Dermatology Outpatient Clinical Note

Dermatology Outpatient Clinical Note Chief Complaint: Female, 48 years old. Patient presents with a persistent, itchy rash on her forearms and neck. History Of Present Illness: The patient reports the rash started approximately three months ago, beginning on her left forearm and gradually spreading to her right forearm and then her neck. Initially, it presented as small, red papules that have since coalesced into erythematous, lichenified plaques. The rash is intensely pruritic, especially at night, often disrupting her sleep. She denies any associated pain or bleeding. She has tried over-the-counter hydrocortisone cream and various moisturisers, which provide temporary relief but do not resolve the condition. There are no clear aggravating or alleviating factors identified, though stress seems to worsen the itch. Past Medical History: * Childhood eczema * No history of skin cancer * No significant surgical history * No hospitalisations for dermatologic conditions * Mild asthma, well-controlled Medications: * Salbutamol inhaler PRN (for asthma) * E45 cream (topical, applied twice daily, no noted dosage) Allergies: * Penicillin (rash) * Nickel (contact dermatitis, confirmed via patch testing) Social History: * Tobacco use: Denies * Alcohol consumption: Occasional, 1-2 units per week * Recreational drug use: Denies * Occupation: Primary school teacher * Living situation: Lives with husband and two children in a house. Family History: * Mother: Atopic dermatitis (confirmed) * Father: No significant dermatologic conditions (denied) * Paternal grandfather: Skin cancer (basal cell carcinoma - confirmed) * Sister: Eczema (confirmed) Review Of Systems: General: Denies fever, chills, weight changes. Dermatologic: As described above, severe pruritus. Respiratory: Mild occasional wheeze, well-controlled with inhaler. Cardiovascular: Denies chest pain, palpitations. Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhoea, constipation. Musculoskeletal: Denies joint pain, muscle weakness. Neurological: Denies headaches, dizziness, numbness, tingling. Psychiatric: Reports increased stress due to persistent itching. Physical Examination: Vital signs: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Skin: Erythematous, lichenified plaques with excoriations present on bilateral forearms and sides of the neck. No active blistering or pustules. Nails: No signs of dystrophy. Hair: Normal scalp and hair distribution. Lymphatics: No palpable lymphadenopathy in cervical, axillary, or inguinal regions. Cardiovascular: S1/S2 normal, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, non-distended. Neurological: Cranial nerves intact, motor and sensory examination within normal limits. Assessment: Clinical impression is chronic eczema, likely atopic dermatitis, given the patient's personal and family history of atopy and the characteristic morphology and distribution of the rash. Differential diagnoses include allergic contact dermatitis (though no new exposures reported) and psoriasis (less likely given the intense pruritus and absence of silvery scales). Plan: * Prescribed Eumovate cream (clobetasone butyrate 0.05%) for application to affected areas. * Fingertip unit explanation was provided and a fingertip unit leaflet was given. * [Link to topical corticosteroids patient information leaflet] * Continue with regular emollients. Advised patient to apply generously twice a day. Allow to soak in and avoid rubbing. Apply after showering. Wait 30 minutes before applying any steroid cream. * [Link to emollient use in skin conditions patient information leaflet] * Consider patch testing if symptoms do not improve with topical steroids or if contact dermatitis is suspected upon follow-up. * Follow-up in 4 weeks to review treatment response. * Discuss triggers and avoidance strategies for eczema exacerbations.