The chief complaints of a patient, which will be discussed in this paper, are of a female student who is nineteen years old and raised an issue as she states, “I experience irritation and feel scratchy because of the rash behind my knees and on my arms.” The subjective and objective data will be collected to evaluate the complaint of the patient and the patient will be guided according to the health promotional strategies.
Subjective Data
Presenting complain: I experience irritation and feel scratchy because of the rash behind my knees and on my arms.
History of presenting complains: The onset of the complaint happened fifteen days ago. According to the patient, after taking a bath or after swimming she feels itchy on her skin. To get relieve from this, the patient used soothing lotion on scratchy and irritating areas of her skin. She was avoiding any detergent, fancy bathing soaps, any other beauty product and she has not tried any new food item in the past 15 - 20 days. The patient was asked if she had any doubts that what could this problem be, and she answered that it could be a reoccurrence of her childhood skin allergy or eczema.
Past medical history: The patient had chickenpox when she was seven years old, history of normal childhood fever and skin allergy (eczema) was recorded. No surgical or blood transfusion history found. The patient is immunized. The last medical examination of the patient was done a year back in her school as a routine checkup, and she was considered completely normal. Gravid, Para, and Abortion are null.
Allergies: The patient is allergic to dust and peanuts and nuts.
Present medications: She used Fexofenadine to cure any dust allergy that is seasonal and Epinephrine auto-injector ( EpiPen) to cure the food allergy. However, the patient does not use these medicines on a regular basis.
Family History: The patient’s grandmother, grandfather, and her mother have high blood pressure. No other significant medical history of her family was seen.
Psychosocial History: No particular problem was noted, no history of addiction or abuse found in the patient.
Systematic review:
General Health: no weakness or current weight loss in a patient and the patient was physically fit.
Skin: she felt irritation and scratchy on her rash behind her knees and her arms. No signs of hair loss and no changes in nails were reported.
CNS: no injury, no headache, vertigo, dizziness or syncope. No complaint of improper vision, inflammation or discharge was seen.
Respiratory: Wheezing when suffering from cold otherwise no wheezing, shortness of breath (dyspnea) and no chest pain associated with breathing.
Cardiovascular system: no chest pain, all negative.
Musculoskeletal system: no positive signs and symptoms recorded.
UTI: negative.
Objective data:
The objective data of the patient was collected through conducting her physical examination. Inspection, palpation, auscultation, and percussion was observed to evaluate any problem in the body system of the patient related to her complain.
The patient was a young student whose age was only nineteen years old, and she was well oriented in time, place and person. The patient was very cooperative and calm and was not addicted to any drugs or alcohol. No other distress recorded.
Weight: 150 lb
Height: 5’6”
Blood Pressure: 120/60 mm Hg, relaxing position.
Temperature: 98° centigrade.
Pulse: 69 bpm, regular;
Respirations: 18 breaths per min,
Nails: no clubbing, no discolorations or nail biting.
Head: average, no tenderness found.
Eyes, nose, neck, mouth and ears: totally normal.
Back and spine: found normal.
Skin: behind the knees or both lower limbs edema with serous exudate, Erythematous papules, weeping and oozing to bilateral antecubital spaces.
Hair: distribution and texture seemed normal.
Lungs and chest: Symmetric chest, clear breath.
Abdomen: Symmetric and flat abdomen and looked healthy. Patient’s bowel habits were normal.
Extremities: the bilateral extremities easily and equally movable.
Musculoskeletal: normal flexion and extension observed.
Health Promotional Strategies
Normal skin seems to be impaired in the patient associated with dermatitis. The features of dermatitis and eczema are irritated inflammation, dry skin, excoriations, fissures, pain, blisters and pruritus. An estimated outcome from the evaluation is that she will have to maintain the normal integrity of her skin concerning the limits of her condition. To assist this female patient to achieve her target I would suggest her to visit the dermatologist, as she may develop some infections which may be related to the inflammation, impaired skin integrity, and excoriation. The physician is expected to advise an antibiotic that is topical.
The skin lesions that were very visible gave an indication of dermatitis. Some more therapeutic indications would be better to recommend to the patient such as avoiding soaps and detergents with fragrance. Keep skin moisturize correctly, prevent allergic foods, take the bath with warm water and try to shorten the time of bath, and avoid unnecessary contact with water for a long time. Prevent using anything that irritates the skin, cold compress, and most importantly keep nails shorter and wash clothes more than regularly.
References
Jarvis, C., 2015. Physical Examination and Health Assessment. Amsterdam: Elsevier Health Sciences.
Peate, I., 2011. Eczema: causes, symptoms and treatment in the community. British journal of community nursing, 16(7), 326-331.
