I Human Case Week #4 A 25 Year Old With Skin Problem Case Assessment 2025, Assignments of Nursing

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| HUMAN CASE STUDY WEEK #4 6512 25 YEAR OLD MALE WITH SKIN PROMBLEM ASSSESSMENT 2025 i-Human Case Week #4 25 ylo 5' 11" (180 cm) 180.0 Ib (81.8 kg) Reason for encounter Skin problem Location Outpatient clinic with laboratory capabilities Case Instructions H&P+Dx CASE PLAY SETUP AND INSTRUCTIONS MODE: This assignment is in Learning Mode. Feedback appears after submitting each section, and a final performance case. ATTEMPTS AVAILABLE: © You are permitted 1 attempt for this assignment. GRADING RUBRIC: + History 40% = Physinal evam 40% History Feedback Ask relevant problem-focused questions to create an accurate initial differential diagnosis list. Various questions may yield the same information. Examples of high-yield questions for this case include: @ Performed X Missed Pivotal Concept Category Addressed e HPI HPI Symptom Symptom HPI HPI HPI HPI HPI HPI Symptom Symptom HPI SH Question How can | help you today? Do you have any other symptoms or concerns we should discuss? Have you had any skin sores or change in color? | Do you have a rash? | When did your rash start? What are the events surrounding the start of your rash? Does anything make your rash better or worse? How severe is your rash? Does your rash come and go? On what part of your body did the rash start and where did it spread? | Do you have any skin itching or burning? Do you have any pain in your leg(s)? When did the pain in your leg(s) start? Have you been exposed to mosquitoes or ticks? Any nites? Response t have this skin problem. No other concems. What other symptoms | would you like to know about? Yes, that area on my left shin. Yes, that area on my left shin. Is that considered a rash? About a day ago. | Nothing that | remember in particular. It just appeared overnight. | Nothing seems to make it better or worse. It does look worse today than it did yesterday though. Well, it seems to be getting worse when comparing to the way it looked yesterday. started. No, this weird skin area is constant since it | Well, it's just on my left shin. My skin isn't really itching. The area where it's red kind of hurts and bums a little. Yes, my left shin hurts in that red area. About the same time the rash started, so about a day. No insect or animal bites that | know of. SH SH SH SH SH Symptom Symptom Symptom | Symptom Symptom | Symptom Symptom | Symptom | Symptom | Symptom || Are you short of | Tell me about the health of your grandparents, parents and children. | Do you drink alcohol? If so, what do you | drink and how many drinks per day? When did you last drink alcohol? Do you use any recreational drugs? If so, what? Do you use injection (IV) drugs? Do you now or have you ever smoked or chewed tobacco? Do you have a problem with fatigue/tiredness? Do you feel unwell, not normal or just "not yourself" (malaise) lately? Have you been having fevers? | Do you have night sweats? Do you have a headache? | Do you have chills? Do you have unusual heartbeats (palpitations)? Do you have any pain in your chest? Does your chest feel tight or heavy? | high cholesterol at 61. My dad is 50 and was diagnosed with eczema at 28. | also have eczema, which is interesting. His dad is 75 and was diagnosed with depression at 45 and high blood pressure at 56. His mom is 75 and was diagnosed with asthma at 22. My brother is 24 and has asthma that he's had since he was 10. Yes, | like to drink with the boys after a good rugby game. | would say | drink about 2 to 4 beers about 3 to 5 times @ month. About 3 days ago. | like to drink with the boys after a good rugby game. | would say | drink about 2 to 4 beers about 3 to 5 times a month. No. Uh, definitely not. No, I've never smoked or chewed tobacco. | think it's a nasty habit to have, so | don't plan on starting now. I haven't felt tired. No, | feel great. ’| Nope. | really only get fevers when I'm sick. |No night sweats. No, | haven't had any headaches. | have a few friends who get migraines, so I'm glad | don't have those. No chills. Nope, | haven't felt anything like that. No. No. Nope. ——,,, VV. eee e | Symptom | Do you have chilis? ; No chills. | Do you have unusual heartbeats a | e Symptom | ee Nope, | haven't felt anything like that. | | (palpitations)? | a Symptom Do you have any pain in your chest? | No. r | Symptom Does your chest feel tight or heavy? No. e | Symptom Are you short of breath? | Nope. eS | Symptom Do you have a cough? | Nope, no cough. * Symptom Do you