Patient states she is healthy and has not had any health concerns in the past, but has had “intense burning” prior to the visit approximately 3-5 days ago.
Skin and Psych Write-up
CC: Red rash on arms and neck, worrying
HPI:
Patient states she is healthy and has not had any health concerns in the past, but has had “intense burning” prior to the visit approximately 3-5 days ago. Patient states she had Varicella as a toddler, and has had one outbreak of Herpes Zoster in elementary school. Unilateral moderate pain to right side of neck and right arm. States to smoke 1 pack/day.
She is also a divorced mother of two teenagers. She has had a successful, well-paying career for the past several years in upper-level management. Even though she has worked for the same, thriving company for over 6 years, she’s found herself worrying constantly about losing her job and being unable to provide for her children. This worry has been troubling her for the past 8 months. Despite her best efforts, she hasn’t been able to shake the negative thoughts.
Family History:
Mother: Healthy
Father: Hypertension, takes BP medicine
Siblings: Healthy
Grandparents: Patient unaware of any pertinent history.
OLDCHARTS
Objective Component:
Vital Signs: BP 134/86
RR 20
Temp 98.7
O2: 99%
Assessment:
Mental health: The patient appears stressed and fatigued. Speech is of normal volume, rate, and words are articulate and fluent. Appears anxious and worried. No derailment of circumstantiality noted. Good judgment and insight. No compulsions, obsessions noted. The patient is orientated to person, place, time, and situation. Recent and remote memory intact.
Skin: Color pink. Skin warm and moist. Nail plates without clubbing or cyanosis. No suspicious nevi noted. Vesicular rash in a dermatomal distribution to neck, back, and arms noted with eruption of vesicles. Demarcated lesions.
HEENT:
Head- Hair is brown, thick, evenly distributed, texture soft. Skull is normocephalic/atraumatic.
Eyes: Brown, with visual acuity 20/30 right eye, and 20/25 left eye. Sclera white, conjunctiva pink. Pupils are 5mm constricting to 4mm, equally round and reactive to pen light and accommodations.
Ears: Rinne test: AC>BC, Weber test: Midline lateralization, and auditory acuity (whisper test) equal in both ears. Bilaterally clear TMs with good cone of light.
Nose: Nose symmetric and patent. Nasal mucosa reddish pink, without exudate. Nasal septum midline. No sinus tenderness.
Throat: Midline lingual frenulum, midline uvula, and tonsils small. Lips are pink, moist, and some cracking noted to lower lip. The oral mucosa is pink and moist, without lesions or nodules. Gums are pink and all teeth present. Dorsum of the tongue symmetric, pink, and smooth. Pharynx without exudates.
Neck: Trachea midline, no difficulties swallowing. Neck supple; thyroid isthmus palpable, lobes palpable but not enlarged.
Lymph Nodes – No cervical, axillary, epitrochlear, inguinal adenopathy.
Thyroid Gland: Thyroid isthmus palpable, lobes not felt.
Cardiac: Carotid upstrokes are brisk, without bruits. Crisp S1 and S2. At the base, S2 is louder than S1, with physiologic split ofA2>P2. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Respiratory: Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.
Plan:
Are there other possible systems to exam?
What other questions could be asked for the HPI?
Does the data included contribute directly to the assessment?
List your diagnosis as well as three differentials and treatment plans for each presenting problem. Place diagnoses in order of priority.
What are some patient education that could be provided?
FREE FROM PLAGIARISM
CC: Red rash on arms and neck, worrying
HPI:
Patient states she is healthy and has not had any health concerns in the past, but has had “intense burning” prior to the visit approximately 3-5 days ago. Patient states she had Varicella as a toddler, and has had one outbreak of Herpes Zoster in elementary school. Unilateral moderate pain to right side of neck and right arm. States to smoke 1 pack/day.
She is also a divorced mother of two teenagers. She has had a successful, well-paying career for the past several years in upper-level management. Even though she has worked for the same, thriving company for over 6 years, she’s found herself worrying constantly about losing her job and being unable to provide for her children. This worry has been troubling her for the past 8 months. Despite her best efforts, she hasn’t been able to shake the negative thoughts.
Family History:
Mother: Healthy
Father: Hypertension, takes BP medicine
Siblings: Healthy
Grandparents: Patient unaware of any pertinent history.
OLDCHARTS
Objective Component:
Vital Signs: BP 134/86
RR 20
Temp 98.7
O2: 99%
Assessment:
Mental health: The patient appears stressed and fatigued. Speech is of normal volume, rate, and words are articulate and fluent. Appears anxious and worried. No derailment of circumstantiality noted. Good judgment and insight. No compulsions, obsessions noted. The patient is orientated to person, place, time, and situation. Recent and remote memory intact.
Skin: Color pink. Skin warm and moist. Nail plates without clubbing or cyanosis. No suspicious nevi noted. Vesicular rash in a dermatomal distribution to neck, back, and arms noted with eruption of vesicles. Demarcated lesions.
HEENT:
Head- Hair is brown, thick, evenly distributed, texture soft. Skull is normocephalic/atraumatic.
Eyes: Brown, with visual acuity 20/30 right eye, and 20/25 left eye. Sclera white, conjunctiva pink. Pupils are 5mm constricting to 4mm, equally round and reactive to pen light and accommodations.
Ears: Rinne test: AC>BC, Weber test: Midline lateralization, and auditory acuity (whisper test) equal in both ears. Bilaterally clear TMs with good cone of light.
Nose: Nose symmetric and patent. Nasal mucosa reddish pink, without exudate. Nasal septum midline. No sinus tenderness.
Throat: Midline lingual frenulum, midline uvula, and tonsils small. Lips are pink, moist, and some cracking noted to lower lip. The oral mucosa is pink and moist, without lesions or nodules. Gums are pink and all teeth present. Dorsum of the tongue symmetric, pink, and smooth. Pharynx without exudates.
Neck: Trachea midline, no difficulties swallowing. Neck supple; thyroid isthmus palpable, lobes palpable but not enlarged.
Lymph Nodes – No cervical, axillary, epitrochlear, inguinal adenopathy.
Thyroid Gland: Thyroid isthmus palpable, lobes not felt.
Cardiac: Carotid upstrokes are brisk, without bruits. Crisp S1 and S2. At the base, S2 is louder than S1, with physiologic split ofA2>P2. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Respiratory: Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.
Plan:
Are there other possible systems to exam?
What other questions could be asked for the HPI?
Does the data included contribute directly to the assessment?
List your diagnosis as well as three differentials and treatment plans for each presenting problem. Place diagnoses in order of priority.
What are some patient education that could be provided?
- Assignment status: Get solution from our writing team
FREE FROM PLAGIARISM
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