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Diagnosis: Acne Vulgaris

Plan:

Pharm Interventions:

Non pharm interventions:

Diagnostic testing:

Education:

Follow up:

and immediately available diagnostic results with interpretation

Correctly lists all diagnoses including differentials (if applicable); Comprehensive plan of care including pharm and non-pharm interventions, diagnostic testing, education, and follow up

Interventions outlined in the plan of care for original and suggested alternatives for response posts are supported with evidence from current, relevant, scholarly, peer-reviewed sources including but not limited to textbooks, practice guidelines, and scientific journals. APA  format for reference citations. ANNP8070 UCMC Skin Assessment Discussion

Skin Assessment

Pt. Initials: GS

 

Date:5/13/2022

 

Age:14

 

Gender: M

 

S:

Cc “I have pimples and redness all over my face”

 

HPI 14-year-old Caucasian Male who presents to the office with his mother, with CC pimples and redness all over face and cannot seem to make it go away. Pt states he has had this problem for a year, but it’s been worse the past 3 months. Patients mother states, “it seems to have gotten worse when we moved to Florida from Colorado last year.” Patient denies any itching, pain, or tenderness. No other complaints. Patient states this is the first time he has ever had this happen since starting a year ago and progressing. Patient has tried over the counter face washes with no changes or improvements. Patient states he washes his face 3-4 times a day. Patient denies being around anyone with a skin condition or any chemicals or changes in environmental. Patient denies any recent changes in body soap, laundry detergent, or lotion. Pt denies any other rashes, lumps, or itching. Denies other skin, nails, or hair changes. Patient denies allergies and no new animals in the home. ANNP8070 UCMC Skin Assessment Discussion

ORDER  A PLAGIARISM FREE PAPER  NOW

PMH- Patient has no past medical history. Patient’s mother concurs.

            Allergies- allergic to PCN (rash)

            Medications- Denies RX medications

OTC or herbal/ Vitamins: Pt denies taking OTC medications, herbal, supplements, or vitamins.  

Surgeries: No previous surgeries

Vaccinations: Denies Flu, pneumonia (patient has had all child mandated vaccines per CDC)

Last Exams: Patient saw PCP at this office 1year ago for routine physical. Pt also sees pediatric dentist once a year. (Last exam 6 months ago)

Psychiatric history: Denies history of depression, anxiety, Suicidal thoughts, or any other psychiatric history

 

ETOH: Denies drinking alcohol

 

Tobacco: denies tobacco use

 

Illegal Drugs: Denies ever using illegal drugs

 

Occupation/Status: Patient is in 9^th grade and is homeschooled by his mother. Not sexually active.

 

Sleep Pattern: Pt states he sleeps about 12 hours a day

 

Exercise History: Reports he works out 4 days a week for about an hour at his neighborhood gym and plays basketball with friends a few nights a week. Pt has been working out for about a 1 year and playing basketball since he was 6 years old. Mother states he has always “been a very active boy and enjoys playing outside”.

Nutrition:

Last 24-hour diet recall: Breakfast: 2 scrambles eggs and 2 pieces of toast with cheese. Lunch: Ramon noodles and a turkey sandwich. Dinner: Chicken and Rice. Snack: Chips, Chocolate granola bar and an energy drink. Drinks 1-2 cans of sprite and/or Dr Pepper every day, 1-2 bottles of water every day. ANNP8070 UCMC Skin Assessment Discussion

FH: Patient denies any family history of throat/mouth/thyroid cancer, glaucoma, or macular degeneration

Paternal Grandfather, 60, HTN

Paternal Grandmother, 56, Hyperlipidemia

Maternal grandfather; living 64y/o, HTN

Maternal grandmother; Living 64, HTN

Father: 36 years old, living, Asthma, Acne Vulgaris, Hay fever

Mother, 34 years old, living, No pertinent medical history

Brother-12 years old – asthma

 

ROS

O:

General appearance: Patient was sitting in exam room AAOX4, no distress noted, Friendly and good historian with mother in the chair next to him. Skin color appropriate for race. Patient was well groomed. Appears to have healthy hygiene and dental hygiene.

Vital signs: BP Left arm sitting 110/70, HR 88 Apical Sinus Rhythm, Resp 17 Regular non labored and even, Temp 97.0 Temporal, O2 sat 100% on room air, denies pain at this time. ANNP8070 UCMC Skin Assessment Discussion

Denies fever, fatigue, or malaise. 5’8, 150lbs, denies weight changes. Appetite good. BMI 22.8 (82%) Healthy weight

 

HEENT:

Head/Neck: patient denies any lymph node pain, goiters, swelling, nodules, headaches, head trauma, dizziness, light headiness, or sinus pressure.

Eyes: denies eye pain, vision changes, itchy or discharge. Denies wearing corrective lenses

Ears: denies changes in hearing, ringing, pain, or discharge.

Nose: denies pain, nose bleeds, polyps, loss of smell, or hay fever.

