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CHIEF COMPLAINT (C/C)
“I have mild itching on my scalp. The itchiness began at one focal point but it is spreading to other areas. I feel like I have lost hair in some regions of the scalp. The itchy areas are painful with non-scaly patches due to persistent scratching.”

HISTORY OF PRESENT ILLNESS (HPI)
A 42-year-old white female patient has reported to the clinic complaining of pruritus and diffusing hair loss on the scalp. The pruritus and hair loss have persisted for the past two weeks. As reported by the patient, her symptoms started like a simple scratch on a focal area of the scalp but it has since spread to other areas characterized by hair loss. She further reports that areas of hair loss have non-scaly patches which do not resolve even by washing. The patient denies using any oral or topical medications to treat her current symptoms. She further indicates that cold weather aggravates the itchiness which is relieved during hot weather. She reports undergoing distress in the past one month due to personal life issues.

PAST HISTORY
CHILDHOOD ILLNESSES:

Does not report a history of chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine

Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018

– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2

HPV Three dose Series completed 2000
Influenza 12/21

COVID vaccine Completed 11/13/21, 3/15/21. She has not received a booster dose for COVID vaccine.
ADULT ILLNESS: Denies a serious medical condition during adulthood.
PSYCHIATRIC ILLNESS: Denies past or present psychiatric illnesses.
ACCIDENTS or INJURIES: Denies accidents or injuries
OPERATIONS: Reports undergoing operation during child birth at the age of 25 years. The patient reports undergoing a caesarian section when she was giving birth to her twins 17 years ago.
ALLERGIES: No known drug or food allergies.
MEDICATIONS: The patient denies using any medications at the moment.
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY: Father died of stroke at the age of 76 years. Mother is 66 years old. She is currently alive and was diagnosed with Type 2 diabetes mellitus 5 years ago. Her diabetes is well-controlled. The patient has three brothers aged 37 years, 34 years, and 32 years and one sister aged 20 years. All her siblings are healthy. Both maternal and paternal grandparents are deceased. The causes of their death are unknown.

SOCIAL HISTORY
Education: A university graduate
Occupation: Accountant
Living situation: Lives with her kids in a rental house
Denies a history of childhood asthma. Denies a history of hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Does not report TB or exposure to TB. Last physical check-up for pulmonary function was five years ago. Denies a history of pneumonia or a history of exposure to chemicals.
CARDIAC: Denies chest pain, or palpitations. Denies paroxysmal nocturnal dyspnea. Does not report orthopnea, edema, palpitations, hypertension, or known heart disease. Denies rheumatic fever, heart murmurs, or pain in posterior calves.

GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching, burping, or passing of gas; denies constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Reports soft brown stool with bowel movements occurring 1-2 times daily.

PHYSICAL EXAMINATION

VITAL SIGNS: BP: 117/73 (sitting, automatic), P: 98, RR: 20, T: 37.6 Ht: 58 inches Wt: 154 lbs; BMI: 24.3 (the patient indicates that this ranges within her usual weight).
GENERAL SURVEY: Alert and oriented to time, person, and place. Evidence of acute distress and fatigue. Well nourished. The patient’s appearance is appropriate for the stated age.
SKIN: Skin is smooth, warm, dry, and intact without rashes, or lesions. Nail beds are pink with no evidence of clubbing or cyanosis.
HEAD:  The head is normocephalic and atraumatic. Hair is short. There is evidence of hair loss in some areas of the scalp. Areas of hair loss appear non-scaly. There is also evidence of hair thinning and broken hair shafts in the regions that surround regions of hair loss on the scalp. There is uneven distribution of hair on the scalp. The remaining hair is black in color. Hair texture is soft. There is no evidence of scarring on the areas of hair loss.

EYES: Clear conjunctivae on both eyes. Both eyes are symmetrical. Lids are without drooping or ptosis. Both sclerae are white. No evidence of hemorrhage or exudates. No icterus or muddy appearance on the sclerae, conjunctivae are pale, corneal clear, PERRLA, EOM are intact, light reflex direct and consensual brisk and intact. No swellings of lesion on eye lids. Visual acuity 20/20 bilateral.  Optic disc with intact red reflex, optic disc with sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.

EARS: Internal and external ears are without edema or tenderness. Both ears are symmetrical and are in line with the outer canthus of the eyes. The pinna can easily be manipulated without difficulties. Rinne test AC>BC. No evidence of obstruction of the ear canals. No evidence of cerumen observed. The tympanic membrane IS pearly grey with good cone of light bilaterally. Weber -midline. Acuity good to whispered voice.

NOSE: Nasal mucosa is moist and pink. No evidence of discharge or nasal congestion. Turbinates are neither boggy nor enlarged. The sinuses are non-tender. The nasal septum is intact and positioned midline.

