Discussion Week 4.docx - NURS 6512 Advanced Health Assessment and Diagnostic Reasoning INITIAL POST Case Study 1 Photo#5 SUBJECTIVE DATA Chief

Discussion Week 4.docx - NURS 6512 Advanced Health...

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NURS 6512: Advanced Health Assessment and Diagnostic ReasoningINITIAL POSTCase Study 1- Photo #5SUBJECTIVE DATA: Chief Complaint (CC): Dry, scaly patches on my skin. History of Present Illness (HPI): LD is a 24 year old Caucasian female who presents today with skin lesions on her lower legs bilaterally x 2 months. She reported that the “lesions seem to go away when her legs get some sun but then come back after some time”. The lesions are red and become dry and scaly. She has associated symptoms of itching. She has been putting Eucerin cream on the lesions but it hasn’t really helped. She feels the severity of her symptom discomfort is getting worse which brings her in today. Medications: 1.Mesalamine 375 mg extended release capsules, 4 caps orally once a day in the morning2.Valtrex 1000 mg tab, 2 tabs every 12 hours for 24 hours as needed for oral herpes.3.Ortho-Novum 7774.Over-the-counter Tylenol 325 mg tabs, 2 tabs as needed.5.Fish oil 1000 mg dailyAllergies: No known allergies.Past Medical History (PMH): 1.Ulcerative colitis2.Herpes simplex virus type 1Past Surgical History (PSH): 1.ColonoscopySexual/Reproductive History: She is sexually active, currently on oral contraception. Has single partner for last 2 years and no pregnancies.Personal/Social History: Denied smoking or illicit drug use, Drinks 3-4 beers or glasses of wine a week.Immunization History: Immunizations are up to date.
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Significant Family History:Father diagnosed with prostate cancer at age 56. Lifestyle: She lives in the city and commutes to work. Works for an active travel company leading biking trips in France and the US. She has a master’s degree and rents an apartment with her boyfriend of 2 years. She is active and eats a healthy diet. She has a good support system of family and friends. Review of Systems: General: No recent weight gains or losses of significance. Patient denies fatigue. She denies fever or chills. No sleep disturbances.HEENT: Denies any change in vision, double vision, or eye pain. Has never worn glasses or contacts. Denies any changes in hearing or ear pain. Denies sinus infections and epistaxis. Last dental exam 2 months ago for regular cleaning. Denies bleeding gums or toothache. Neck:No injury or pain. Breasts: Denies any breast changes. No history of masses, rashes, or lesions on breasts. Respiratory: Denies cough or sputum production. No dyspnea on exertion. Cardiovascular/Peripheral Vascular: No history of murmur. No chest discomfort or palpitations. No edema or claudication. Gastrointestinal: + occasional abdominal pain in past, no nausea or vomiting, + irregular bowel pattern in past. Denies acid reflux. Genitourinary:Denies changes in urinary pattern. No incontinence, no history of STDs or HPV, patient is heterosexual. Musculoskeletal: No limitation in range of motion. No history of trauma orfractures. Denies arthritis.
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