Mouth/Throat denies sore throat, difficulty swallowing, loss of taste, gum bleeding, carries or lesions. Denies TMJ

Respiratory: denies SOB, cough, asthma, nasal discharge, allergies, or swollen glands.

GI: denies heartburn or indigestion, constipation, vomiting, nausea, diarrhea, masses, hernias, or bowel changes.

Skin: C/o pimples and redness to face denies any other rashes, cyanosis, clubbing of fingers, night sweats, or changes in nails or hair

 

Physical Assessment:

Head:

Inspection: Normocephalic, symmetric, clear of scars, acne, bumps, bruises, redness, rash and swelling, no drooping, no weakness, or involuntary movement.

Palpation/Auscultate: No lesions, bumps, tender spots, or scabs felt. Mandible is symmetric with no cracks or pops during palpations when assessing TMJ and having pt open mouth (with fingers by the tragus of the ear) Lymph nodes are non-palpable and non-tender. Temporal artery no bruits

ORDER  A PLAGIARISM FREE PAPER  NOW

Neck:

Inspection: Accessory muscles symmetrical while head erect and still and trachea(midline) on observation. Lymph nodes not swollen on inspection. Supple with full ROM. Face symmetrical, no drooping

Palpation: Lymph nodes are non-palpable and non-tender. Thyroid is soft and smooth on palpation with proper upward movement when swallowing (Standing behind pt, had pt tip head forward and toward the side to be examined and swallow). Thyroid moves up into assessors’ fingers when swallowing bilaterally. Carotid arteries +3/4 with palpation on one side at a time. ANNP8070 UCMC Skin Assessment Discussion

Auscultation: Trachea no stridor, Carotid arteries no bruits, Thyroid no bruit

Eye:

Visual Acuity: Snellen 20/20 bilaterally, EOM intact,

Visual fields normal by confrontation (standing 2 feet away-looking into eyes at eye level- flickering finger until they can see / cover one eye at a time)

Corneal light reflex- symmetric bilaterally. (Shines light 12in away while pt looks straight ahead).

Cover- uncover test: no weakness noted / gaze remained normal ( pt stares straight at nose, cover one eye at a time)

Cardinal Fields of gaze-Tracking of object with both eyes

Inspection: no papilledema, conjunctiva- pink, moist, clear, Sclera white. No crusting or drainage around tear ducts/eyelids. Brows and lashes present. Cornea and lens smooth.

Palpation: eversion of upper lids, no color change, swelling or lesions

Funduscopic: PERRLA, Red reflex present bilaterally, macula is approximately 2.5 disc flat with sharp margins. Vessels present. No crossing defect, retinal background even with no hemorrhages or exudate, macula even color bilaterally.

 

Ear:

Hearing test:

Whisper test- passed- patient able to hear whispered words bilaterally from 2 feet away with one ear covered at a time

Rinne- AC>BC bilaterally (using the tuning fork placed behind ear on bone, tell me when it stops, move to the front of the auricle, and tell me if you can still hear it)

Weber- not lateralized (using the tuning fork, tell me which ear or both that you hear it in)

Inspection: External- symmetric bilaterally, no drainage, bruising, edema, or erythema noted.

Palpate: no tenderness or pain. (Pushed on tragus and mastoid bone)

Otoscopic: TM bilaterally pearly gray with light reflex and landmarks intact, no perforations, no foreign bodies or ear wax. Inspected internal ear and malleus (short process and handle) ANNP8070 UCMC Skin Assessment Discussion

Nose :

Inspection : External- Symmetric, no drainage, polyps, or secretions observed

Patency : Internal- Nares patent, septum midline and symmetric. Mucousa pink and dry

 

Sinus :

Palpation/ Transillumination : Non tender, no edema. Normal transillumination (using the light)

 

 

Mouth:

Inspect & Palpate: Can clench teeth

Breath: No halitosis

Lips: moist, not cracked, no erythema or sores

Tongue: midline, pink and smooth, no lesions

Buccal mucosa: moist, pink, no edema

Gums: moist, pink, no edema, or sores/ulcers

Teeth: straight with good dentition

Uvula: midline, rises on phonation

Throat/Tonsils: Pink mucosa, no lesions, or exudate/ Tonsils grade 0 with no spots or lesions observed

Gag reflex present

 

 

Skin:

Presence of comedones, papules, pustules, and erythema on face. Grade 3. No other lesions or rashes noted on neck, trunk, or other body parts. No warts or moles noted on skin.

 

Differentials: Folliculitis, Rosacea

Diagnosis: Acne Vulgaris

 

Plan:

Pharm Interventions:

Non pharm interventions:

Diagnostic testing:

Education:

Follow up:

and immediately available diagnostic results with interpretation

 

Correctly lists all diagnoses including differentials (if applicable); Comprehensive plan of care including pharm and non-pharm interventions, diagnostic testing, education, and follow up

 

Interventions outlined in plan of care for original and suggested alternatives for response posts supported with evidence from current, relevant, scholarly, peer-reviewed sources including but not limited to textbooks, practice guidelines, and scientific journals. ANNP8070 UCMC Skin Assessment Discussion.APA  format for reference citations