Patient History and Physical Examination
Patient Name: Mary
Chief Complaint: Face rash.
History of present illness: the rash has never occurred before.
Past Medical History
Mary has got tonsillectomy at age 9 for chronic strep throat infections. She has been healthy as an adult, never had children, never been hospitalized for any reason.
Family History: the mother has been diagnosed with rheumatoid arthritis. Her father is healthy.
Personal and Social History
The patient is a 35 years old electrical engineer. Does not smoke; drinks a glass of wine nearly every night with her dinner; denies illicit drug use. A master’s degree in engineering; has lived with her boyfriend for the past 5 years.
Review of Systems
General: rash on the patient’s face that has been present for 1 week. No new soaps, detergents, lotions, environmental exposures, medications, and foods. The rash is across the patient’s face and the bridge of her nose. The lesions itch and are painful; first noticed the rash after spending a week hiking and camping in the Appalachians.
Skin: rash across the face and the bridge of the nose; denies any spread of the rash to other areas.
Head and Neck deny headache, no complaints on the neck function.
Eyes, Ears, Nose, Throat, and Mouth: ear pain, nasal or sinus congestion; mouth soreness.
Lymphatic System: weight loss.
Chest and Lungs deny chest pain, shortness of breath, cough.
Heart and Blood vessels: regular heartbeat, no chest pain, no racing heart, no swelling of feet or legs, no pain in legs while walking.
Gastrointestinal System: no polydipsia, polyphagia, no abdominal pain.
Genitourinary System: no pain with urination or polyuria, constipation, or diarrhea.
Musculoskeletal System: muscle aches and pains that are worse in the hand and wrist. Denies early morning joint stiffness or difficulty with being able to move in the morning.
Nervous System: fatigue.
General: young-looking female with no apparent acute distress, is alert, answers questions appropriately. Exhibits a slightly somber effect due to tiredness.
BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F.
Mental Status: no mental problems identified.
Skin: Several erythematous plaques scattered over the cheeks and the bridge of the nose, sparing the nasolabial folds.
Head: hair evenly distributed, no issues identified.
Eyes: sclera white, conjunctivae clear; pupils constrict from 4 mm to 2 mm and equal, round, and reactive to light and accommodation.
Ears: Canals patent; landmarks easily visualized.
Nose: No septal deviation.
Throat and Mouth: oropharynx moist with erythema in the posterior pharyngeal wall; no exudates; shallow ulcers in the buccal mucosa bilaterally.
Neck: Neck supple without cervical lymphadenopathy or thyromegaly.
Chest & Lungs: no issues, no cough or wheezing.
Breast: No discharge, no dimpling, wrinkling, discoloration; no lumps, or bumps.
Heart: normal rate and rhythm, no edema or murmurs.
Abdomen: No issues identified.
Musculoskeletal System: Full range of motion; no swelling or deformity; muscles with normal bulk and tone.
Neurologic System: alert young woman, sitting comfortably on the examination table.
Nursing Care Plan
Subjective: itchy and painful face rash that gets worse from environmental contact.
Objective: the patient is complaining about the face rash with itchy lesions that have never occurred before.
Nursing Diagnosis: body soreness, fatigue, and fever are all symptoms associated with the face rash; specific actions to mitigate the mentioned symptoms are needed.
- It is expected that the accompanying symptoms of muscle ache, fever, soreness, and fever will be eliminated.
- The patient will manage the face rash and prevent it from occurring in the future.
- The patient will be asked to pay more attention to the condition of throat and mouth and contact a practitioner (otolaryngologist) for further assessment and possible diagnoses.
- The patient will be encouraged to make changes in her lifestyle, dietary, and self-care practices in order to prevent the rash from re-appearing.
- Introduce a skincare routine that will be free of harmful chemicals and substances that can exasperate the condition of Mary’s skin (Group, 2015).
- Conduct several skin assessments (especially with regards to color, the state of the rash, skin texture, and the presence of scarring) after the introduction of the new routine.
- Instruct the patient to manage the fatigue and fever through healthy sleep, rest, appropriate diet, liquids, and vitamins. The patient can also engage in mild relaxation exercises (e.g. yoga) to achieve a balanced body and mind.
- The introduction of probiotics as a therapeutic option for the internal treatment of the rash (Kim, 2017). The rationale for their use is that the patient was likely to come into contact with bacteria during her hike, and probiotics can play a beneficial role in dealing with the bacteria.
- Changing the diet to accommodate for the avoidance of irritant foods and drinks, especially alcohol.
- Since the patient indicated that getting outside made the face rash worse, it is recommended to take preventative measures such as non-irritating sunscreen and protective clothing to limit the influence of the environment on the rash.
Since the patient indicated having tonsillectomy to deal with a throat infection and because the current symptoms also include mouth soreness, it is important to educate the patient about the importance of further assessment and possible treatment. Also, it is recommended that the patient visits a professional to test for allergies for different plants, foods, and substances to avoid similar skin reactions in the future. Lastly, patient education should also take into consideration providing information on safety measures that should be taken outside during hikes, especially in locations such as the Appalachians, where the climate and possible sources of bacteria are different from those to which the patient is accommodated (immune) (Fin, Burns, Mearns, Yule, & Robertson, 2006).
Fin, R., Burns, C., Mearns, K., Yule, S., & Robertson, E. (2006). Measuring safety climate in health care. Quality & Safety in Health Care, 15(2), 109-115.
Group, E. (2015). .
Kim, B. (2017). .