Pt is an 11y.o. black female who presents with worsening rash on bilateral arms and increased itching and flaking to scalp. Has a PMH of eczema not requiring treatment, and scalp that gets flaky in colder weather, which is a known trigger of eczema. Has family hx. of eczema. Has failed tx. with corticosteroid hydrocortisone 2.5% oint. Diet-loves chips and fast food. New appearance of bilateral inner arm rash which pt describes pain and burning which, nothing relieves, 7/10 pain. Skin has excoriated areas on rash from scratching. Also, an area of scaling and erythema to rash on arms approx. 3in. in diameter. Found cerumen impaction to left ear on exam. Diagnosis acute eczema flare-up with seborrheic dermatitis, and cerumen impaction left ear . Ruling out psoriasis d/t it is commonly on knees, elbows, trunk, and scalp, appears in cycles. Rashes appear to be purple with gray scale on brown or black skin, which the patient does not have. (Mayo Clinic, 2023).

A: Assessment:       

Diagnosis #1:                                                                      ICD-10 Codes:

 Eczema Flare-Up with Seborrheic Dermatitis           –Itching  L29.9

                                                                                             –Skin rash/scaly R23.4

                                                                                         -Flaky skin on scalp R23.4

                                                                                              –Painful rash R20.8 

                                                                                          -Tired appearance R53.83

                                                                                          -Mild eczema- L20.9

                                                                                          -Seborrheic Dermatitis L21.9

                                                                                          -Acanthosis Nigricans L83.0

                                                                                           -Eczema Flare-Up L20.83

Diagnosis #2:

Cerumen Impaction Left Ear                                ICD-10: Cerumen impaction left ear H61.22

CPT Codes:

69210 69210 Removal of impacted cerumen requiring instrumentation, unilateral.

99204 Clinic visit moderate requiring 45-59 minutes.

P: Plan:

Diagnosis #1: Seborrheic Eczema Flare

Diagnostic Orders:

• Routine labs of CBC, CMP.

Therapeutic:

• Stop hydrocortisone cream. Start Protopic Ointment 0.03%. Apply a thin layer to affected areas. One tube. 3 refills. Apply it to the affected skin bid. Stop once the rash is resolved (Drugs.com, 2023).
• Start Nizoral Anti-Dandruff Shampoo. OTC. Use it 2-3 times weekly. Let sit for a few minutes, rinse then use a moisturizing conditioner. Tendency to dry out hair. Can cut back to 1-2 times week. May use for up to 8 weeks. If rash develops or symptoms don’t improve in 2-4 weeks stop product and notify provider (Drugs.com, 2023).

Education:

• Discuss new medications, purpose, & side effects with patient and mother.
• Education on how diet and environmental allergens/irritants can trigger flare-ups. Discuss the Mediterranean Diet which includes foods lots of veggies, whole grains, legumes, fish with omega 3 fatty acids, and olive oil. Research has shown that this diet helps decrease inflammation in the body (Cleveland Clinic, 2023).
• Home Remedy to soften Scales from scalp includes applying mineral oil to scalp, leave on for 3 hrs., then comb hair, then wash and condition (Mayo Clinic, 2023).
• Avoid skin and hair products that contain alcohol, these can dry your scalp and increase scaling/flakiness.
• Increased stress, exposure to pet dander, and other allergens and irritants can trigger eczema flare-ups.
• Discuss referral to a Dermatologist for further evaluation and management. They will do a patch test which involves small areas of different substances in a square and they monitor for positive reactions and treat accordingly (Mayo Clinic, 2023).
• Follow up appointment in 2 weeks to monitor progress with medications, routine lab review, and evaluation of flare-up.

Consultation/Collaboration:

• Referral to Dermatology for Skin Patch test and further evaluation and management of patient’s eczema and flare-ups. They may also do additional testing to rule out different conditions, and test if the immune system is overactive.
• Consult with Pharmacist to see if there is a copay assistance program for the Protopic Ointment.

Diagnosis #2: Cerumen Impaction Left Ear

Diagnostics:

• N/A. No labs or diagnostic testing required.

Therapeutics:

• Recommend OTC glycerin drops. Apply monthly in each ear to soften wax and

      prevent recurrent blockage.

Education:

• The ear canal can become blocked with cerumen if the body produces too much, or if cleaned improperly. Do not use a cotton swab, pencils/pens, bobby pins, or any other objects in your ear, this will push cerumen into the eardrum and can cause pain, decreased hearing, damage to eardrum (U.C. Davis, 2023).

Consultation/Collaboration: N/A.  No need currently. If this becomes a recurring issue, then would refer to ENT.

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