Write up a history and physical assessment and patient centered plan of care for the integumentary system and head, neck and lymphatic system.
Patient Name: John Smith
Age: 45 years old
Chief Complaint: “I have noticed a rash on my back and it’s been itching for a few days now. I also have a sore throat and swollen lymph nodes in my neck.”
History of Present Illness: The patient reports a rash on his back that started a few days ago. It is itchy and has spread to other parts of his body. He also reports a sore throat and swollen lymph nodes in his neck. He denies any fever, chills, nausea, vomiting, or diarrhea.
Medical History: The patient has a history of hypertension and takes medication for it. He has no known allergies.
Social History: The patient is a smoker and reports drinking alcohol occasionally. He works in construction and is exposed to sunlight and dust.
Integumentary System: The skin is warm, dry, and intact. There are multiple red, raised, and scaly lesions on
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Head, Neck, and Lymphatic System: The head is normocephalic and atraumatic. The scalp is intact with no evidence of lesions or masses. The neck is supple with palpable, tender, and enlarged lymph nodes in the anterior and posterior cervical chains. There is no evidence of thyroid enlargement. The throat is erythematous with tonsillar enlargement and exudate. There is no evidence of uvular deviation.
Plan of Care:
Integumentary System: The patient will be prescribed topical corticosteroids to manage the rash and reduce itching. He will also be advised to avoid scratching the affected areas to prevent further irritation. The patient will be advised to avoid sunlight exposure and wear protective clothing when working outdoors. He will be instructed to keep the affected areas clean and dry and avoid sharing personal items like towels and clothes.
Head, Neck, and Lymphatic System: The patient will be prescribed antibiotics to treat the bacterial infection causing the sore throat and tonsillitis. He will be advised to rest and drink plenty of fluids to promote healing. The patient will be instructed to avoid smoking and alcohol to prevent further irritation of the throat. He will also be advised to avoid close contact with others to prevent the spread of the infection. The patient will be instructed to monitor his symptoms and report any worsening to the healthcare provider.
Follow-up: The patient will be scheduled for a follow-up appointment in 2 weeks to assess the response to treatment and monitor for any complications. The patient will be advised to seek immediate medical attention if he experiences any breathing difficulties, severe pain, or fever.