wheeze? Not that I've noticed. e SH Have you been in a hot tub recently? Nope. My friend has one though. e@ \SH — you recently traveled? Where did you 4), recent travel. e HPI sheet aiteroty Se ee ee Nope, no new soaps or anything. Do you have any tingling and/or numbness f ' . e —— anywhe re? | No, not that I've noticed. In addition to the relevant problem-focused questions mentioned above, communication techniques promote rapport-building and unbiased data-gathering during the patient's history. Examples of key techniques in this case include: @ Performed X Missed Pivotal rm aoe Category Question Response s: a | “Tes Ey ; : 1 8 Comm | bay symptom is the most distressing for | The skin problen. |, | Well, 'm a little worried since it looks like it's | e Comm | Tell me how that makes you feel. sprending: | | Well, it doesn't affect it too much rightnow.| ® Comm How does this affect your life? have rugby practice in a few days, so | | | wanted to get patched up as quick as | possible. | orthostatic blood pressure ©) @ orthostatic blood pressure (BP) (BP) inspect skin overall auscultate heart auscultate lungs inspect lower extremities assess light touch/pain sensation of lower extremity @ inspect skin overall @ auscultate heart @ auscultate lungs @ inspect lower extremities @ assess light touch/pain sensation of lower extremity ® Not Required, Not Inappropriate @ Performed Correctly @ Performed Correctly @ Performed Correctly @ Performed Correctly @ Performed Correctly * weight @ weight @ Not Required, Not Inappropriate « blood pressure @ blood pressure @ Performed Correctly * pulse @ pulse @ Performed Correctly @ Assess capillary refill: Toes * pulse interpretation @ pulse interpretation @ Performed Correctly * respiration @ respiration @ Performed Correctly * temperature @ temperature @ Performed Correctly « Spo: @ Spo: @ Performed Correctly . oT blood pressure ©) @ orthostatic blood pressure (BP) @ Not Required, Not Inappropriate * inspect skin overall @ inspect skin overall @ Performed Correctly Case Findings Unilateral, left leg redness for 1 day Left leg pain for 1 day No injuries, falls, insect or animal bites PMH of eczema Steroid cream provides no improvement to rash LLE with one localized area erythema, poorly demarcated borders LLE exam: one localized area of swelling, warmth, and tendemess No area of palpable fluctuance, nodule, or discharge No lesions, vesicles, or pustules noted Medications/Allergies Family history Social history (habits) ROS: Inquiry into constitutional symptoms ROS: Inquiry into cardiovascular symptoms ROS: Inquiry into respiratory symptoms ROS: Inquiry into additional skin symptoms ROS: Inquiry into endocrine symptoms Communication: Elicit the patient's perspective Case Problem Statement This patient is a 25-year-old male with a PMH of eczema who reports one day of left anterior lower leg erythema and pain unimproved with topical steroid cream use. He denies fever, recent travel, sick contacts, skin contact with irritative substances, flu-like symptoms, injuries, falls, prolonged immobility, insect or animal bites, vascular disorders, and a family history of thrombotic disorders. Physical exam reveals one localized area of anterior left lower extremity erythema with poorly demarcated borders, mild swelling, warmth, and tenderness. No lesions, vesicles, pustules, discharge, or palpable fluctuance or nodules are present. Plan Feedback Pharmacologic Care: * Prescribe cephalexin 500 mg every 6 hours for 7 days. * Do not apply triamcinolone acetonide to the affected area. * May take over-the-counter ibuprofen as needed for pain: follow manufacturer's package instructions. Supportive Care: Take antibiotic with food to avoid gastrointestinal upset. Recommend taking daily probiotic or eating daily yogurt to restore gut bacteria while taking antibiotic. Avoid touching or scratching the affected area; wash hands after touching the affected area to avoid spread. Marked borders of indurated area with permanent marker to monitor for spread. Patient Education: * Educated on new diagnosis, treatment, and medication side effects. * Reviewed red flag symptoms which require immediate follow-up, such as fever, red streaking, discharge, increased pain, redness, swelling, etc. If symptoms continue or worsen, advised to go to the emergency room. * Educated the patient on the importance of diet when maintaining a healthy lifestyle. Recommend eating 3 balanced diet of lean meats, vegetables, fruits, and whole grains. Follow-Up: * Recommend scheduling recheck in 2-3 days, follow up sooner if needed.