Krystall Huffman 22116026 Exam039823 Essay

1283 WordsJun 15, 20156 Pages
Dermatology Chart Note 1 Yanktonai, Lakota # 765851 May 2, 2015 SUBJECTIVE Patient is a 9 year old adolescent male, presents with a 2 day history of itching encrusted sores especially around the mouth area. Parent is using OTC antibiotic ointment with no improvement, no recent history of fever. Parent states that pat recently visited a petting zoo OBJECTIVE HEENT are basically unrevealing. Temp in the office today is 98.4. The outer area of the mouth extending into the chin reveals macules, vesicles, copious purulent exudate forming honey- colored crust on a erythematous base. Skin on trunk, arms and legs is clear. No other symptomology ASSESSMENT Impetigo PLAN 1. Rx for Mupirocin ointment applied to infected area TID. 2. Advised…show more content…
She has been sleeping better and her appetite has improved. She believes the outpatient therapy session have helped her with coping mechanisms. She has been trying to use diaphragmatic breathing techniques to assist her with her anxiety symptoms Objective Vitals Temp: 98.6 P: 83 Res: 18 BP: 126/70 General alert and compliant Effect has improved display of a variety emotional expressions APPEARANCE hygiene appears to be good. No detection of a skin lesions or rash HEART regular rate and rhythm LUNGS clear ASSESMENT Generalized anxiety disorder with mild depression. PLAN Continue Lexapro at 5 mg a dose and Klonopin at 3mg a dose. Continue outpatient counselling. Patient will follow up in 2 weeks or earlier if anxiety symptoms worsen. Milton E. Eisenberg, MD ME:hpi d&t 5/4/2015 Psychiatry Consultation Akhtar, Renita M. # 09438 May 4, 2015 CHIEF COMPLAINT This patient has been referred to me by her primary care physician. Patient states she has been suffering from irritability. She states that she has been very irritable for short periods of time. She associates these feelings with her depression. HISTORY PRESENT ILLNESS The patient is a 56 year old female who has recently lost her job and has been financially struggling. She has isolated herself from friends and family members. She claims to be close to her older sister but

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