Notes on Tina Jones Health Assessment Skin, Hair and Nails Assessment -Shadow health Latest Version, By Toprank

Patient presented for assessment, gave consent for examination. Patient in good spirits and conversational throughout exam. PMH: diabetes, hypertension. Patient admitted for wound to R plantar foot. Upon inspection, serosangineous/ purulent drainage noted. Positive granulation noted, no necrotic tissue present, red peripheral tissue noted, edema noted. Patient reports wound was healing slowly. Denies history of delayed healing of injuries or wounds Patient reports improvement of swelling, warmth, and discharge since admission to hospital. Denies any odor. Current pain level 5/10. Patient reports headache and blurred vision when reading or studying starting "a few months ago". Last eye exam "as a kid at the doctor" . Denies family hx of eye disease. Educated the importance of regular eye exams r/t diabetes. Denies current eye pain, itching, burning or discharge. No abnormalities noted. Patient reports acne since middle school, increased when she is due to menstruate. Seen provider in high school was prescribed tetracycline and prescribed topical cream in the past with no improvement. No further follow up for acne reported by patient. Currently uses face wash every night before bed with minimal improvement. Patient reports acne on her face and back. Reports face is oily, does not dry out from face wash. Patient reports an increase in body hair "all over" for "a really long time". g