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Claire Soap Note
SUBJECTIVE
Biodata
Name: Claire Muthoni
Age 30
Gender F
Residence Mississippi
Marital status SINGLE
Date of admission 5/23/20
PC:
My skin has started growing pimples that are sometimes painful in the past one month.
The pimples have been producing pus for the past one month
I have also started seeing rashes on my skin for the last one month
History of presenting illness
Clare was last well two months ago when she started developing rashes on her elbow and forearm. The onset of the outbreaks was one month ago and was spreading from the elbow area to her forearm. There was a slight pain associated, which she graded as 3/10, especially when she scratched her skin, and bleeding occurred. The rashes were also related to small pustules that popped up scratching. She hasn’t taken any interventions since they started developing. The overall severity is rated at 7/10 since she has to wear long sleeves before going anywhere and has severely interrupted her healthy life. The pustules are small in size, located in a circular motion around the elbow, and are associated with the pain. She hasn’t taken any interventions.
PMH: admissions for asthma when she was a child.
Allergies: allergy to dust, cold, and is gluten.
Medication Intolerances: no hypersensitivity to penicillin and other drugs.
No history of trauma, blood transfusion, and surgeries.
Tipple Serology is negative, blood group b+
Immunizations are given to date
Familial History
Father is alive, but has arthritis and has been receiving some drugs for it. Once developed, a case of psoriasis that relapsed on treatment.
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Mother is alive and well, with no illnesses.
Grandfather and grandmother alive, but both have hypertension. No arthritis, diabetes, heart diseases, lung disease, or autoimmune case reported.
A distant uncle also has reported cases of arthritis.
Social history
Clare lives in her apartment in Mississippi
She works as a school teacher
Education level us graduate
Clare can also be able to pay for her medication as well.
She does not take alcohol, smoke, or use any recreational drugs of abuse.
She currently has a universal health insurance card that can cater to her insurance.
Review of Systems
Claims her weight has significantly reduced since some of her clothes no longer fit her. She has also been feeling a bit fatigued and weak but with no fever, chills or night sweats,
Cardiovascular system
No palpitations, no difficulty breathing, no orthopnea, no PND, leg swelling, or edema.
Respiratory
No chest pain, no coughing, no hemoptysis, no wheezing or dyspnea.
GIT
No diarrhea, no vomiting, no abdominal pain, constipation, no hemorrhoids, no eating disorders, standard stool color.
Genitourinary system
No associated Urgency, no frequency, no burning sensation, standard urine color, no hematuria, dysuria, or urine dribbling.
Obstetrics and Gynecological
Currently sues three months depo with an active sexual life sexual activity, no std
Fe: the last pap-smear done three months ago, no breast self-examination or mammograms are done ever, menstrual flow last one week ago
No vaginal discharge, no history of pregnancy hx
Musculoskeletal
Rashes around the left elbow
Mild elbow pain
Movement at the joint 180 degrees
No swelling
No stiffness
Breast examination
No lumps, no breast pain, no peau de orange,
Heme /Lymph/Endo
HIV negative, no easy disability, no previous blood transfusion hx, no night
Sweats, no swollen glands, no polydipsia, no polyphagia, and no heat/cold intolerance.
Psychiatric
No history of Depression, Claire has been feeling anxious about late due to her condition and wants it treated immediately. No change n sleeping patterns, no suicidal
Ideations or attempts, no previous history of mental disease.
Neurological
No dizziness, no headache, normal sensation on the skin, no blurred vision, no weakness, normal senses.
ENT
No Ear pain, no hearing loss, No tinnitus, or discharge.
Eyes
No eye pain. Blurring or itching. No history of blurry vision.
OBJECTIVE
Height 2.11m
Weight 77
BMI 17.30
Temp 37.2
BP 124/83
Pulse 76
Respiratory rate: 19
General appearance
Claire is a middle old lady appears well-kempt, and well cared for. She is no respiratory distress; she is also alert and answers her questions well.
