subjective data.
Patient Information:
Age:18 months old Sex: Male
CC: The mother of the chief complainant provides that “In the last few weeks her child has been experiencing persistence facial rash making the child restless especially at night to when the child scratches her”
the mother brought her five years old to the clinic due to development of URI and right ear pain that
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HPI
The patient is a young male child aged 18 months who was brought to the clinic due to a persistent facial rash. According to the mother the child developed rushes around his cheek and the condition has been worsening over the past few days leading to symptoms such as child discomfort and restlessness. The child has been unable to sleep well due to continuous scratching of his skin during the night. Even though the mother records that his child looks healthy and well nourished, it is evident that due to atopic dermatitis, the young child is feeling unwell. Physical examination and assessment indicate that the child's vitals as per the time he was brought to the clinic were as follows. weight 23.4 lbs, height 31.8 inches, BP 120/76, HR 100, RR 26, and Temperature 98.6 F.
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HPI cont.………..
Major symptoms identified during the physical assessment of the child included dry, red, and scaly patches on the child’s cheeks. These symptoms also spread to the chin, extensor surfaces of his extremist, and the mouth as well. Worth noting from the said assessment is that the child has also a plaque-like appearance on his face. In addition to that, the child’s diaper area has been identified with different skin rashes within the diaper area. Diaper rash or spares are normally caused by bacteria along with other factors such as allergic reactions to foreign bodies or dye in disposable diapers. It may also be triggered by reactions to the detergent used to wash cloths on the affected kid’s skin. Child medical history does not reveal cases of child sickness nor admission to the hospital for treatment.
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Current Medical History and classical symptoms.
The diaper area is spared. .
A persistent facial rash.
The child has become restless especially at night .
Patient’s cheek areas have a plaque like and weepy appearance.
The child has dry, scaly, and red areas on his cheeks.
The child scratches in his sleep..
As described in the case study the client age 18 months old has indicated wide range of symptoms of acute dermatitis including scratches and becoming restless more so at night, having red, scaly and dry skin around the cheeks and the chin., developed a plaque and weep appearances on his cheek as well as diaper area appeared spared.
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Medication History
Current Medications: no current medication details have been provided.
Allergies: As provided in the patient medical history there is no known food or medication allergies attributed to the young child.
PMHx: no immunization report has been provided and as per the past medical history the patient has never been exposed to any form of surgery
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Family Medical History Summary
Father- no details provided
Mother- no information provided
Sister- no history provided
Paternal Grandfather- no past information was provided
Paternal Grandmother – no history provided
Maternal Grandmother- no past information given on this.
Paternal Grandfather- no details given.
With reference to the data given on the case study, no evidence was provided about family medical history.
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Social History
As mentioned early the patient is a young child aged 18 months and has been brought to the clinic by his mother. The social history of the child has not been provided but from the mother’s assertion, the child lives with his mother.
The case study never provided sufficient details on the client’s social history.
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Patient Profile
The patient is a 18 month -year-old male.
He has become restless more at night due to scratches triggered by acute dermatitis. .
The mother brought the child to the clinical facility seeking to get medical assistance.
As the mother reports, the child had developed a persistent facial rash accompanies with other symptoms such as plaque like and weepy appearance, diaper region becoming spared, unable to sleep well, and his chin mouth areas and chin appearing dry, red and scaly.
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Review of Systems
GENERAL: The patient looks healthy and well-oriented, as well as alert. His mother provides that the child is only having persistent facial rashes with symptoms such as red, dry, and scaly signs around the chick.
Constitutional: no malaise and fever
HEENT: the mother reports no headache
Eyes: his vision is normal without any impairments or defects.
Ear: no loss of hearing reported.
Nose: no running nose, congestion, or sneezing reported.
Throat: no sore throat
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Review of Systems Cont’d
SKIN: His skin is scaly, dry, has a weepy appearance, and has rushes and diaper spare. The regions of the cheeks appear plaque-like and with reddish scaly patches on the cheeks.
CARDIOVASCULAR: The medical report indicates that the patient has a regular heart rate with no murmur.
RESPIRATORY: The patient reports negative on having a cough or shortness of breath.
GASTROINTESTINAL: he also dines of having nausea or vomiting.
GENITOURINARY: no change in the patient’s urinary pattern.
NEUROLOGICAL: he also denies feeling dizzy or losing memory.
MUSCULOSKELETAL: The patient complains of having pain in his right leg on the great toe
,
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Review of Systems Cont’d
HEMATOLOGIC: Declines of having bleeding disorders.
LYMPHATICS: negative report on enlarged nodes.
PSYCHIATRIC: the mother reports that her son experiences sleeping difficulties, especially during the night due to the continuous feeling of scratching.
ENDOCRINOLOGIC: no endocrine symptoms noted.
ALLERGIES: no report whether the child is allergic to food, environment, or medication.
,
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Objective data
Physical Examination
Vital Signs: weight 23.4 lbs, height 31.8 inches, BP 120/76, HR 100, RR 26, and Temperature is 98.6 F
General: The patient is well-nourished, in physical health, and with no major health complications.
HEENT: normal vision, his hearing ability is intact, no sore throats and no runny nose
Lungs: the patient has regular respiration with no incline of coughing.
Heart: He has a regular heart rate rhythm and no murmur.
Abdomen: it is soft, not tender, and without rash.
