Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things. HEENT:PERRLA, Extraocular movement’s intact, oral mucus and pharynx clearNeck:No bruit, jugular vein distention or tmegally noted to Carotids.Chest/Lungs: Anterior, posterior & lateral upper and lower lobes clear to auscultationHeart/Peripheral Vascular: regular rate and rhythm; no murmur noted; radial and pedal pulse +2.Abdomen: Normal bowel sounds to upper and lower quadrants(x4), no pain, complaint or discomfort with palpation, no rebound tenderness.Genital/Rectal:genitalia intact, no rash, trauma, discharge or s/s of infection noted. Musculoskeletal:Neurological:Skin:Labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. Skin biopsy, ECG (Normal sinus rhythm).Differential Diagnosis:1.) Psoriasis2.) Seborrheic dermatitis (seborrhea)3.) Eczema© 2014 Laureate Education, Inc.Page 3 of 4
Diagnoses/Client Problems:Hypertension (Controlled)DepressionPsoriasisAlcohol abuse (one 24 pack of beer a week)ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.REFLECTION:This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? © 2014 Laureate Education, Inc.Page 4 of 4
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- Summer '16
- History, Laureate Education, Medical diagnosis, James Cook