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Health Assessment (NR304) Health Assignment Example Week 4

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Health assignment example week 4

Chamberlain College of Nursing

Health Assessment (NR304)

Discussion Differential Diagnosis for Skin Conditions
Week 4
PHOTO #4
SUBJECTIVE DATA:
Patient Initials: __RG_____ Age: __27___ Gender: ___female
Chief Complaint (CC): “I have piece of skin on my back not sure what it is, it is really
bothering me. I hurts when I try to shave near it”
History of Present Illness (HPI):
Patient is a concerned 27 year old Hispanic female who presents with complaints of several
small cutaneous, soft flesh like colored, pedunculated areas of flesh on her left arm pit (Ball,
Dains, Flynn, Solomon, & Stewart, 2015). The acrochordon cutaneous tags has been there for
over a month. The “small, soft, common, benign, usually pedunculated neoplasm” lesions
(Schwartz, 2017), do not cause any pain, itch, and have not changed in size and color. Patient
states she has never had them before and recently gained 40 lbs in the last 3 months. Patient has
(6) “filiform lesions of approximately 2 mm in width and 5 mm in length occurring on her left
axilla area (Schwartz, 2017).
Medications: Tylenol 325 mg x2 tabs q 4 hrs as needed (pain). Recently started herbal life
supplement for weight loss.
Allergies: RG states she has No known allergies (NKA)
Past Medical History (PMH): tubal pregnancy at age 21
Past Surgical History (PSH): Gallbladder surgery in 2000
Sexual/Reproductive History: Heterosexual, denies any recent sexual activity in the past 2
years
Personal/Social History: occasional smoker 1-2 cigarettes a day, denies use of illegal street
drug use, drinks on weekends (alcoholic beverages) with a meal on occasion. Eats frozen dinner
prepped meals at work and for dinner during the week. Eats out on weekends with friends.
Immunization History: Tdap- last 2011, all other vaccination are current
Family History: Mother is diabetic, father has HTN, paternal and maternal grandparents all
deceased and died of diabetic complications. One brother who has no medical history age 18.

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Health Assessment (NR304) Health Assignment Example Week 4

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