Integumentary/Hematologic/Lymphatic: + for multiple 1-2 mm firm, elevated papules , appearing bright red, diffuse over his chest and upper abdomen, non-blanchable. No rashes, itching, or bruising. Denies any bleeding disorders, excessive bruising or blood transfusions. Endocrine: No endocrine issues or hormonal disorder. Allergic/Immunologic: + history of generalized hives as a child after ingestion of amoxicillin. OBJECTIVE DATA: Physical Exam:
5 Comprehensive Soap Note Vital signs: B/P 122/78, right arm, sitting, adult regular cuff; P 74 and regular; T 97.6 orally; RR 19; non-labored; Wt: 193 lbs; Ht: 6’1; BMI 25.5 General: A&O x3, NAD, does not appear uncomfortable HEENT: PERRLA, Extra Ocular Muscle Intact, Ear canals patent. Nasal mucosa pink, normal turbinates. No septal deviations. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth in good repair. Neck: Carotids no bruit, jugular vein distention or t-megally, Full ROM Chest/Lungs: Clear to auscultation AP&L, Symmetric chest wall, respirations non- labored. Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; S1 S2; +2 peripheral pulses bilaterally, no edema Abdomen: benign, normal bowel sounds in all 4 quadrants, no rebound tenderness, no masses. Genital/Rectal: Deferred at this time. Musculoskeletal: Symmetric muscle development; muscle strengths 5/5 all groups Neurological: CN II – XII intact, DTR’s intact, speech clear and in good tone. Skin/Lymph Nodes : multiple 1-2 mm firm, elevated papule, color appears bright red, diffuse over the chest and upper abdomen, non-blanchable. ASSESSMENT: Diagnostics: None required Differential Diagnosis (DDx):
6 Comprehensive Soap Note o Glomeruloid hemangioma-Small, firm, red-to-violaceous, vault formed papules, papulonodules, subcutaneous pale blue compressible tumors, wine-red sessile or pedunculated papules, or injuries with cerebriform morphology. They extend in estimate, estimating couple of millimeters to couple of centimeters in distance across, and are found essentially on the storage compartment and proximal appendages and is portrayed by lone or numerous blue-red papules (Gupta, et al., 2013). o Petechiae is red to purple injuries showing up on the mucous films and skin. Injuries can be macular and discernable (American Academy of dermatology, n.d.). Petechiae is little sores estimating under 0.5 cm (Ball et al., 2015). o Cherry angioma-Cutaneous vascular expansion which shows as single or different spots and happens transcendently on the upper trunk and arms.
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