WU, F18, N6512, Wk. 4, skin, AssignWrights c5a4a907-4d64-4b6b-bdcd-aed0eb3c041b. Advanced Health Assessment & Diagnostic Reasoning (NURS - 6512) Week Four Discussion Comprehensive SOAP Template Figure Two Patient Initials: _Unidentified Age: _Unidentified Gender: _Unidentified SUBJECTIVE DATA : There are no subjective data or patient information given about this patient. Chief Complaint (CC): None History of Present Illness (HPI): There is no patient’s identification such as age, sex, marital status given about this patient. However, the skin looks that of an older Caucasian patient. There is also no information about onset of symptoms, location, duration, character, aggravating factors, relieving factors, treatment, or severity. There are scatter cherry red spots on the patient’s skin. Medications: Not stated. Allergies: Not stated. Past Medical History (PMH): Not stated. Past Surgical History (PSH): Not stated.
Sexual/Reproductive History: Not stated. Personal/Social History: Not stated. Immunization History: Not stated. Health maintenance: Not stated. Significant Family History: Not stated. Lifestyle: Not stated. Review of Systems: An inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced. Typically, both positive and negative symptoms are documented. (Sullivan, 2012). General: No information about the general well-being such as weight loss, weight gain, fatigue, weakness, fever, chills, or night sweats given about the patient figure two. HEENT: Neck: Breasts: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Musculoskeletal:
Psychiatric: Neurological: Skin: Patient stated that there are several small bright, red, circular or oval shaped spots on the skin Hematologic: Endocrine: Allergic/Immunologic: OBJECTIVE DATA : These are the findings resulting from direct observation- what you see, hear, or touch. Relate physical findings to the processes of inspection, palpation, auscultation, and percussion, making the clear the process of detection so confusion does not occur. (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Physical Exam: Vital signs: No vital sign information given about figure two. General: HEENT: Neck: Chest/Lungs: Heart/Peripheral Vascular: Abdomen:
Genital/Rectal: Musculoskeletal: Neuro: Skin: Several small, bright red clearly circumscribed vascular tumors on the skin noted. ASSESSMENT: Lab Tests and Results: Diagnostics: The diagnosis can be made clinically; however, biopsy allows histopathologic confirmation in doubtful situations. Procedures: A skin biopsy (shave or punch) allows histologic confirmation of the diagnosis. Differential Diagnosis (DDx): 1.) Acute Urticaria 2.) Blue Rubber Bleb Nevus Syndrome 3.) Cherry angiomas 4.) Cutaneous Melanoma 5.) Infantile Hemangioma Diagnoses/Client Problems: Cherry angiomas
PLAN: This section is not required for the assignments in this course but will be required for future courses.
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