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Patient’s past Medical History

Chief Complaints

The patient in question is suffering from a rash that has spread all over her face and the bridge of her nose. The rash has caused lesions on her face that itches and aches. the reasons for the crash are not yet known since no prior diagnosis or treatment has been sought. Therefore, a diagnosis of the ailment will be conducted to determine the cause of the rash that has affected the patient’s face and bridge of the nose.

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History of Present Illness

The patient first noticed the rash on her face after a week spent hiking and camping in the Appalachians. The Appalachians are known for various ailments with signs and symptoms which include rash amongst others, but at the moment the cause is yet to be disclosed as the physician has to look into various factors and symptoms that may act as causative agents of the patient’s ailment (Madigan, 2012). Today, the rash on her face has caused lesions that itch and ache. In spite of the rash which remains on her face, she has not witnessed its spreading to other parts of her body. When outdoors, the itching and ache caused by the lesions increases tremendously, which is not true when she stays indoors. Also, she has noticed sores in her mouth and increased muscle aches and pains in different parts of the body. The muscle aches are worse in the hands and wrists.

Past Medical History

The patient’s past medical history states that she has never experienced that kind of rash before. However, looking at the patient’s history, we notice that she had been admitted for tonsillectomy at the age of nine which was as a result of a chronic strep throat infection. Other than the strep throat infection, the patient has never suffered from any serious illness since she has never been hospitalized.

Family History

A study of the family history shows that she has a mother who has rheumatoid arthritis. Her father is healthy and has not been diagnosed with any ailment or disease that could shed light on the patient’s ailment. There is no medical information provided by her siblings.

Personal and Social History

The patient has used the name Mary in registering for the checkups. She is a thirty-five-year-old electrical engineer who holds a master’s degree in engineering. Her hobbies are hiking and camping. The patient is moderate with drug treatment: she is not a smoker, and she has not used any illicit drugs without a physician’s approval. However, she takes a glass of wine after an evening meal on a daily basis. Details about the patient’s marital status have been disclosed as she has admitted to living with a boyfriend during the past five years. However, in spite of living with her boyfriend, she has no children.

Physical Examination

The patient is a healthy woman who does not suffer from any severe ailment other than the tonsillectomy she underwent as a child. Presently, however, she has complained of a rash on her face that has caused aches and itchy lesions. In addition, the patient has also complained of having mouth soreness and increased muscle aches and pains, especially towards the wrists and hands.

The patient is mentally stable. She is focused on every aspect of her life, even during her examination with the physician studying the cause of the rash on her face. Also, judging from her personal and professional life, she is deemed mentally stable as she has been able to complete all responsibilities delegated to her and other goals in life like graduating from the school of engineering.

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The patient’s skin is healthy and she has not reported any complications with her skin other than her face. However, the patient has been experiencing fever on her head. Her eyes are sclera is white and conjunctive bright with pupils that constrict from 4mm to 2mm. In addition, the pupils are equal on all sides, round and are responsive to light of different magnitude, suggesting that her eyes are in perfect shape. Her throat is moist with erythema in the posterior pharyngeal wall with no exudates. Her mouth has shallow ulcers in the buccal mucosa bilaterally and has a neck that is supple as it lacks cervical lymphadenopathy or thyromegaly. The causative agent of the shallow ulcers in the patient’s mouth is the mouth sore. Her blood pressure (BP) is 112/66mm Hg; HR is 62 BPM and a regular respiratory rate, which has been measured to be at 12 breaths/ min. Her body temperature is at 100.3°F. Besides, the patient still has full control of her body parts as she is capable of moving each and every part of her body. However, the patient has been experiencing increased muscle aches and pains that are worse towards the hands and wrists. There is no swelling or deformity noticed on her body or limbs, and her muscles are normal as they have the bulk and tone.

Presumptive Nursing Diagnosis

Based on the observation and examination of the patient, my likely nursing diagnosis of the rash on the diagnosis on what may have caused the rash to the patient’s face is known as sumac rash. Sumac rash is an allergic reaction that commonly appears on the skin. Its causative agent is poison ivy (Marx, Hockberger, Walls, Adams, Rosen, 2006). In the patient’s case, she must have been in contact with the plant poison ivy, especially since her rash worsens when she is outdoors. Besides, the rash is not communicable as it does not spread through fluids (Molloy, 2007). This explains why the patient has reported that the rash has only affected her face as she might have washed the oil of the plant from her face after contact with the plant with her face. The symptoms of the rash caused by ivy poison are extremely itchy and leave a patchy rash where the plant touched the skin (Church, 2005). Also, the mouth soreness is presumably a result of the rash caused by the plant as the plant is known for causing a rash on the mouth and other genitals or around the eyes.

Teaching and Nursing Care Plan

The nursing care plans for related impaired skin integrity that are caused by irritants or allergens like Sumac rash can be easily identified through characteristics like inflammation, dry, flaky skin, pain, and blisters. This can be accurately assessed through assessing skin, noting color, moisture, and erythema to determine the type of skin dermatitis as different skin dermatitis have distinct characteristic patterns of changes in the skin and lesions. Secondly, one can also identify the signs of itching and scratching as there exist different characteristic patterns that are associated with scratching(Faber, Hay, & Naafs, 2013).

There are also different therapeutic actions that may be applied in the case of Sumac Rash, and they include: The patient should drink cold compressed water or milk. Secondly, the patient can use calamine which is a nonprescription lotion. Thirdly, she can use Aveeno oatmeal which is a byproduct put in the bath to relieve the itching. Lastly, the use of oral antihistamines such as diphenhydramine also remedies the rash (Faber et al., 2013).

References

Church, B. (2005). Medicinal plants, trees, & shrubs of Appalachia: A field guide. Glenville, WV: B. Church.

Faber, W. R., Hay, R. J., & Naafs, B. (2013). Imported skin diseases. Chichester, West Sussex: Wiley-Blackwell.

Madigan, M. T. (2012). Brock biology of microorganisms. San Francisco: Benjamin Cummings.

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Marx, J. A., Hockberger, R. S., Walls, R. M., Adams, J., & Rosen, P. (2006). Rosen’s emergency medicine: Concepts and clinical practice. Philadelphia: Mosby/Elsevier.

Molloy, J. (2007). The best in tent camping: The Southern Appalachian & Smoky Mountains: a guide for car campers who hate RVs, concrete slabs, and loud portable stereos. Birmingham, Ala: Menasha Ridge Press.

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