Subjective Data:

• The patient is a 22-year-old female who presents with a complaint of a rash on her chest and back. She reports that the rash has been present for about 2 weeks and is getting worse. She says that it is not itchy or painful, but it is unsightly and she is self-conscious about it. She has no other medical problems and is not taking any medications.

Objective Data:

• On physical examination, the patient has a diffuse, erythematous rash on her chest and back. The rash is not raised or weeping, and there are no lesions or papules. The patient’s skin turgor is good and her mucous membranes are moist. Her vital signs are within normal limits.

Assessment:

• The most likely diagnosis for this patient is a contact dermatitis. This is a rash that is caused by an allergic reaction to a substance that comes into contact with the skin. The most common causes of contact dermatitis are cosmetics, soaps, detergents, and jewelry.

Plan:

• The patient will be advised to avoid the substance that she is allergic to. She will also be prescribed a topical steroid cream to help relieve the inflammation and itching. The patient will be seen again in 1 week to assess her response to treatment.

Skills (assessment techniques) utilized during the assessment:

• Inspection: The patient’s skin was inspected for color, texture, lesions, and edema.
• Palpation: The patient’s skin was palpated for temperature, turgor, and moisture.
• Auscultation: The patient’s lungs were auscultated for breath sounds.
• Odor: The patient’s skin was assessed for any unusual odor.