Case Study 33 Year Old Caucasian Female

Kathleen Cornell, FNP Student

SUNYITNovember 2014

DemographicsAge: 33 Year Gender: Caucasian FemaleHeight: 5’5Weight: 124lbBMI: 20.6Source of encounter: Primary Care Physician visit

Chief Complaint33 Year old Caucasian female presenting to the office with a two week history of small open areas on arms that itch.

History of Present Illness33 Year old Caucasian female presenting to the office today for complaints of small open areas on upper extremities that itch. She currently works as a Veterinarian and was in Georgia two weeks ago where she volunteered to neuter and spay cats and dogs. She does not recall getting bit by anything does recall having a very active kitten who bit her left hand, she immediately washed the site and did not notice anything different.

HPI Cont’dIt was one day after returning she noticed on her right forearm an area that was the size of a pin head that itched and she couldn’t help but scratch the area. She applied cortisone cream thinking it was a bug bite. The cream stopped the itching but a few more areas appeared on her arm as well as the right arm. She has been using the cream twice a day which has dried the areas up but continue to be there and now she

HPI Cont’dThinks there are more spots on her lower shins. Denies fever, weight loss, pain or unusual drainage. Has not taken any over the counter oral medications, but did medicate herself with Keflex 500mg once a day for five days prior to her trip to Georgia.

Past Medical HistoryLast Physical exam 9/14Medications: NoneAllergies: NKDA, food or latex allergyMedical Illness: NoneSurgeries/Injuries: Fractured right wrist age 12, surgical history wisdom teeth age 18, denies blood transfusions

PMH Cont’dSurgeries/Injuries: Fractured right wrist age 12, surgical history wisdom teeth age 18, denies blood transfusionsChildhood Illness: Chicken pox age 6Immunizations: Up to date with immunizations, last tetanus shot 2011, vaccinated Hep B series, Declines HIV or Hep C testing at this time.

Social HistoryVeterinarian has worked for the past five years at local office in Albany, NYMarried for the past three years, has no children lives in a home with three dogs, two cats, fish, two horses, three goats, 20 chickens. Husband in a Large breed Veterinarian. Does not smoke, drinks alcohol socially three drinks a month.

Social History Cont’dDenies use of street drugs. Nutritional status will eat cereal bar for breakfast, two to three cups of coffee a day with skim milk and tsp. sugar. Lunch is generally a salad or something quick with a diet coke, dinner usually chicken or fish depending on what husband cooks. Exercises five times a week, running or biking. Wears a bike helmet and seatbelt drives speed limit.

Family HistoryMother alive and well age 60, Father alive and well 65, two siblings a sister age 25 lawyer with a history of Celiac disease, brother alive age 32 healthy. Maternal GM – alive age 80, HTN, diabetes type II, Maternal GF – alive age 85, HTN. Paternal GM – deceased age 80 MI, Paternal GF – alive age 85 healthy bikes ten miles a day, swims three times a week.

ROSGeneral: Denies any fever, chills, weight loss, malaise, fatigue, night sweatsSkin: Pale, warm, right and left forearms scabbed areas, no pigment changes to other areas of the body, denies brittle nails.Head: Denies any lumps, swollen glands, pain or stiffness, trauma or change in range of motion, or dizziness, headaches.

ROS Cont’dEars: Denies any pain, discharge, ringing of the ears, hearing loss, dizziness.Eyes: Denies any redness, tearing, discharge, burning, double vision, history of glaucoma or cataracts. Last eye exam 8/13 without corrective lenses.Nose/Sinuses: Denies any change in smell, obstruction, bloody nose, itching, or pain to face.

ROS Cont’dMouth/Throat: Denies any hoarseness, excessive salivation, or dryness, ulcers, disturbance in taste, or soreness of tongue or throat. Last dental exam 5/14.Respiratory: Denies any pains, shortness of breath, wheezing, bronchitis, asthma, denies lumps to breasts, nipple discharge, pain, does self breast exam.Heart: Denies any chest pain, murmurs, palpitations, swelling.

ROS Cont’dPV: Denies any leg cramps, varicose veins, cold extremities, Claudication.GI: Denies any nausea, anorexia, difficulty with swallowing, bloating, abdominal pain, diarrhea, constipations, jaundice.GU: Denies any change in frequency of urination, pain with urination, foul odor, or blood, no flank pain. Last OB/GYN exam 5/14. No sexual difficulties.

ROS Cont’dMusculoskeletal: Denies weakness, rigidity, numbness, tingling, decreased range of motion, or pain.Neurological: Denies dizziness, headaches, loss of memory, tremors, problems with speech, anxiety, depression.Hematological: Denies bleeding, bruising easily, recurrent infections, anemia.

ROS Cont’dEndocrine: Denies goiter, hot or cold intolerance, frequency in urination or thirst.Psychiatric: Denies anxiety, depression, hallucinations, suicidal ideation or sleep disturbance.