MOUTH AND THROAT: The buccal mucosa is moist. The tongue is positioned midline, moist, pink, and without fasciculation. The teeth in good arrangements on the gums. No evidence of cavities. The gum is pink with no evidence of gingivitis or halitosis. No tonsils or erythema observed on the throat. No exudates, lesions, or nodules. The pharynx is pink in appearance.
NECK: The trachea is positioned midline. The neck is supple with no adenopathy observed. Thyroid gland is normal without masses. Palpable thyroid isthmus. Carotid pulse 2+ bilaterally without bruit. No jugular vein distention (JVD). No stridor observed.
RESPIRATORY: Normal diaphragmatic excursion. The chest wall is symmetric and without deformity. No tenderness on palpation of anterior and posterior chest. No signs of trauma observed. No evidence of respiratory distress. Clear lung sounds in all lobes of the lungs bilaterally without wheezes, rales, or Ronchi. Normal Resonance on percussion of all lung fields.
CARDIOVASCULAR: The external chest is normal in appearance without palpable lifts, heaves, or thrills. Invisible PMI and is palpated in the 5th intercostal space at the midclavicular line. Normal heart rate and rhythm. No murmurs, rubs, or gallops. S1 and S2 are heard and are of normal intensity. No increase carotid pulsation on inspection; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; Heart sound one (S1) and heart sound two (S2)-normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.

ABDOMEN: Abdomen is soft and protuberant, no scars. Normal bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness. No tenderness on light and deep palpation Liver, spleen, and kidneys non-palpable. Umbilicus is midline with no evidence of herniation. No abnormal masses observed.

PROBLEM LIST
Mild pruritus or itching on the scalp

Sudden hair loss

Diffuse hair loss on the scalp

Non-scaly patches on regions of hair loss on the scalp

Absence of scarring in the affected areas of the scalp

Hair thinning/broken hair shafts

Areas of hair loss are non-erythematous
ASSESSMENT
Alopecia (non-scarring)

DIFFERENTIAL DIAGNOSIS
Trichotillomania

Lichen planopilaris

Stress

Anemia
DIAGNOSTIC PLAN:

Diagnostics

-Pregnancy test

-Psychological assessment to determine the degree of stress, the source of a stressful events, and use of hair products

-Pull test to establish whether there is evidence of active hair shedding

MEDICATION

-Intralesional triamcinolone acetonide injected intradermally

-2% solution of topical minoxidil

REFERRAL:
-Psychiatrist

-Gynecologist

-Dermatologist

Follow UP in 2 weeks:

PATIENT EDUCATION

Your primary diagnosis is non-scarring type of alopecia. Alopecia is a disease condition in which patients present with hair loss on the scalp. It is called nonscarring type because there is lack of scars on the areas of hair loss. Non-scarring alopecia may be triggered by numerous factors including stress, exposure to chemical agents, use of strong hair products, hormonal imbalance, or pregnancy-related reactions in women (Poonia et al., 2020). Non-scarring alopecia is reversible, especially when appropriate treatment is started early. Patients with non-scarring alopecia usually experience mild itchiness on the scalp characterized by hair loss which may be focal or diffuse. Hair thinning and softness are additional symptoms that are usually experienced by people non-scarring alopecia. In non-scarring alopecia, regions of hair loss can form non-scaly patches but are usually non-erythematous. Your alopecia may be attributed to a recent event of stress that are reportedly experiencing, hormonal changes, some cosmetic products that you are currently using on your hair, or exposure to some chemical agents that you might not be aware of (Oner & Akdeniz, 2021). Such substances usually cause hair non-scarring hair loss, especially in females You will be treated with intralesional triamcinolone acetonide intradermally to help relieve disease symptoms (American Academy of Family Physicians, 2020; Kapoor et al., 2020). You will also be given a 2% solution of topical minoxidil that you will be required to apply on your scalp twice a day for two weeks before visiting the hospital again (Wall et al., 2022). You will be referred today to a psychiatrist to assess the level and potential impact of your stress. Additionally, you will need to visit a dermatologist who should conduct a further assessment to establish possible causes of your alopecia and to recommend the most appropriate interventions. You will also need to visit a gynecologist to assess if there is an imbalance in the levels of your sex hormones. You are advised to engage in physical activity and consume a diet that is rich in proteins, fruits, and vegetables (Trueb, 2021). Feel free to reach the clinic using the number provided in your forms if you experiencing problematic symptoms.

References

American Academy of Family Physicians. (2020). Hair loss: Common causes and treatment. https://www.aafp.org/afp/2017/0915/p371.html

Kapoor, P., Kumar, S., Brar, B. K., Kukar, N., Arora, H., & Brar, S. K. (2020). Comparative evaluation of therapeutic efficacy of intralesional injection of triamcinolone acetonide versus intralesional autologous platelet-rich plasma injection in alopecia areata. Journal of Cutaneous and Aesthetic Surgery, 13(2), 103–111. https://doi.org/10.4103/JCAS.JCAS_16_19

Öner, Ü., & Akdeniz, N. (2021). Nonscarring scalp alopecia: Which laboratory analysis should we perform on whom? Turkish Journal of Medical Sciences, doi: 10.3906/sag-2106-28. Epub ahead of print. PMID: 34688244.

Poonia, K., Thami, G. P., Bhalla, M., Jaiswal, S., & Sandhu, J. (2020). Non-scarring diffuse hair loss in women: a clinico-etiological study from tertiary care center in North-West India. Journal of Cosmetic Dermatology, 18(1):401-407. doi: 10.1111/jocd.12559. Epub 2018 May 17. PMID: 29774652.

Trüeb R. M. (2021). “Let Food be Thy Medicine”: Value of nutritional treatment for hair loss. International Journal of Trichology, 13(6), 1–3. https://doi.org/10.4103/ijt.ijt_124_20

Wall, D., Meah, N., Fagan, N., York, K., & Sinclair, R. (2022). Advances in hair growth. Faculty Reviews, 11, 1. https://doi.org/10.12703/r/11-1