MS: Denies myalgia/arthralgia, no history of arthritis, gout, or impacts on movement for ADLs. No history of fractures. Psych: Denies depression, anxiety, mood disorders, sleep disturbances, or mental health history. Feels safe at home. Denies suicidal/homicidal history. Neuro: Denies history of seizures, dizziness, paresthesia, or memory problems. (+) for headaches on occasion. No tremors or abnormal movements. Denies trouble with gait or coordination and denies falls. Integument/Heme/Lymph: + skin abnormality growth on neck since 2 years ago, denies pain. Denies history of skin cancer or removal of growths/lesions. Denies bleeding disorders, bruising, clotting disorder, or transfusions . Endocrine: Denies any endocrine history or hormonal therapy. Allergic/Immunologic: Denies history of allergies or immune deficiencies. OBJECTIVE DATA: Physical Exam: Vital signs: B/P 120/80, left arm, sitting, regular cuff; Pulse 75 and regular, Temp 98.7 orally, RR 17; non-labored, Weight: 142 lbs; Height: 5'9; BMI 21 General: A&O x 4, reliable historian HEENT: PERRLA, Extra ocular movements intact, conjunctiva pink, no drainage from the eyes or nose, oronasopharynx is clear Neck: No bruit – carotids, no jugular vein distentions Chest/Lungs: Chest symmetrical, lungs clear anterior and posterior. Heart/Peripheral Vascular: regular rate and rhythm, no murmur, rub, or gallop; pulses +2 bilateral radial, and bilateral pedal ABD: no organomegaly, no tenderness, no rebound, no guarding Genital/Rectal: external genitalia intact, no lesions, no hemorrhoids Musculoskeletal: strong 5/5 strength upper extremities bilaterally, 5/5 strength lower extremities bilaterally, symmetrical Neuro: CN II – XII intact Skin/Lymph Nodes: Good turgor. Many flat hyperpigmented nevi on back, arms, and chest that range from tan to brown. Palpated 1 area of hyperpigmented skin ranging from
5 tan-to pink that was moveable on his neck. The skin abnormality in question is soft, is pedunculated, and is irregular in shape. Denies any pain when palpating. ASSESSMENT: Differential Diagnosis (DDx): 1.) Acrochordon (Skin tags) 2.) Neurofibromas 3.) Basal Cell Carcinoma Diagnoses / Client Problems: 1.) History of tobacco use – 28.5 pack year history DIAGNOSIS: The differential diagnosis for this skin condition listed acrochordon, neurofibromas, and basal cell carcinoma. Lipoff et al. (2018) states that acrochordons are among the most common skin lesions found and can mimic benign melanocyte nevi and neurofibromas. Out of the three potential diagnoses acrochordon is the skin condition diagnosis chosen for this patient.
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- Summer '15
- Acrochordon, J.O., Week 4 Assignment Example