What should the initial history include

Reference no: EM133509421

Case: A 25-year-old patient reports "itching all over my body" and is seeking treatment for the condition. Upon assessment, the nurse notes reddened areas on the patient's arms, chest, and upper legs. The patient reports that this reddening is from scratching for the last 3 days. The patient reports intense itching around the undergarments as well. There is no apparent evidence of breaks in the skin, welts, pustules, or insect bites on the patient's skin. The area around the patient's undergarments appears chaffed, but no raised or open areas and no drainage are noted. The patient scratches around the undergarments but over the clothing, which has protected the skin from scratch marks. The patient's back also appears chaffed. The patient reports a history of environmental allergies with nasal symptoms due to pollens and pet dander. The patient reports no recent change in prescribed medications, no use of supplements, and no use of new lotions or creams. Upon further questioning, the nurse notes the patient has recently changed laundry detergent. The patient reports using oral diphenhydramine to assist with the symptoms and topical diphenhydramine, has been helpful as well. The patient reports drowsiness with the diphenhydramine, which is making it difficult to complete his daily routine. The patient is informed of treatment, and follow-up is recommended in 1 week if symptoms do not improve.

Case Questions

What should the initial history include?

Reference no: EM133509421

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