Full Dermatology Case Study: Kaylee Hales (2025 iHuman Simulation) – Allergic Contact Derm, Study notes of Nursing

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Full Dermatology Case Study: Kaylee Hales (2025 iHuman Simulation) – Allergic Contact Dermatitis from Plant Exposure | Complete HPI, Assessment, Diagnosis, Treatment & Follow-Up Plan

iHuman Case Study Example: Kaylee Hales – Dermatology

Case (2025)

Patient: Kaylee Hales Age: 16 years Sex: Female Date of Visit: [Insert Date] Preceptor: [Insert Name]

S – Subjective

Chief Complaint: "I've had this red, itchy rash on my arms and legs for a few days." History of Present Illness (HPI): Kaylee Hales is a 16-year-old female who presents with a 4-day history of an erythematous, pruritic rash on her forearms, wrists, and lower legs. She describes the rash as dry, raised, itchy, and occasionally oozing when scratched. She suspects possible allergen exposure from cats at a neighbor's house where she babysat recently. She denies any known allergen or chemical exposure. She applied OTC hydrocortisone with minimal improvement. She denies systemic symptoms such as fever, malaise, or pain. Past Medical History (PMH):

• Asthma (mild, well-controlled)
• Allergic rhinitis/seasonal allergies
• No history of eczema or previous similar rashes Surgical History:
• None Medications:

A – Assessment

Primary Diagnosis:

• Atopic Dermatitis (Eczema) – Likely triggered by allergen exposure (cat dander) Differential Diagnoses:

1. Contact Dermatitis – Localized allergic reaction possible, but less likely due to distribution and history.
2. Scabies – Less likely due to lack of burrows or involvement in finger webs/genitals.
3. Tinea corporis – Fungal infection unlikely due to no annular lesions or central clearing.
4. Psoriasis – Considered, but lesion distribution and history less supportive.

P – Plan

Diagnostics:

• No labs or cultures needed at this time
• Diagnosis is clinical based on history and exam Treatment:
• Prescribe Topical corticosteroid (e.g., triamcinolone 0.1% cream) BID
• Recommend non-scented emollients (e.g., Aquaphor, Eucerin) after bathing
• Antihistamine (e.g., cetirizine or diphenhydramine at night) for pruritus Education:
• Avoid scratching
• Avoid exposure to potential allergens (e.g., cats)
• Use lukewarm water for bathing
• Moisturize immediately after showers
• Apply steroid sparingly to affected areas Follow-Up:
• Recheck in 2 weeks
• Return sooner if rash worsens, spreads, or signs of infection develop

O – Objective

Vital Signs:

• Temperature: 98.4°F (36.9°C) – afebrile
• Heart Rate (HR): 76 beats per minute – regular
• Respiratory Rate (RR): 16 breaths per minute – unlabored
• Blood Pressure (BP): 108/72 mmHg
• Oxygen Saturation (SpO₂): 99% on room air
• Height/Weight: Within normal limits for age
• BMI: Normal range

General Appearance:

• Alert and oriented ×
• Well-nourished, well-developed adolescent
• No acute distress

Skin:

• Erythematous, dry, scaly patches noted bilaterally on: o Volar aspects of forearms o Wrists o Anterior lower legs
• Lesions are ill-defined , lichenified plaques with excoriations due to scratching
• Some areas with serous crusting , consistent with scratching/often oozing
• No vesicles, pustules, or ulcerations observed
• No signs of secondary bacterial infection (e.g., honey-colored crusting or purulence)

HEENT:

• Head: Normocephalic, atraumatic
• Eyes: Conjunctivae clear, sclerae white, no periorbital rash or swelling
• Ears/Nose/Throat: Mucosa moist, no nasal discharge, oropharynx clear, tonsils normal
• No lymphadenopathy or facial rash noted

Neck:

A – Assessment

Primary Diagnosis:

Atopic Dermatitis (Eczema) – Likely triggered by allergen exposure (cat dander) Rationale: Kaylee presents with a pruritic, erythematous, dry rash with lichenification and excoriation, distributed symmetrically over the flexor surfaces (forearms, wrists, and lower legs). The chronic itch-scratch cycle, absence of systemic symptoms, and a personal and family history of allergic conditions (asthma, seasonal allergies) are consistent with atopic dermatitis. The likely trigger may be environmental (recent exposure to cats), which aligns with a classic atopic presentation.

