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Thursday, September 06, 2007

Skin, Abdominal, Musculoskeletal Writeup

Patient Profile: A.S., 28 year old female, married

Chief Complaint: “I’ve been watching a spot on my arm and I’ve noticed it’s changed shape.”

History of Present Illness: Pt states that she has been going to tanning beds for several years and has noticed a mole that has started to change shape and coloration.

Past Health History: No major illnesses. Cesarean section in 2002.

Family History:
Paternal Grandfather (72) HTN
Maternal Grandfather (71) HTN, DM
Paternal Grandmother (70) Healthy Maternal Grandmother (68) Deceased MVA
Father (66) Healthy Mother (65)
Sister (32)
Patient (28) Healthy

Current Health: Sulfa allergy. Denies tobacco and drug use. States drinks 1-2 beers on the weekends. Drinks hot tea in morning and water rest of day. Sleeps approx. 7 hours nightly. States moderate exercise by walking and occasional aerobics.

Psychosocial History: Married mother of one child (4 yrs) Owns home and works full time as a cashier. Adequate insurance. Graduated highschool with no college.

Review of Systems:
General condition: States no weakness, fatigue, chills, or weight loss.
Skin: Denies any rashes, hives, bruising, or skin dryness. Denies any lacerations or lesions. States cesarean scar on abdomen. States mole on left arm 1cm with irregular border brown in color.
GI: No reported pain, nausea, vomiting, constipation, diarrhea, indigestion, rectal bleeding or change in bowel habits.
Musculoskeletal: No reported myalgia, stiffness, swelling or deformity.

Physical Examination:
Vital signs: BP 118/72 Pulse 68 Resp. 20 Height 5’4” Weight 160

Skin: Warm with good turgor. Intact with smooth texture. Pale pink in untanned areas. Scattered freckles consistently colored except for single brown mole 1 cm in diameter with irregular borders. Vertical surgical scar on abdomen from cesarean approx. 6 inches long.

GI: Slightly obese abdomen. Centrally located umbilicus. Surgical scar noted in lower abdominal quadrant approximately 6 inches in length. Silver colored striae noted scattered at lower abdominal and hip areas. Bowel sounds present in all four quadrants. No bruits in the renal, aortic, iliac or femoral areas. No visible aortic pulsations or peristalsis. Tympanic percussion in all four quadrants without pain. Liver palpated two fingers breaths below right costal margin. Spleen and kidneys not palpable. No herniations. No costovertebral tenderness noted.
Musculoskeletal: Posture erect with head midline. No kyphosis, scoliosis, or lordosis noted. Phases conform in gait. Weight evenly distributed, both feet straight ahead, no toeing in or out, all movements coordinated and rhythmic, arms swing in opposition, stride length appropriate. Balance intact. Patient can tandem walk, heel to toe walk, perform deep knee bend and hop in one place. Negative Romberg sign. Positive finger-thumb opposition, toe tapping and heel down shin. Full range of motion of neck, spine and extremities. Normal flexion and extension of upper and lower extremities. Strength 5/5 in all extremities.

Medical Diagnosis: Possible malignant melanoma. Referral to dermatologist for evaluation and potential removal.

Nursing Diagnosis:
Risk for altered skin integrity, as evidenced by neoplasm.
Risk for altered circulation, as evidenced by family history of HTN and patient BMI.

Education: Teach risks of sun bathing and tanning booths. Use of sunblock. Signs and symptoms of HTN per family history. Yearly checkups. Proper diet to encourage weight loss.