INTRODUCTION
For this assignment, you will be given a case study. Review the information provided and answer the questions. Be sure to cite and reference your sources. Look at the case study as if the subject is a patient in your office seeking care. What are your immediate concerns? What needs to be done for them? Be thorough and succinct in your responses. Your submission must be in SOAP note format.
CASE STUDY
Chief Complaint
“I have had this itchy, scaly rash on my scalp and knees for 2 weeks. Because the rash is on my face, I do not want to go outside of my home because I feel other people are always staring at me. I have not been able to sleep, eat, or concentrate.”
History of Present Illness
K.B. is a 30 y.o. white female who presents to the office with a 2-week history of an itchy, scaly rash on both knees and scalp. She states she has had some rashes in the past but never as severe and never on her scalp. For the past 2 weeks she has not been able to sleep or to concentrate at work. When she gets home from work, she stays in the room alone.
Past Medical History
General Health: Hypertension, Allergic rhinitis
Immunizations: Up to date
Hospitalizations: Only hospitalized for childbirth
Surgeries: None
Obstetrics: G2P2
LMP: Total hysterectomy due to fibroid tumors
Medications: Lisinopril 20 mg daily, Loratadine 10 mg daily
Allergies: NKDA
Family History:
Mother 52 has hypertension
Father 53 alive and well
Brother 32 has hypertension
Sister alive and well
Has one son 9 and one daughter 8, both alive and well
Social History: The patient lives with her husband and 2 children. She works for Regions Bank as a bank teller. She does not drink alcohol or smoke cigarettes. She denies any physical or mental abuse.
Review of Systems:
General: No weight loss or weight gain in the last year. No history of fatigue, fever, or chills.
Skin, Hair, and Nails: Has scaly rash on scalp and knees. No changes in any moles. Denies any problems or changes in hair or nails.
HEENT:
Head: Denies dizziness, lightheadedness, headaches. Eyes: Denies any eye pain or redness, does have tearing and itchiness. Denies blurred or double vision, does not wear contacts or glasses. Ears: Denies any ear pain, drainage. Nose: Has been having clear nasal drainage, congestion, sneezing, and itching. Denies any changes or problems with sense of smell. Throat: Denies any sore throats, vocal changes, masses, swelling, or difficulty swallowing. Denies any neck pain, masses or swelling; no swelling of thyroid gland.
Respiratory: Denies any SOB, dyspnea, wheezing or cough.
Breast: No history of breast tenderness masses or discharge.
Cardiovascular: Denies any chest pain, palpitations, history of rheumatic fever, hypertension. No problems with heart or edema in extremities.
Gastrointestinal: No complaints of nausea, vomiting, or abdominal pain.
Genitourinary/GYN: Denies any dysuria, hematuria, or history of UTIs. No history of urinary frequency.
Musculoskeletal: Denies any weakness, numbness, erythema, twitching, or pain. No joint pain, tenderness, or history of head trauma.
Peripheral Vascular: Denies swelling in face, hands, feet. No history of leg cramps.
Neurologic: Denies fainting, seizures, headaches, weakness or paralysis.
Psychological: Has not been able to sleep, eat, or concentrate for the past 2 weeks.
OBJECTIVE:
General Appearance: 30-year-old white female, alert and well groomed. Noted to have some silvery plaques to bilateral knees and frontal portion of scalp.
Vital Signs: BP 128/72 HR 70, RR 18, Temp. 98.7, HT 5’7ʺ, WT 168
Patient awake, alert, oriented x 4 in NAD
Skin: warm and dry to touch. Silvery plaques to bilateral knees and scalp
HEENT: head nontraumatic, normocephalic
Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted
Ears: bilateral TM with good cone of light and intact
Nose: mucosa pale and boggy, septum midline; no sinus tenderness appreciated
Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate. Post-nasal drip noted
Neck: supple; trachea midline; no LAD
Resp: regular and unlabored; lungs with end expiratory wheezing throughout
CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated
Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion
Genitalia: deferred
Rectal: deferred
Extremities: warm and without edema; calves supple, non-tender
PV: no LE edema
MS: MAEW
Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact
INSTRUCTIONS:
Address the following items:
List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.
At this time, what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?
What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?
What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.
What is your comprehensive plan of care? Include your rationales.
