Everyday Heatlh Inc 2013 Resources for dermatology and visual conditions

Everyday heatlh inc 2013 resources for dermatology

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Everyday Heatlh Inc. (2013). Resources for dermatology and visual conditions. Retrieved from PATIENT NAME: John Smith AGE: 55 SEX: Male DOB: April 1, 1960 Subjective Data CHIEF COMPLAINT: “I have itchy patches of skin on my arms (image #5) and red blister looking things (image #2) on my torso.” HISTORY OF PRESENT ILLNESS: This 55 year-old patient presented to the clinic this morning with complaints of pruritus of circumscribed, dry, scaling plaques on the posterior aspect of his forearms. The patient recalls that the plaques started out much smaller a few months ago and have progressively grown in size. He states that the pruritus is intense at times but denies any pain or other associated symptoms. In addition, he tried applying over the counter lotion to the areas with no relief of symptoms. In addition, the patient is concerned about some cherry red, discoid, papules that are present on his torso. He explained that they have been present for years but he became concerned when he scratched one and it began bleeding profusely. He denies any associated symptoms or exacerbating factors of the papules. PAST MEDICAL HISTORY: Medical: 1. Hypertension: diagnosed at age 41 2. Myocardial infarction: age 52 3. Coronary artery disease: diagnosed at age 50 4. Dyslipedemia: age 50 Surgical: 1. Heart catheterization with stenting to the RCA (Dr. Smith, Joplin, MO), age 52 2. Cholecystectomy (Dr. Coy, Joplin, MO), age 44
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Medications: 1. Aspirin 81mg PO daily 2. Simvastatin 20mg PO daily 3. Lisinopril 20 mg PO daily Allergies: Sulfa drugs and Penicillin – both cause a rash Health maintenance: Mr. Smith presents for routine physicals on a yearly basis. The last time he completed any routine blood work was at his routine examination 2 years ago. Immunizations: Mr. Smith is current on his immunizations and receives the yearly influenza vaccination with the last one in September of 2014. FAMILY HISTORY: Father deceased at age 51 as a result of a vehicle accident and mother is 76 and also has hypertension and coronary artery disease. One sibling, age 49, has diabetes but is otherwise well with no significant health history. Mr. Smiths 2 children are well with no significant health history. PSYCHOSOCIAL HISTORY: Mr. Smith is married and resides with his wife. One child still lives at home and the other child lives in town at his own residence. Mr. Smith is a high school graduate and works stocking shelves at the local grocery store. His wife is a nurse and receives medical benefits through her place of employment. He denies any financial concerns. He is a 1 pack per day smoker times 20 years but denies the use of alcohol or recreational drugs. He does not engage in any regular exercise program and lives a somewhat sedentary lifestyle when not at work. He does not have any special diet considerations but does eat a well balanced diet and avoids caffeine. REVIEW OF SYSTEMS: General: No recent changes in weight and denies any fatigue, night sweats, fever, or chills.
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