Subjective Data

Chief Complaint (CC): itchy, scaly, and thick patches of skin

History of Present Illness (HPI): 34-year-old Vietnamese male presents to the clinic for itchy,
dry, and flaky patches of skin. Denies recent injury, trauma, or burns.
Past Medical History (PMH): seasonal allergies
Disabilities: none
Illnesses: none
Surgeries: none
LMP/OB: n/a
Hospitalizations: none
Trauma: none
Medications: Denies taking any medications and other OTC medications
Allergies: none
Immunizations: Flu shot 2023, COVID 2023
Exercise/Leisure: 60 mins of exercise 3x week
Sleep: 8 hours a night
Diet: American and Vietnamese food
Safety measures: wears sunscreen
Family/Social History: Single, no children, denies smoking, alcohol, or drug use
Mother: 50 years old with HTN and psoriasis
Father: passed at age 55 years old, healthy
Grandmother: passed at age 81 years old, healthy
Grandfather: passed at age 82 years old, healthy
Sibling: 1 brother 36 years old, healthy
Review of Systems (ROS)
General:
Skin: Rash, dry, flaky, and erythematous skin front R knee, silvery plaques, pain 2 out of 10
HEENT: Denies headache, any vision change, hearing change or vertigo, sore throat, denies and
lumps or stiffness.
Neck: Denies swelling or tenderness
Resp: Denies cough wheezing or shortness of breath.
CV: Denies chest pain, palpitations or any dyspnea.
GI: Denies nausea, vomiting, or any abdominal pain.
GU: Denies any urgency, frequency or burning sensation upon urination.
MS: Denies any joint pain or swelling, denies muscle weakness.
Neuro: Denies numbness or tingling, any sensation change, no syncope or dizziness.
Endocrine: Denies cold or heat intolerance, excessive thirst or hunger
Psych:. Denies any depression or mood disorder, supportive family members.

Objective Data
Vital Signs: Temp 37C, BP 120/76, HR 76, RR 16, O2 100% RA, pain 2/10 Ht. 5’8” Wt. 160
lbs BMI: 24.3
Physical Exam
General (Constitutional): Pleasant 34-year-old male in no acute distress, cooperative with the
exam.
Skin: rough, erythematous, dry, silvery plaques anterior R knee. Warm and dry, no pallor or
cyanosis
Lungs: CTAB, no wheezes, rales, or rhonchi
Heart: RRR, no murmurs, rubs, or gallops
Neuro: AOx4, gross motor and sensation intact

Assessment
Diagnosis: psoriasis
Differential Diagnosis:

 Eczema
o r/t allergies, hot baths/showers, soaps/lotions, stress.
o Pt denies any allergies, no new products have been used, and denies being
under any stress. No swelling or inflammation of the skin present.
 Contact dermatitis
o r/t soaps/detergents, cleaning products, hair dyes, deodorants, latex, nickel
o Pt denies new products being used, no swelling present, and no blisters.
  Psoriasis
o r/t to immune system disorder, irritation of skin, family history

Plan

Diagnosis: Psoriasis
Pharmacological treatment/non-pharmacological treatment:
Medication: corticosteroid cream 2x/day
Patient education:

 Apply corticosteroid cream to the front of right knee, 2x/day.

 Treatment of psoriasis takes time, results may be seen in 2-6 weeks.
 Monitor skin for changes, call if skin is worsening.

Labs and Diagnostic: CBC w/ differential

Referral: none
F/U Plan: follow-up appointment in 4-5 weeks to assess the site and adjust the treatment plan, as
needed. If psoriasis becomes severe, will refer to dermatologist.