Skin
No hair changes, and has rashes, mild skin changes-skin desquamation on her left elbow, and pustules indicating underlying lesions. Pustules measure 2mm in diameter ad is around 50 on her elbow. Skin desquamation measures around 5 cm on her lower forearm with skin peeling.
HEENT
Claire’s Head is norm cephalic, atraumatic, and with no lesions noted; her hair evenly distributed and the natural black color.
Eyes: non-remarkable
Ears: non-remarkable
Eyes: non-remarkable
Neck: no remarkable
Cardiovascular-non remarkable
Respiratory: non-remarkable
Gastrointestinal: non-remarkable
Breast-non remarkable
Genitourinary-non remarkable
Musculoskeletal; Full ROM seen in all four extremities as the patient moved about the exam room.
Neurological: non-remarkable
Psychiatric: non-remarkable .
Action
From the history, Clair manifests with dermatological pathology with pustules on her left elbow, that is painful with scratching. The pustules are associated with a rash that is prevalent on the left forearm and elbow.
The onset being insidious rules out infections since they are acute, leaving dermatological disorders. Clair also has distant uncles and a father who has arthritis. She also has asthmatic conditions as s child. These point to an autoimmune disease ( Mahil & Barke & Capon, 2019).
General lab evaluations: UECs/LFT and full blood tests. FBC helps rule out any anemia associated with her fatigue
Her lab evaluations should include skin scrapings from the affected area. Her blood should also be tested for CPR and ESR indicative of any infections.
Tests
Wood lamps’ and KOH tests to rule out any fungi infestations.
Dermatoscopy, done to evaluate her pustules and skin lesions.
Antinuclear antibody to check for autoimmune diseases such as arthritis and psoriasis
Patch test to check for any risk of allergies on her skin
Lupus Band test to check for lupus erythematosus that could be in its earlier stages.
Genetic testing for HLA b-27 and HLA CW6 ( Nattkemper et al., 2018)
Consultation from the chief dermatologist
Differential diagnosis
Pustule psoriasis
Mycosis fungoides
Subcorneal pustulosis
The above disease is characterized by skin desquamation, skin color changes, and pustule formation. However, the familial predisposition and history of cold point an autoimmune disease. This makes psoriasis as the principal differential diagnosis. Despite this, many autoimmune and skin conditions overlap.
Plan
For the itching
Use steroid creams such as to reduce the inflammatory reaction on the affected areas ( Chan & Adam & Adam 2016) . Antifungal medication ketoconazole should also be administered topically for the affected areas.
Clair should also use non-irritative soaps and cream to avoid triggering any autoimmune reactions ( Hoegler et al., 2018) . Clothing should also be lightweight to prevent trapping any heat that could irritate the skin. These include nylon and wear.
Clair should also avoid scratching her rashes to prevent the risk of infection at the site.
Pain: Ibuprofen after meals to counteract the pain.
References
Chan, L. Y., Adam, R. S., & Adam, D. N. (2016). Localized topical steroid use and central serous retinopathy. Journal of Dermatological Treatment , 27 (5), 425-426.
Hoegler, K. M., John, A. M., Handler, M. Z., & Schwartz, R. A. (2018). Generalized pustular psoriasis: a review and update on treatment. Journal of the European Academy of Dermatology and Venereology , 32 (10), 1645-1651.
Mahil, S. K., Barker, J. N., & Capon, F. (2019). Pustular forms of psoriasis-related to autoinflammation. In Textbook of Autoinflammation (pp. 471-484). Springer, Cham.
Nattkemper, L. A., Tey, H. L., Valdes-Rodriguez, R., Lee, H., Mollanazar, N. K., Albornoz, C., ... & Yosipovitch, G. (2018). The genetics of chronic itch: gene expression in the skin of patients with atopic dermatitis and psoriasis with severe itchiness. Journal of Investigative Dermatology , 138 (6), 1311-1317.