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Objective data cont’d
Physical Examination cont’d
Abdomen: it is soft, not tender, and without rash.
Genital/Rectal: there is an adequate tone with no masses.
Skin: But the skin is scaly, reddish, and with plaque-like patches on his cheek.
Musculoskeletal: no joint pain nor joint discomfort.
Neurological: alert and well oriented
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Laboratory or Diagnostic Examination.
Assessment.
Allergic contact dermatitis can be attributed to the development of symptoms such as plaque-like patches, and scaly and dry skin. This condition develops due to exposure of allergic people to allergies such as cosmetics, plants, or fragrances
Diagnostic tests were carried out.
Blood test- to determine the amount of allergens and allergy triggers
patch testing- to check for hypersensitive reactions
A punch skin biopsy-to determine and diagnose inflammatory skin conditions.
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Risk Factors for Acute dermatitis
Sex or gender. Male are more prone to dermatitis than female.
Occupation that exposed people to solvents, dust or metals.
Exposure of children to poor day care practices.
Exposure to environmental; conditions that trigger allergy reactions.
Genetic factors.
Being born by Cesarean section
Having a high birth weight
Being born to a mother who is older
Age
Other health conditions.
.
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Diagnosis and differential diagnosis
From the assessment of the patient's subjective and objective data along with reference to the classical symptoms, some of the possible types of dermatitis the patient is suffering from include Flexural eczema ICD10- L20.82, Atopic Dermatitis ICD10- L20.9 or Infantile eczema ICD10- L20.83.
It is good to note that Flexural eczema ICD10- L20.82 is a type of eczema that manifest itself around the joints more so the elbow and knees.
Its symptoms include itchy rashes on the skin.
Given that the child developed scaly, itchy rashes and dry skin around his cheeks and chin, this symptom can be associated with Flexural eczema ICD10-L20.82 (Azizi & Maibach, 2020)
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Diagnosis and differential diagnosis. Cont’d
The second deferral is Infantile eczema- ICD10- L20.83 which is accompanied by itchy rashes that become severe at night just like the symptoms presented by the client who was unable to sleep at night due to scratching of itching rashes on his face and around the chin.
The third one is atop Atopic Dermatitis ICD10- L20.9 which can be ruled as the primary condition affecting the patient.
This can be associated with persistent development of facial rashes which have spread to the cheeks and the chin leading to symptoms such as dry, itchy rashes and plaque-like patches as well as diaper spare signs on the diaper area
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Major symptoms for acute dermatitis
Dry, scaly skin.
Redness and swelling.
Thickened skin.
Small, raised bumps that may become crusty and leak fluid if scratched.
Rough Bumps in hair follicles.
Darkened skin around the eyes.
Skin changes around the mouth, chin, eyes, or ears.
Rash on swollen skin
Thickened skin.
Thickened skin.
Severe itching.
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Treatment
Recommended medication for atopic dermatitis in children can include topical corticosteroids or calcineurin inhibitors. Hydrocortisone is an example of topical corticosteroids that could be given to the patient.
It should be carefully applied to the affected skin twice daily for a period of 2 weeks.
The mother should take caution while applying the cream to avoid the development of other complications.
Also, 0.03% of tacrolimus ointment (Protopic) might be considered.
It is applied to the affected skin two times per day and the duration should take two weeks
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Teaching and Health Promotion
The mother should be advised on the precautions to take while washing and giving the patient required medication.
She should be taught to always keep the child away from very humid or very dry air.
The child should be always be kept away from potential allergens such far from pets.
The child should be washed with warm oatmeal containing ant-inflammatory components to protect the child from potential irritants.
The mother should be advised to moisture the skin of the baby daily.
Lotion and odor-based ointment should be avoided.
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Follow-up
The patient ought to be closely monitored through medical follow ups to ensure the mother adheres to best practices that help manage acute dermatitis.
This will help also to ensure that recommended ointments and prescribed medications are given on timely basis within the stipulated duration.
The patient should return to he clinical after 21 days for assessment of the condition.
This helps in determining his response to the medications provided and pave way for decision making if treatment plan should be altered more so when the symptoms continue exacerbating.
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References
Amber, T. (2019). Seborrheic dermatitis. Adult-Gerontology Acute Care Practice Guidelines. doi:10.1891/9780826170057.0015c
Azizi, N., & Maibach, H. I. (2020). Are topical corticoids efficacious in acute irritant dermatitis: The evidence. Dermatitis, 31(4), 244-246. doi:10.1097/der.0000000000000574
SEMON, H. C. (2013). Dermatitis MEDICAMENTOSA (Acute vesicular iodine dermatitis). An Atlas of the Commoner Skin Diseases, 48-49. doi:10.1016/b978-1-4832-8304-3.50023-7
Stoner, R. C., Ophaug, S., Simpson, E., & Hanifin, J. (2020). Acute pancreatitis in 2 adolescent boys on Dupilumab therapy for atopic dermatitis. Dermatitis, 32(1), e21-e23. doi:10.1097/der.0000000000000651
Stoner, R. C., Ophaug, S., Simpson, E., & Hanifin, J. (2020). Acute pancreatitis in 2 adolescent boys on Dupilumab therapy for atopic dermatitis. Dermatitis, 32(1), e21-e23. doi:10.1097/der.0000000000000651
