Lab 1: General, Mental Status Exam, Skin s1


Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. If no information was given in the case, assume a normal finding (i.e. such as a finding from your lab partner).

Provider Name: Bugs Bunny, M2, 333-ACME

Date: Physical exam on 2 January 2010, 10:15 am

Patient ID: Patient Name, age, date-of-birth, profession

CC: chief complaint and duration

Vital signs

Temp:98 °F Pulse: 60, regular rate and rhythm

Resp: 12 BP: 125/75 (sitting, right arm)

Pain: 0/10 2nd BP: 148/84 (seated, right arm)

Height: 5’ 3” (by pt. report)

Weight: 132# (by pt. report)

BMI: please calculate(kg/m2)

Skin, Nails, & Hair

Color pink. Skin warm and moist. No rash, petechiae, or ecchymosis. No suspicious nevi [Use A,B,C,D criteria. If suspicious nevi present, include size, color, and recent changes]. Nails without clubbing or cyanosis. No sign of onychomycosis in hands or tocnails. Hair distribution is full, with no signs of seborrheic dermatitis or alopecia.

[illustration as appropriate]

Please include your suspected diagnosis for the cases given in the class handout, as well as a brief (1 – 3 sentences) justification for your diagnosis. (1 pt)


Synched 1-10 with “3)Derm_PE_1-1-09” and Bates 10th ed pg 170