Question Q.Start with the presenting chief complaint diagnosis firs

Question Q.Start with the presenting chief complaint diagnosis first then make plan (Diagnostics, Therapeutic,Educational and consultation for these diagnois?  Number each diagnosis.A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication}.Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed}. Pertinent positives and negatives must be found in the write-up.CC: chief complaint – “This rash is getting worse, even with the creams you gave me”.  HPI: history of present illness – Patient is an 11-year-old black female who presents with complaint of worsening rash on bilateral arms and increased itching and flakiness on her scalp.    PMH: past medical history – She has a past medical history of mild eczema with no prior treatment needed before this fall.  There is no reported history of asthma. Allergies:   NoneMedications:  Hydrocortisone topical cream 2.5% to be applied twice daily to affected area.  General: She reports having a rash on her arms for the last month that is worsening.  She reports trying “the cream that was prescribed” with little to no improvement.  She also states that her scalp is itchy and flaking over the last month.  Her mother reports she has always had a flaky scalp in the colder months, but the itching is new.  Skin: She denies any new skin lesions, growths and hair or nail changes.  She reports that the “rash” that she has in the inside of her upper arm and some new “flaking” on her scalp. She denies noticing any skin changes to the skin on her neck.     Health Science Science Nursing NU 500 Share QuestionEmailCopy link Comments (0)

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