Case Study:

Ms. Hampton is a 25 y/o female presenting with an itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash. Upon examination, the left inner forearm is noted with itchy erythematous papules in a linear configuration with vesicles. The bilateral inner thighs were noted with raised confluent erythematous papules 10×12 cm with vesicles in various stages.

 

Instructions: Answer the following questions. As you can see, I already have the primary and differential diagnosis.

 

Management Plan Template:

 

Primary Diagnosis and ICD-10 code: Also include any procedural codes.

3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.

 

Primary Diagnosis:

     Allergic Contact Dermatitis L23.9

 

Differential Diagnosis:

    1. Cellulitis L03. 90

     2. Herpes Zoster (Shingles) B02.9

     3. Hot Tub Folliculitis L66.2

 

Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

 

Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?

 

Therapeutic modalities: pharmacological and nonpharmacological management.

 

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.

 

Patient education: Explanations and advice given to patient and family members.

 

Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.

 

 Scholarly references (minimum of 3, timely, that prove this plan follows current standard of care).\”

 

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