Discuss a pediatric patient, black female, 5 years old that comes to the office with her mom who is concerning about her daughter having pubic hair and body

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Demographics

Name: C.J.

Age: 16 years old

Gender: Male

Chief Complaint (Reason for seeking health care)

‘I have had this dried, scaly gray patch on the inner right side of my leg for about two weeks. It's rough and itchy, but it has not improved.’

History of Present Illness (HPI)

C.J. reports a dry, scaly gray patch on the inner right leg, first noticed three weeks ago. No pain, redness, or warmth, just slight itching. He has not tried new detergents, soaps, or personal care products. The lesion did not improve with OTC moisturizers. He denies any fever, chills, or systemic symptoms. His mother indicates that the lesion has marginally increased in size. C.J. plays school sports, notably wrestling, which includes skin-to-skin contact. He showers everyday and wears fresh clothing, but teammates share towels. No prior history of similar skin conditions.

Allergies

None

Review of Systems (ROS)

General: Fever, chills, weight loss, weariness, and recent illness are absent.

Head and neck: No throat pain, stuffiness, earache, headache, or vision alteration.

Neck: No neck stiffness, pain, edema, or mass is reported.

Lungs: The patient denied cough, wheezing, shortness of breath, or other lung symptoms.

Cardio: No chest discomfort, palpitations, dizziness, syncope, or other cardiac issues.

Breast: No lump, soreness, enlargement, or nipple discharge.

GI: The patient reports no nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in appetite.

M/F Genital: No complaints of discomfort, discharge, lesions, swelling, or any urinary symptoms are observed in the patients.

GU: The patient has no complaint of dysuria, polyuria, hematuria, or urinary incontinence.

Neuro: No dizziness, headaches, numbness, tingling, weakness, coordination, or balance issues.

Musculoskeletal: The patient reported no joint discomfort, muscular weakness, stiffness, edema, or mobility restriction.

Activity: The patient has no mobility, endurance, or functional capacity issues.

Psychosocial: The patient does not report having depression, anxiety, mood swings, behavioral changes, or school stress.

Derm: There is a single, circular, dry, scaly, gray lesion with mild erythema on the inner right leg.

Nutrition: The patient denies the changes in diet, decreased appetite, or any nutritional deficiencies in the last few months.

Sleep/Rest: No problems with going to sleep, staying asleep, being sleepy during the day, or changes in sleeping habits in the last month.

LMP: Not applicable as the patient is male.

STI Hx: The patient denies a history of any sexually transmitted diseases, unsafe practices, or any signs and symptoms suggestive of such diseases.

Vital Signs

Vital Signs: Temperature: 37.0°C; Pulse: 78 bpm; Respiration: 16 breaths per minute; Oxygen Saturation: 98% RA; Blood Pressure: 110/70 mmHg; Weight: 58 kg (128 lbs); Height: 66 inches (168 cm); BMI: 21.0 kg/m².

Labs

No labs performed.

Medications

None

Past Medical History

History of mild seasonal allergies. No chronic illnesses.

Past Surgical History

None

Family History

No family history of skin conditions or autoimmune disorders.

Social History

• Lives with parents.

• No tobacco, alcohol, or drug use.

• Active in school sports.

Health Maintenance/ Screenings

Immunizations up to date. No recent screenings.

Physical Examination

General: The patient is a well-nourished teenage male who is at ease and not in any form of discomfort.

HEENT: The head size is normal; no lesions, swelling, or other abnormalities were observed in the eyes and ears.

Neck: The neck is normal with no lumps that can be felt and the neck is not stiff.

Lungs: No wheezing, rales, or respiratory distress are audible on auscultation of bilateral breath sounds.

Cardiovascular: Regular pulse rate, no S1 and S2 sounds or murmurs.

Breast: There is no lump, pain or change in the skin of the breast when touched during the examination.

GI: There is no distention or tenderness in the abdomen, and bowel sounds are auscultated in all four quadrants.

M/F Genital: There was no lesion, rash, swelling or discharge observed on the external genitalia of the male.

GU: No swelling, discomfort, or inflammation was detected in the genitourinary system during the examination.

Neuro: The patient is fully oriented to the person, place, and time and has everyday speech and motor coordination.

Musculo: All the extremities have full active and passive mobility without any pain or deformities.

Activity: The patient is able to walk, maintain balance, and coordinate his movements normally.

Psychosocial: The patient is well-oriented, has a normal mood and affect, and does not seem bothered by the issues being discussed.

Derm: A well-defined, 4 cm dry, scaly gray patch with mild erythema is present on the inner right leg, with no pustules, vesicles, or exudates.

Diagnosis

Atopic Dermatitis: The primary diagnosis for this patient is atopic dermatitis, a relapsing or chronic eczematous skin disease manifested by dryness, itching, and scaling. It is most prevalent in adolescents and is closely related to a history of allergic or asthmatic conditions (NIH, 2022). The skin change on the inner right leg, described as a dry, scaly gray patch with mild erythema, corresponds to atopic dermatitis. A variety of environmental factors, irritants, and genetic factors cause it. If not well controlled, atopic dermatitis may cause skin infections, thickening of the skin, and frequent relapses, which are likely to affect the patient's quality of life.