Supporting Findings:

• Symmetrical, dry, itchy rash in classic locations
• Excoriation and lichenification
• Known history of atopy (allergic rhinitis, mild asthma)
• No systemic signs of infection or acute illness
• Minimal to no improvement with OTC hydrocortisone

Differential Diagnoses:

1. Allergic Contact Dermatitis

o Reason for Consideration: Kaylee had recent exposure to cats and possibly other environmental allergens at a new location (neighbor’s house). o Why Less Likely: Contact dermatitis usually presents with more localized, sharply demarcated lesions at the site of direct contact. Kaylee’s rash is more generalized and chronic-appearing, which supports atopic dermatitis.

2. Scabies

o Reason for Consideration: Pruritus and excoriations. o Why Less Likely: No burrows noted, no involvement of finger webs, axillae, or genital region. No other household members affected. Lesion distribution and history are inconsistent with scabies.

3. Tinea Corporis (Fungal Infection)

o Reason for Consideration: Pruritic rash. o Why Less Likely: Lacks classic annular (ring-like) pattern with central clearing. No scaling at edges. No KOH prep performed, but clinical appearance is not typical.

4. Psoriasis (Plaque Type)

o Reason for Consideration: Well-demarcated plaques and family history could point toward psoriasis. o Why Less Likely: Lesions not silvery-scaled, not on extensor surfaces or scalp. Family history does not include psoriasis. Chronic pruritus and lichenification suggest eczema more than psoriasis.

5. Impetigo (Secondary Infection)

o Reason for Consideration: Excoriations and minor crusting could raise concern. o Why Less Likely: No honey-colored crusting or bullae. No signs of spreading infection or systemic illness. No history of contact with infected individuals. P – Plan (Treatment & Management) Pharmacologic Treatment:

1. Topical Corticosteroid: o Medication: Triamcinolone acetonide 0.1% cream o Directions: Apply a thin layer to affected areas twice daily (BID) for up to 7–10 days o Purpose: Reduce inflammation, itching, and rash severity o Education: Use only on affected areas; avoid face and groin; discontinue after improvement to prevent skin thinning
2. Oral Antihistamine (for itching relief, especially at night): o Option 1: Diphenhydramine 25–50 mg PO at bedtime o Option 2: Cetirizine 10 mg PO once daily (non-sedating alternative) o Purpose: Help control nocturnal itching and improve sleep Non-Pharmacologic Treatment:
3. Skin Hydration: o Recommend liberal use of fragrance-free emollients such as: ▪ Aquaphor , Eucerin , or Vaseline o Apply immediately after bathing to lock in moisture and throughout the day as needed
4. Bathing Instructions: o Take short, lukewarm baths or showers (avoid hot water) o Use mild, unscented soap (e.g., Dove Sensitive, Cetaphil cleanser)

✅ FOLLOW-UP PLAN

Scheduled Follow-Up:

• Recheck appointment in 2 weeks to evaluate: o Response to topical corticosteroid o Reduction in rash severity and pruritus o Skin healing (less excoriation, lichenification) o Adherence to moisturizing regimen o Avoidance of identified or suspected triggers

Monitoring and Clinical Goals:

• Lesions should show visible improvement (reduced erythema, dryness, and itching)
• Nighttime itching and sleep disturbance should subside
• Patient should demonstrate improved understanding of chronic care measures
• No signs of secondary bacterial infection (e.g., pustules, crusting, warmth, spreading redness)
• No recurrence with continued emollient use and trigger avoidance

Instructions for Earlier Return or Urgent Follow-Up:

Kaylee and her parent/guardian were advised to return to the clinic sooner than 2 weeks or seek immediate care if any of the following occur:

• Worsening rash despite treatment
• Development of pain, swelling, pus, or yellow crusts (suggestive of secondary infection )
• New or spreading lesions in atypical locations (e.g., face, genitals, trunk)
• Development of fever, malaise, or systemic symptoms
• Any allergic reaction to prescribed medications (rash, swelling, shortness of breath)
• No improvement after 7–10 days of treatment

Long-Term Management Consideration:

If Kaylee experiences recurring episodes of dermatitis:

• May consider referral to a dermatologist or allergist

• Possible need for patch testing or allergen identification
• Discussion about long-term control with low-potency steroid creams or calcineurin inhibitors for flare-prone areas