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Physical Assesment Case Study
Pages 4 (1004 words)
Physical Assessment of a Patient with Complaints of Skin Rash across Face and Other Symptoms Introduction 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.
Client was awake, alert and coherent. Physical assessment revealed erythematous plaques covering both cheeks, and at the bridge of her nose, without affecting the nasolabial folds or any other part of her body. 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. Interview and Health History 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. ...
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