Initial Post Pictures #2/3 Patient Initials: ___FF ____ Age: __68 _____ Gender: __M _____ SUBJECTIVE DATA: Chief Complaint (CC): “My wife tells me I should be concerned about an increase in these discolored, bumpy areas on my chest and face.” History of Present Illness (HPI): 68-year-old white male who presents with concerns to lesions noted on anterior trunk (picture #2) and left cheek (picture #3). Indicates lesions in both areas are painless and do not itch or burn. Client is not bothered by lesions, but wants reassurance they are normal. - Client notes lesions on chest have been slowly increasing over the past several years and seem to appear, then change from bright red to brown, but do not seem to disappear. He reports picking at some of the chest lesions and reports they bleed profusely, heal quickly, but do not disappear. No treatments have been tried. - Lesions on left cheek have been present for over a year with no change in size or presentation. Has not noted any new lesions or changes to current lesions. Has not noted any crusting or bleeding of lesions. No treatments have been tried. Medications: multivitamin daily Allergies: Reports no allergies to food, medication or environmental factors Past Medical History (PMH): Reports normal childhood illnesses of varicella, rubella and mumps. Indicates no significant illnesses as an adult. History of right arm fracture with closed reduction at age 20 from an industrial accident with no further problems. Past Surgical History (PSH): Reports no past surgical history Personal/Social History: Client lives with wife. Retired attorney. Spends time outdoors fishing and playing golf Reports no tobacco, alcohol or drug use. Follows a regular diet. Moderately intense activity (racquetball / basketball) approximately 3 times per week. Immunization History: Up to date on immunizations. Last Tdap 2015 / Flu Fall 2016 / pneumonia PCV13 age 65 and PPSV23 age 66. Significant Family History: Children – alive (ages 38 and 40). No significant history Siblings – alive (age 70) multiple basal cell carcinoma (starting age 60). Reports this brother moved to AZ and has spent considerable time in the sun Parents: Mother alive, age 87 dx with hypertension (age 60), and arthritis (age 70) Father died age 55 from industrial accident Grandparents Maternal grandmother died age 72 from pneumonia. History of dementia (age 68) Maternal grandfather died age 85 “old age.” Reports no significant medical problems. Paternal grandmother died age 30 during childbirth Paternal grandfather died age 60 myocardial infarction. Diabetes (age 50).
Lifestyle: Alaska native, moved to WY 2 years ago. Active in community events. Active in Presbyterian church. Married for 42 years and reports no other sexual partners. (2) Children and (4) grandchildren live close and are part of support system. Active social life with friends and family. Wears hat and sunscreen when outdoors in sun since moving to WY.
You've reached the end of your free preview.
Want to read all 4 pages?
- Summer '15