HPI: 59 y/o patient came into the office today c/o:
24-year-old male presents with itchy rash to both arms, neck and face. He first noticed the rash two days ago after returning from a camping trip with friends. The rash is spreading and did not improve with over-the-counter itch cream or Benadryl.
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Review of systems:General: No fever, chills, or weight changes or sweating or general weakness.
Eyes: No blurred or double vision or pain or redness.
Ears: No pain or decrease in hearing.(Allergic Reaction Soap Note)
Nose: No runny nose or blockage or bleeding.
Throat: No sore throat.
Head: No headache.
Chest: No chest pain or cough or shortness of breath or wheezing.
Prostate: No urinary frequency or dysuria or urethral discharge or pain on sitting.
Heart: No irregular heart beat or palpitations or chest pain.
Gastrointestinal: No abdominal pain or nausea or vomiting or diarrhea or constipation or difficulty swallowing or rectal bleeding or bloating or distension or hemorrhoids. l23.7 allergic reaction soap note.
Genitourinary: No dysuria or urethral discharge or pain on sitting.
Musculoskeletal: No joint or back pain or muscle problems or weakness.
Skin: Diffuse rashes spread across the trunk, arms, neck, head, and face. No bruises or skin masses or other skin complaints.
Neurologic: No weakness or headache or seizures or numbness or tingling.
Psychiatric: No anxiety or depression or suicidal/homicidal thoughts.
Endocrine: No excessive thirst or excessive urination or excessive heat or cold.
Immunologic: No tuberculosis or hepatitis or HIV or recurrent infections.
Hematologic: No anemia or easy bruising or bleeding.(Allergic Reaction Soap Note)
PMHx: none
FamilyHx: none
SocialHx: Pt is a student.
Allergies: NKA
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Objective:
General: Normotensive, in no acute distress.
Head: Normocephalic, no lesions.
Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.
Ears: EAC’s clear, TM’s normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.(Allergic Reaction Soap Note)
Abdomen: Soft, no tenderness, no masses, BS normal.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: Physiological, no localizing findings.
Skin: No lesions noted. Diffuse rashes spread across the trunk, arms, neck, head, and face.
Allergic Reaction Soap Note
Assessment:
Differential Dx:
Rash and other nonspecific skin eruption. R21
Pruritus, unspecified. L29.9
Actual Dx:
Poison ivy, oak, sumac or other plant dermatitis L23.7 (allergic) (contact)
ICD-10-CM Codes. (2019). Retrieved from https://www.icd10data.com/ICD10CM/Codes/
Plan:
Education I would discuss with and provide to the pt.
Rubbing alcohol
Rubbing alcohol can remove the urushiol oil from the skin, helping to minimize discomfort.
People should do this as soon as possible after contact with poison ivy, particularly within the first 10 minutes of exposure. If going camping or hiking, it is a good idea to carry alcohol wipes at all times.(Allergic Reaction Soap Note)
The U. S. Food and Drug Administration (FDA) advise that urushiol can remain on the surface of most items that come into contact with poison ivy, sometimes for years, unless treated with rubbing alcohol or water.
Shower or bathe
Thoroughly wash the skin, and under the fingernails, with plain soap and lukewarm water to remove plant oils. Water can be used instead of rubbing alcohol, although it is best to use alcohol first and then shower or bathe.(Allergic Reaction Soap Note)
It’s believed that showering within 60 minutes of exposure may help limit the spread and severity of the rash.
Wash anything that comes into contact with the plant. People should wear rubber gloves when doing this.
Cold compress
Cool, wet compresses can help to reduce itching and inflammation.
To make a compress, run a clean washcloth under cold water. Wring off excess water. Apply to the skin for 15 to 30 minutes. Repeat this several times a day as needed.
Some people find relief by soaking the compress in an astringent liquid to further reduce swelling and itching. Examples of astringent liquids include aluminum acetate, apple cider vinegar, and chilled black tea.
Resist scratching the skin
Scratching the skin can lead to an infection. It may also cause blisters to burst, which may then become infected.
Blisters that do open should be left alone, as the skin covering the wound can provide protection and reduce the risk of infection. l23.7 allergic reaction soap note(Allergic Reaction Soap Note)
Unscrubbed fingernails may also contain traces of urushiol, which can be transmitted to the skin through scratching. This can lead to further itching and a more severe poison ivy rash.
