25-YEAR-OLD FEMALE WITH ALLERGIC
CONTACT DERMATITIS: HISTORY, PHYSICAL
EXAMINATION, DIFFERENTIAL DIAGNOSIS,
AND MANAGEMENT (NURS 5308)
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Krista Hampton
Age 25 years old
Gender Female
Ethnicity Caucasian
Occupation English teacher (7th and 8th grade)
Height 5'5" (165 cm)
Weight 120 lb (55 kg)
BMI 20.0 (Normal range)
Source Patient (self)
Reliable, alert, cooperative, and able to provide clear
Reliability
history
, Category Details
Ceclor (Cefaclor) – developed hives as child when takin
Allergies
for otitis media
Chief Complaint: "I have this ugly looking rash on my upper
thighs"
Encounter Type: Outpatient clinic visit
NURS 5308 Focus: Advanced health assessment,
differential diagnosis, and evidence-based management of
dermatologic conditions
PART 2: PAST MEDICAL HISTORY (PMH)
Category Details
Childhood "Usual coughs and tummy ache – nothing
Illnesses remarkable"
Adult Illnesses Denies any chronic conditions
Medical Conditions None
Surgeries None
Hospitalizations None
Obstetric History Nulliparous
Key Points:
No prior history of similar rashes
No chronic medical conditions
, No prior dermatologic issues
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Details
None No prior surgical history
PART 4: MEDICATIONS
Current Medications
Medicati Frequen Prescrib
Dose Purpose
on cy er
Birth
Unkno Prescrib Contracepti
control Daily
wn er on
pill
OTC/Herbal Supplements
None reported
Key Medication Questions Answered
No treatments tried for the rash
No recent antibiotic use (allergic to Ceclor – avoids)
Birth control pill is only daily medication
PART 5: FAMILY HISTORY