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history and physical examination and presumptive nursing diagnosis

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history and physical examination and a presumptive nursing diagnosis essay assignment

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Mary is a 35 years old electrical engineer who presents to the office for evaluation of a rash on her face that has been present for 1 week. She denies new soaps, detergents, lotions, environmental exposures, medications, and foods. The rash is across her face and the bridge of her nose. She states that she first noticed it after spending a week hiking and camping in the Appalachians. The lesions itch and are painful. She has not tried anything to make it better, but she has noticed that going outdoors makes it worse. She denies any spread of the rash to other areas. She has never had this rash before.

She has noticed some increased fatigue, fever, and weight loss. She denies headache, sore throat, ear pain, nasal or sinus congestion, chest pain, shortness of breath, cough, abdominal pain, and pain with urination, constipation, or diarrhea. She does have mouth soreness. She has noticed some increased muscle aches and pains, which are worse in the hand and wrist. She denies early morning joint stiffness or difficulty with being able to move in the morning. She denies temperature intolerance, polyuria, polydipsia, or polyphagia.

She had a tonsillectomy at age 9 for chronic strep throat infections. She has been healthy as an adult. She has never had children. She has never been hospitalized for any reason.

Her family history is significant for a mother with rheumatoid arthritis. Her father is healthy.

She does not smoke; she drinks a glass of wine nearly every night with her dinner; she denies illicit drug use. She completed a master’s degree in engineering. She has lived with her boyfriend for the past 5 years.

Patient is an alert young woman, sitting comfortably on the examination table. BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F. Several erythematous plaques scattered over the cheeks and the bridge of nose, sparing the nasolabial folds. Normocephalic, atraumatic. Sclera white, conjunctivae clear; pupils constrict from 4 mm to 2 mm and equal, round, and reactive to light and accommodation. Oropharynx moist with erythema in the posterior pharyngeal wall; no exudates; shallow ulcers in the buccal mucosa bilaterally. Neck supple without cervical lymphadenopathy or thyromegaly. Full range of motion; no swelling or deformity; muscles with normal bulk and tone.

Instructions:

    Make a whole history and physical examination in a comprehensive manner with all its elements included: CC, HPI, PMH, FH, SH, MEDICATIONS, ALLERGIES, ROS PER APPARATUS OR SYSTEMNS, HEAD TO TOE PHYSIACL EXAMINATION PER SYSTEMS ( write your presentation in H&P format no paragraph format).

          Based on this information, what is your presumptive nursing diagnosis? All nursing diagnosis that apply to the case written in NANDA format related to … and evidence by…., NO MEDICAL DIAGNOSIS.

  Teaching plan and nursing care plan per each nursing diagnosis on this case.

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