(2015). Cherry angiomas appear as tiny bright ruby-red, round papules that may become brown with time (Ball, Dains, Flynn, & Solomon, 2015). Image # 5 (Dry, silvery, scaling papules and plaques). Patient Initials: E.P. Age: 20 Gender: Female Subjective Data: Chief Complaint (CC) : “I started noticing these plaques on my elbows, and now I have them on my knees as well, they are very itchy” History of Present Illness (HPI): Emily is a 20-year-old Caucasian female who is presenting with complaints of itchy, dry, plaques over her elbows and knees. She states that she only started noticing these plaques a few days ago, but they have become very prominent and itchy with scales forming on top. Denies constitutional symptoms, denies fever, or pain. Medications: none Allergies: No Known Allergies Past Medical History: No significant medical history Past Surgical History: None Sexual / Reproductive History: Heterosexual, no children. Sexually active with a single partner, not married. Personal / Social History: Never smoked, denies alcohol. Reports experimenting with THC a few times in the past. Immunization History: Her immunizations are up to date. She requests the flu shot be administered this visit. Significant Family History: Her father has HTN, well controlled. Her mother is healthy. She has two younger brothers ages 14 and 18, healthy.
Lifestyle: Emily has a boyfriend, she lives with her parents at this time and is applying to a few universities. They live in a two-story house, her father is a commercial air plane pilot, and her mother is veterinarian. Both of her brothers are students. She reports being somewhat active, but she enjoys reading, shopping, and just hanging out with her friends. She spends a lot of time on her smart phone and tablet, on social media. She and her brothers eat mainly frozen meals, pizza, and fast food, as both their parents work a lot, and don’t have time to cook everyday. Review of Systems: General: Well-nourished young lady, slightly overweight, reports no discomfort. Reports a good appetite, sleeps well 8 to 10 hrs per night. HEENT: No changes in vision or hearing. Has not had an eye exam. No glaucoma, diploplia, floaters, excessive tearing, or photophobia. Denies ear infections, tinnitus, or ear discharge. She reports her sense of smell is intact, and denies sinus infections. Her last dental exam was 6 months ago, denies oral lesions, gingivitis, or gum bleeding. Denies difficulties swallowing. Neck: denies pain, swelling, or injury. Respiratory: denies cough, denies shortness of breath, and dyspnea. Cardiovascular (CV): Denies chest pain and palpitations. Gastrointestinal (GI): Denies abdominal pain, nausea and vomiting. No changes in bowel pattern. Genitourinary (GU): denies dysuria or frequency.
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- Summer '15