Differential Diagnosis

Nummular Eczema: The condition causes circular, scaly, irritating plaques that may seem like fungus (Hardin et al., 2020). Nummular eczema lesions are more circular and less maculopapular than atopic dermatitis; they are intensely pruritic, and many ooze. Dry skin, allergies, or irritation from certain substances cause it. The diagnosis is clinical, but differentiation is essential since the management of the two conditions may differ.

Tinea corporis: This is a fungal skin disease caused by dermatophytes, and it presents itself as a circular, scaly skin lesion with a raised, red margin and central clearing (Yee & Al Aboud, 2023). It is usually unilateral and can be diagnosed by potassium hydroxide (KOH) microscopy, while atopic dermatitis is not. It is, therefore, essential to differentiate it from eczema since antifungal treatment is needed.

Psoriasis: Psoriasis is a chronic autoimmune disorder characterized by thick, silvery-white scales on red plaques (Mane & Bais, 2024). While atopic dermatitis lesions are well-demarcated, scaling, and often more superficial, psoriasis plaques are thicker, less easily removed from the skin surface, and have nail changes or joint pain. In general, the presence of a positive family history, absence of severe pruritus, and histopathological examination can differentiate between the two conditions, psoriasis and eczema.

ICD 10 Coding

L20.9 (Atopic Dermatitis)

B35.4 (Tinea Corporis)

L30.0 (Nummular Eczema),

L40.0 (Psoriasis),

Pharmacologic treatment plan

· Topical Corticosteroid (Hydrocortisone 2.5% Cream): A low-potency corticosteroid twice daily for two weeks lowers inflammation, erythema, and pruritus. It works for mild atopic dermatitis when applied thinly.

· Topical Emollients (Petrolatum-based moisturizer): Frequent use of a fragrance-free moisturizer restores the skin barrier, avoiding flare-ups and corticosteroid use. Moisturizers should be applied immediately after bathing to lock in hydration.

· Oral Antihistamine (Cetirizine 10 mg once daily): Cetirizine is a second-generation antihistamine that helps control pruritus without causing excessive drowsiness. It reduces scratching, nightly itching, and sleep difficulty.

Diagnostic/Lab Testing

· Serum IgE Levels: High serum immunoglobulin E (IgE) levels suggest an allergic propensity, frequent in atopic dermatitis sufferers.

· Patch testing: It identifies contact allergens that may worsen eczema. Fragrances, metals, and preservatives irritate.

· Skin Biopsy (if uncertain diagnosis): If therapy fails, a punch biopsy confirms histological characteristics of atopic dermatitis and screens out psoriasis or fungal infections.

Education

· Explain to the patient that atopic dermatitis is a lifelong chronic condition caused by the weakening of the skin’s barrier and immune system, not from poor hygiene (Mayo Clinic, 2023).

· Remind the patient to use only gentle, non-scented moisturizers and mild soaps for bathing to avoid worsening skin symptoms.

· Instruct the patient to avoid any substances that may worsen the condition, such as harsh soaps, allergens, stress, and extreme temperatures.

· Suggest trimming the nails and wearing soft cotton gloves at night so that one does not scratch the skin and cause an infection.

Anticipatory Guidance

· Managing flare-ups: Inform the patient that flare-ups may manifest as increased redness, itching, and skin thickening, and the patient should seek medical attention if the situation persists.

· Minimizing the Risk of Infection: Emphasize keeping the skin clean and refraining from scratching the area excessively to prevent bacteria or fungus from entering.

· Maintaining Skin Hydration: Encourage the patient to apply a thick moisturizer immediately after bathing and throughout the day to prevent excessive dryness.

· Psychological Considerations: Explain the possible effects of atopic dermatitis on the mental health of the patient and ensure that the patient shares their stress or anxiety about the condition with the healthcare provider (Courtney & Su, 2024).

Follow up plan

· Follow-up in two weeks to assess response to corticosteroids and determine if extended treatment is necessary.

· Monitor for side effects of corticosteroid use, including skin thinning or rebound flare-ups, and adjust treatment accordingly.

· Consider referral to a dermatologist if symptoms persist despite adherence to prescribed therapy or if an alternative diagnosis is suspected.

Prescription

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References

Hardin, C. A., Love, L. W., & Farci, F. (2020). Nummular Dermatitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK565878/

Mane, R., & Bais, S. (2024). Psosriasis: A Comprehensive review on Clinical Features, Diagnosis and Treatment. International Journal of Pharmacy and Herbal Technology, 2, 2977. https://ijprdjournal.com/myapp/uploads/392-MANE%20RUTUJA%202977-2992.pdf

Yee, G., & Al Aboud, A. M. (2023). Tinea corporis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544360/

Courtney, A., & Su, J. C. (2024). The Psychology of Atopic Dermatitis. Journal of Clinical Medicine, 13(6), 1602. https://doi.org/10.3390/jcm13061602

Mayo Clinic. (2023, May 9). Atopic dermatitis (eczema) – Symptoms and causes. Atopic Dermatitis (Eczema); Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/atopic-dermatitis-eczema/symptoms-causes/syc-20353273

NIH. (2022, November). Atopic Dermatitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/atopic-dermatitis

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)_______________C.J_______________ Age ____16_______

Date: _______________

RX __________ Hydrocortisone 2.5% Cream____________________________

SIG: Apply a thin layer to affected area twice daily for two weeks.

Dispense: _______ 30 grams ____ Refill: __None_______________

No Substitution

Signature:____________________________________________________________