Shellie Ray CRNP - Home
SUBJECTIVE:CHIEF COMPLAINT: “ My son has a red, itchy rash on his arms, legs and ankles”HISTORY OF PRESENT ILLNESS: 14 month old white male presents to clinic with mother with complaints of a red rash located in bilateral antecubital and popliteal areas and around ankles. It has been present for almost 1 week now with no improvement. It is pruritic and seems to get worse when he goes outside to play in the heat. She has only used baby lotion to treat it with no improvement. Mom states that his diet has not changed and noted that they are very careful when introducing new things into diet due to food allergies.PMH: Allergy testing at 8 months old after having allergic reaction ( lips and tongue swelling, rash/hives to neck and trunk) to ice cream. Allergies noted to milk, dairy products, peanuts, pollen, ragweed, pet dander. Allergic rhinitis twice over past few months. Otitis media to right ear at 11 months.Sx: noneAllergies: NKDA, milk, dairy products, peanuts, pollen, ragweed, pet danderMedications: Zyrtec 2.5 mg daily, Epipen Jr. PRN anaphylaxis Age/health status: 14 month old male appearing to be in a good present state of healthImmunizations: UTDFAMILY HISTORY:Father: HTNMother: asthma, environmental allergiesSocial History: Only child living at home with mother and father. No smokers in the house, no pets. Attends daycare.REVIEW OF SYSTEMS:Constitutionals: Denies fever, change in weight or irritability.HEENT: Denies ear pulling, nasal congestion. Positive for history of allergic rhinitis.Respiratory: Denies cough, sputum, hemoptysis, dyspnea, wheezing, Denies history of asthma, bronchitis, pneumonia. Integumentary: Positive for dry, pruritic skin. Allergic: Positive for allergies to milk, dairy, peanuts, ragweed, pollen and pet danderObjective:Height: 31 in. Weight: 22 lbs BMI: 27.6Vital Signs: T 98.9 P 98 R 22 BP 98/60 Constitutionals: Alert, comfortable, smiling, sitting in mom’s lap, in no acute distressHEENT: Normocephalic. Conjunctiva pink, sclera white. PERRLA. Ears: TM with good cone of light, ears without pain, redness, drainage, wax present. Nose: mucosa pink, septum midline. No sinus tenderness. Mouth: Two bottom teeth noted, tooth buds on top. No presence of thrush. Tongue midline, tonsils present, pharynx without exudate. Neck: supple, no palpable nodes.Cardiovascular: S1, S2 no S3 or S4. No gallops or murmurs. Brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric.Respiratory: Clear to auscultation bilaterally, no rales, wheezes or rhonchi. Integument: Dry skin with thickened, red, maculopapular areas in the bilateral antecubital and popliteal areas as well as around the ankles. No crusting, drainage or pustules noted. ASSESSMENT:Differential Diagnosis: Atopic dermatitis (Eczema)Contact dermatitisSeborrheic dermatitisPsoriasisScabiesDiagnosis: Atopic dermatitis (Eczema) ICD9- 691.8 PLAN: Elidel 1% cream BID. Twice daily use a pea sized amount and spread on affected areas only until symptoms are under control. This medication is not to be used long term, only when flare ups occur. Do not put occlusive dressing over ointment. Antihistamine to control itching. Diphenhydramine HCL 6.25 mg every 4-6 hours PRN itching.Use a skin emollient twice daily such as Aquaphor or petroleum jelly. Apply the Elidel to the affected skin only first, let absorb and then apply the emollient to entire body.Avoid long baths which will dry skin. Bathe less frequently to avoid excessive skin dryness. When bathing use tepid water and a mild, unscented soap or a nonsoap cleanser such as Cetaphil. Immediately after getting out of the bath, pat the skin dry and use the emollient to seal in the skins moisture.Keep fingernails short to prevent scratching the skin. Eliminate trigger foods one at a time for 1 month at a time to see improvement. Teach mother signs and symptoms of bacterial skin infections and to report signs immediately to clinic.Return to clinic next month for well child visit. ReferencesCash J C Glass C A 2011 Family practice guidelinesCash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company. Dunphy L M Winland-Brown J E Porter B O Thomas D J 2011 Primary care: the art and science of advanced practice nursingDunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: the art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company. 2012082821040868339467020120828210601934854742012082821060193485474 ................
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