Wk4Assgn1+Walton+H.doc - 1 Advanced Health Assessment of Skin Conditions Helen Walton Walden University NURS 6512 Advanced Health Assessment and

Wk4Assgn1+Walton+H.doc - 1 Advanced Health Assessment of...

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1 Advanced Health Assessment of Skin Conditions Helen Walton Walden University NURS 6512 Advanced Health Assessment and Diagnostic Reasoning December 22, 2019
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2 Advanced Health Assessment of Skin Conditions During a comprehensive or a functional health examination, a comprehensive review of the patient’s integumentary system is paramount. While focusing on other warrented systems throughout the human body, none is larger and more of a mystery to the clinician then that of the integumentary system ( Clark, Pope, & Jaboori, 2015). While focusing on concerns and specific symptoms and complaints by the patient involving illness; precise observation of the skin with direct and open questioning should occur. It is an opportunity to note discolorations, irregularities, damage, tissue breakdown and biomarkers and employ them as a diagnositic tool ( Brian, Vinayak, Javier, Stephanie, Robert & Manoj, 2017). The integumentary system examination provides critical data to identify, treat, educate and refer for skin conditions such as cherry angiomas, capillary hemangioma, and eczema. Patient Initials: SG Age: 62 Gender: Female SUBJECTIVE DATA: Chief Complaint : Image #2 Red bumps on trunk, chest and upper back. History of Present Illness (HPI): 62-year-old Caucasian female presents to the office this morning indicating concern over the rash on her chest, abdomen, and upper back. There are numerous (30-40), red macules and papules of fluctuating sizes noted across the abdomen, chest and upper back. The macules and papules present with distinguishable boundaries. It is noted that 3 of the papules on the upper back have been irritated and opened and are currently in the inflammatory phase; one area approximately 3mm-has fibrous scar tissue forming. The patient complains that the macules under her bra and underwear open, become irritated, and bleed on her clothes periodically. SG rated her pain at a 0/10. Medications: 1. Albuterol 90mcg 2 puffs every 6 hours as needed 2. Breo 100/25 1 puff every day 3. Nexium 20mg every day 4. Over the counter Calcium 1200mg every day 5. Over the counter Vitamin C 500mg every day
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3 Allergies: 1. No Known Drug Allergies 2. Seasonal Past Medical History (PMH): 1. Gastroesophageal reflux (GERD)-Nexium 2. Asthma-well controlled on current medication 3. Post-menapausal Past Surgical History (PMH): 1. Right knee-open reduction internal fixation 2014 2. Appendectomy 1978 Sexual/Reproductive History 1. Heterosexual 2. G0P0A0 3. Post-Menapausal since 2008 Personal /Social History: Smoked cigarettes for 2 years between ages 16 and 18. Currently has 2-3 glasses of wine weekly when socializing with friends. Immunization History: 1. Influenza immunizationa in October 2019. 2. Received a Tdap; Hepatitis A; Hepatitis B in 2017 as an employment mandate (School substitute). Significant Family History: 1. Both parents are alive, mother sufferes with NIDDM 2. Lost a younger sister to CVA in 2017 Review of Systems : GENERAL: Denies changes in health status, no complaint of pain; weight has been relatively steady since 2008, no complaint of weakness.
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  • Summer '15
  • Complaint, Pleading, Physical examination, Medical diagnosis, hemangioma

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