- HIM FPX 4610 Assessment 1 Progress Note- The Skin.
Skin Progress Note Template
| Number | Medical Term | Common Term |
| Example 1 | Gastritis | Having stomach pain or an infection |
| Example 2 | Esophagogastroduodenoscopy | A way to look at the throat, the gastrointestinal tract, and small intestine via a scope |
| 1. | Oriented x3 | The person is aware of what’s going on around them and can talk, understand, and understand things (Heerema, 2022). |
| 2. | Integumentary exam | A check of the scalp, nails, and hair to see if there are any problems (Vasylivna Ponomarenko et al., 2022). |
| 3. | Upper extremities | The hands and forearms (Karamians et al., 2019). |
| 4. | Left radial | The arm bone that is nearest to thumb (Soydan, 2018). |
| 5. | Erythematous macules | Red dots on the skin that are tiny and flat (NIH, 2021). |
| 6. | Ulnar | The arm bone that is proximal to finger (Usta et al., 2021). |
| 7. | Actinic keratosis | A rough, scaly place on the skin that emerges from being in the sun for an extended period of time (Marques & Chen, 2022). |
| 8. | Bilateral | taking place on each side of body (Taggart et al., 2019). |
| 9. | Linear excoriation | Cuts or scratches on the skin that are straight or thin (Snorrason et al., 2015). |
| 10. | Fissuring | Splits or breaks in the skin, mostly on the tips of the fingers (Jahnny & Ashurst, 2021). |
| 11. | Superficial | Things that are lumpy or rough on the skin’s surface (Jacobson et al., 2022). |
| 12. | Deep subcutaneous masses | Those lumps or bumps that are under the layers of skin connected to the muscle area (De Marchi et al., 2020). |
| 13. | Lipomas | These are supple, fatty development that usually show up under the skin. Most of the time, that they look like a small, moveable lump beneath the skin. (Charifa et al., 2020). |
| 14. | Sebaceous cysts | Small, round pimples that are filled with oil that typically show up on the face, the neck, or chest (Zito & Scharf, 2020). |
| 15. | Biopsy | A medical examination in which a tiny bit of tissue is taken from the body and studied in a lab to figure out which sickness or condition it is (Information et al., 2016). |
References
Charifa, A., Azmat, C. E., & Badri, T. (2020). Lipomas, Pathology. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK482343/
De Marchi, A., Pozza, S., Charrier, L., Cannone, F., Cavallo, F., Linari, A., Piana, R., Geniò, I., Balocco, P., & Massè, A. (2020). Small subcutaneous soft tissue tumors (<5 cm) can be Sarcomas and Contrast-Enhanced Ultrasound (CEUS) is useful to identify potentially malignant masses. International Journal of Environmental Research and Public Health, 17(23), 8868.
https://doi.org/10.3390/ijerph17238868
Heerema, E. (2022). What Does Oriented x1, x2, x3 and x4 Mean in Dementia? Very well health.
https://www.verywellhealth.com/what-is-orientation-and-how-is-it-affected-by-dementia-98571
Information, N. C. for B., Pike, U. S. N. L. of M. 8600 R., MD, B., & Usa, 20894. (2016). What happens during a biopsy? In www.ncbi.nlm.nih.gov. Institute for Quality and Efficiency in Health Care (IQWiG).
https://www.ncbi.nlm.nih.gov/books/NBK348942/
Jacobson, J. A., Middleton, W. D., Allison, S. J., Dahiya, N., Lee, K. S., Levine, B. D., Lucas, D. R., Murphey, M. D., Nazarian, L. N., Siegel, G. W., & Wagner, J. M. (2022). Ultrasonography of superficial soft-tissue masses: Society of radiologists in ultrasound consensus conference statement. Radiology, 304(1), 18–30.
https://doi.org/10.1148/radiol.211101
HIM FPX 4610 Assessment 1 Progress Note- The Skin
Jahnny, B., & Ashurst, J. V. (2021). Anal Fissures. PubMed; Statpearls publishing.
https://www.ncbi.nlm.nih.gov/books/NBK526063/
Karamians, R., Proffitt, R., Kline, D., & Gauthier, L. V. (2019). Effectiveness of virtual reality- and gaming-based interventions for upper extremity rehabilitation post-stroke: A meta-analysis. Archives of Physical Medicine and Rehabilitation.
https://doi.org/10.1016/j.apmr.2019.10.195
Marques, E., & Chen, T. M. (2022). Actinic Keratosis. PubMed; Statpearls publishing.
NIH. (2021). Erythematous macule (Concept Id: C2228270) – MedGen – NCBI. Www.ncbi.nlm.nih.gov.
https://www.ncbi.nlm.nih.gov/medgen/1390597
Snorrason, I., Olafsson, R. P., Houghton, D. C., Woods, D. W., & Lee, H.-J. (2015). “Wanting” and “liking” skin picking: A validation of the skin picking reward scale. Journal of Behavioral Addictions, 4(4), 250–260.
https://doi.org/10.1556/2006.4.2015.033
Soydan, E. (2018). Coronary angiography using the left distal radial approach – An alternative site to conventional radial coronary angiography. The Anatolian Journal of Cardiology.
https://doi.org/10.14744/anatoljcardiol.2018.59932
Taggart, D. P., Benedetto, U., Gerry, S., Altman, D. G., Gray, A. M., Lees, B., Gaudino, M., Zamvar, V., Bochenek, A., Buxton, B., Choong, C., Clark, S., Deja, M., Desai, J., Hasan, R., Jasinski, M., O’Keefe, P., Moraes, F., Pepper, J., & Seevanayagam, S. (2019). Bilateral versus single internal-thoracic-artery grafts at 10 years. The New England Journal of Medicine, 380(5), 437–446.
https://doi.org/10.1056/NEJMoa1808783
Usta, H., Eraslan, U., Sarıipek, M., & Kitis, A. (2021). Ulnar styloid fracture accompanying distal radius fracture does not affect hand function, but what about hand dexterity? Journal of Hand and Microsurgery.
https://doi.org/10.1055/s-0040-1721564
Vasylivna Ponomarenko, O., Ludmila, N., Serhieieva, Parkhomenko, K., & Ponomarenko, O. (2022). Surgical treatment results in patients with defects of the integumentary tissues of the trunk and limbs of mechanical origin. Journal of Medicine and Life.
https://doi.org/10.25122/jml-2022-0019
Zito, P. M., & Scharf, R. (2020). Cyst, Epidermoid (Sebaceous Cyst). PubMed; Statpearls publishing.