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5. Topical lotions and creams
Several lotions that can help relieve the symptoms of a mild poison ivy rash are available without a prescription.
Hydrocortisone creams and calamine lotion are two products commonly used to reduce itching and swelling.
The FDA advise that products containing zinc acetate, zinc carbonate, and zinc oxide treat the oozing and weeping caused by poison ivy. Users should always apply these products as per the instructions on the label.(Allergic Reaction Soap Note)
Aloe Vera gel, taken from the aloe Vera plant, is another soothing topical poison ivy remedy.
Oatmeal bath
According to research, oatmeal has antioxidant and anti-inflammatory properties that benefit a variety of inflammatory skin conditions.
Adding oatmeal or an oatmeal-based product to a lukewarm bath is a simple poison ivy remedy. Soaking in the tub for up to 30 minutes may provide symptom relief.
Bentonite clay
Bentonite clay is a popular natural clay used in a variety of beauty and personal care products.
Some people report relief from poison ivy rash after applying a paste of bentonite clay and water to the affected area.
Research suggests that using a modified version of bentonite clay (quaternium-18 bentonite) effectively prevents or reduces the allergic contact dermatitis caused by poison ivy and poison oak.(Allergic Reaction Soap Note)
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Allergic Reaction Soap Note.
Baking soda
Also known as sodium bicarbonate, baking soda is a salt that is mainly used in baking. However, it is also used as a natural cleaning agent and as a home remedy for various ailments.
Adding a cup of baking soda to the tub is recommended by the American Academy of Dermatology for relief from poison ivy rash.
Leonard, J. (2019). Poison ivy: Home remedies and how to recognize it. Retrieved from https://www.medicalnewstoday.com/articles/318059.php(Allergic Reaction Soap Note)
Prescription:
OTC Pramoxine-Calamine medicated lotion. Apply to affected areas every 6 to 8 hours as needed.
Medication instructions and educatio9n for the pt.
Calamine is for external use only. Do not swallow it and do not use it on the eyes or mucous membranes such as the inside of the mouth, nose, genital (sex organs), or anal areas.
To use calamine lotion:
Shake the lotion well before using.
Moisten a pledget of cotton with the lotion.
Use the moistened pledget to apply the lotion to the affected skin area(s).
Allow the medicine to dry on the skin.(Allergic Reaction Soap Note)
Review of systems:
General: No fever, chills, or weight changes or sweating or general weakness.
Eyes: No blurred or double vision or pain or redness.
Ears: No pain or decrease in hearing.(Allergic Reaction Soap Note)
Nose: No runny nose or blockage or bleeding.
Throat: No sore throat.
Head: No headache.
Chest: No chest pain or cough or shortness of breath or wheezing.
Prostate: No urinary frequency or dysuria or urethral discharge or pain on sitting.
Heart: No irregular heart beat or palpitations or chest pain.
Gastrointestinal: No abdominal pain or nausea or vomiting or diarrhea or constipation or difficulty swallowing or rectal bleeding or bloating or distension or hemorrhoids. l23.7 allergic reaction soap note.
Genitourinary: No dysuria or urethral discharge or pain on sitting.
Musculoskeletal: No joint or back pain or muscle problems or weakness.
Skin: Diffuse rashes spread across the trunk, arms, neck, head, and face. No bruises or skin masses or other skin complaints.
Neurologic: No weakness or headache or seizures or numbness or tingling.
Psychiatric: No anxiety or depression or suicidal/homicidal thoughts.
Endocrine: No excessive thirst or excessive urination or excessive heat or cold.
Immunologic: No tuberculosis or hepatitis or HIV or recurrent infections.
Hematologic: No anemia or easy bruising or bleeding.(Allergic Reaction Soap Note)
PMHx: none
FamilyHx: none
SocialHx: Pt is a student.
Allergies: NKA
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Objective:
General: Normotensive, in no acute distress.
Head: Normocephalic, no lesions.
Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.
Ears: EAC’s clear, TM’s normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.(Allergic Reaction Soap Note)
Abdomen: Soft, no tenderness, no masses, BS normal.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: Physiological, no localizing findings.
Skin: No lesions noted. Diffuse rashes spread across the trunk, arms, neck, head, and face.
Allergic Reaction Soap Note
Assessment:
Differential Dx:
Rash and other nonspecific skin eruption. R21
Pruritus, unspecified. L29.9
Actual Dx:
