A 35 year old female, Mary, educated to masters level in engineering and working as an electrical engineer, presented with complaints of a skin rash across her face and bridge of her nose that is sensitive to touch and outdoor exposure. She also complains of fatigue, fever,…
Aside from that, her head was found to be normocephalic with no signs of trauma or other deformities. She had clear white sclera and clear conjunctiva; her pupils were reactive to both light and accommodation. Erythema was noted on the posterior wall of her pharynx, and ulcers were found on both of her buccal mucosa. Her neck showed no swelling or bumps, and no traces of lymphadenopathy or thyromegaly. Patient had no trouble achieving full range of motion in her joints with no obvious swelling or deformities. Patient’s vital signs showed a normal heart rate at 62 beats per minute, normal respiratory rate at 12 breaths per minute, a normal blood pressure of 112/66 mmHg, and an elevated temperature of 100.3 degrees Fahrenheit.
Patient reported that the rash was first noticed after a week outdoor hiking and camping in the Appalachians. She denies exposure to any new skin products, usage of medications, environmental exposure, and food allergies. She has not taken any medication for the rash. She denies experiencing headache, sore throat, ear pain, nasal congestion, chest pain, shortness of breath, cough, pain during urination, urination and diarrhea. She reports no stiffness in the joints or difficulty in getting up in the morning.
The only surgical procedure that the patient has undergone was a tonsillectomy at age 9 due to her chronic strep throat infection. Other than that, she has not had any other diseases needing hospitalizations as an adult.
Based on the information, the patient’s main concern is the rash on her face and what it means. Considering the location, the shape, and the other symptoms, it could be a malar rash pointing to Systemic Lupus Erythematosus, but since it is yet to be diagnosed, the more pressing concern is her fatigue. This can be caused by not enough energy being produced to cope with the ...
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“Physical Assesment Case Study Research Paper Example | Topics and Well Written Essays - 1000 Words - 1”, n.d. https://studentshare.net/nursing/554343-physical-assesment-case-study.
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