Physical ExamVitals: B/P 110/74, P 76, R 14, T- 98.6, Weight: 124lb, Height: 5’5, BMI: 20.6.General Appearance: Well developed, well nourished thin 33 Caucasian female, alert, oriented to person, place, and time, well groomed, cooperative.

Physical Exam Cont’dSkin: Pink, warm, right and left upper extremities with 5-6 5mm round raised crusted areas without drainage, red in color, edges approximated, surrounding tissue without redness or warmth. Right shin 1 5mm round raised crusted area without drainage red in color edges approximated, no other areas on trunk, chest, buttocks, back, neck, feet unremarkable without change in tissue.

Physical Exam Cont’dHead: Normocephalic, hair brown, evenly distributed, no lesions, scabs, raised areas, scales.Ears: Tragus symmetrical without lesions, scars, no pain on palpation, pigment change, right ear cone of light at 5 o’clock tympanic membrane visualized, left ear cone of light at 7 o’clock tympanic membrane visualized, hearing intact with whisper test.

Physical Exam Cont’dEyes: Pupils equal and reactive to light 2 +, no strabismus, nystagmus, ptosis, chlazion, sclera white, Consensual reaction, extra-ocular movements equal bilateral. Red reflex noted equal in both eyes.Nose: Nares symmetrical, turbinates pink without discharge, swelling, redness, or polyps, no pain on palpation to frontal sinus.

Physical Exam Cont’dMouth: Lips dry without crack, hard and soft palate without swelling, lesions, stensen ducts visualized and patent, uvula midline without deviation or shift with vocalization, No foul odor, teeth with repair to molars top and bottom.Neck: No jugular vein distention, trachea midline, thyroid palpable, no goiters, lymph nodes non palpable submentle, submandibular, supraclavicular, no resistance with range of motion.

Physical Exam Cont’dRespiratory: Thorax symmetrical with inspiration and expiration, lungs clear on auscultation AP and Lateral, no pigeon chest, barrel chest or deviation, no increase in AP diameter.CV/PV: Heart rate regular on auscultation, PMI at 5th ICS/MCL, jugular pulses equal bilaterally, distal pulses equal, no heaves, thrills, S1 greater than S2, Homan’s negative.

Physical Exam Cont’dGI: No scars, lesions, abdomen round, soft on palpation, positive bowel sounds all quadrants, no guarding or pain on palpation, no organomegaly over liver or spleen.

Differential DiagnosisSkin and soft tissue infections Arthropod bites and stingsContact dermatitisBed bugs

Photo

http://www.webmd.com/skin-problems-and-treatments/picture-of-folliculitis

Definitive Reason for Diagnosis

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus or staph because it's resistant to most commonly used antibiotics.The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, like sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Domino, 2014

Definitive Reason Cont’dThough most MRSA infections aren't serious, some can be life-threatening, and difficulty to treat it affects all ages.MRSA is spread by touching another person who has it on the skin. Or you could get it by touching objects that have the bacteria on them.Two types: HA-MRSA infections typically are associated with invasive procedures or devices, such as surgeries, intravenous tubing or artificial joints.Domino, 2014

Definitive Reason Cont’dCA-MRSA often begins as a painful skin boil. It's spread by skin-to-skin contact. At-risk populations include groups such as high school wrestlers, child care workers and people who live in crowded conditions, recent hospitalization.Signs of CA-MRSA Red bump that may be pus filled (sometimes mistaken for a spider bite), warmth, pain, swollen, red, tender skin lesions.

(Domino, 2014)

Reason for DiagnosisPreceptors Diagnosis: Contact dermatitisMy diagnosis: Based on appearance and lack of healing for two weeks, the lesions are spreading elsewhere on the body mainly lower extremities with no history of insect bite or bed bugs

Diagnostic TestsTissue sample or nasal secretions swab is the most cost effective test. Wound cultures

(Domino, 2014)

Management PlanCA-MRSA – TreatmentResistant to B-lactams – oral cephalosporins, antistaphylococcal penicillins, macrolides, and quinolones. First line of treatment: 7-14 day course of Trimethoprim/sulfamethoxazole (TMP-SMX)DS 160mg/800mg 1-2 tablets daily by mouth.

Management Plan Cont’dDoxycycline or minocycline 100mg by mouth twice a day.Clindamycin 300-600mg by mouth three times a day – check D-zone disk diffusion test – this will show inducible clindamycin resistance in CA-MRSA resistant to erythromycin.

http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_faqs.html.

ReferencesDomino, F. (2014). The 5 Minute Clinical Consult Premium (22nd. Ed, pp. 800-801). Philadelphia, PA: Lippincott Williams & Wilkins.

The Center for Disease and Prevention. (2014). Retrieved from http:// www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_faqs.html.

WebMD (2014). Skin problems. Retrieved from http://www.webmd.com/skin-problems-and-treatments/picture-of-folliculitis