Allergic/Immunologic: Allergic to Penicillin drugs. No food or environmental allergies. No immune deficiencies. OBJECTIVE DATA: Physical Exam: Vital signs: BP: 140/80 left arm, P: 104, Temp: 98.7F orally, RR 18, WT: 170lbs HT: 6”0 Feet, BMI 23.1. General: Alert and oriented x4. Good hygiene and grooming noted. Pleasant and healthy appearing talkative male. No current distress noted. © 2014 Laureate Education, Inc. Page 2 of 4
HEENT: Appropriate shaped head form and circumference. PERRLA. No discoloration or discharge noted. Oral mucosa smooth, red and intact. No Tonsils noted. Healthy dentition. No impairment of hearing noted. Neck: Trachea symmetric with midline. Appropriate posture. Full movement. No swelling, pain or deformity present. No JVD or carotid bruit noted. Chest: Normal-shaped muscular chest noted without any lumps, discharge, or skin changes noted. Lungs: Clear, even, and unlabored breaths auscultated. Symmetric chest rise. Heart: Regular heart rhythm auscultated. No murmur noted. S1 and S2 auscultated. Peripheral Vascular: Strong palpable peripheral pulses. No edema observed. Abdomen: Active bowel sounds in all four quadrants. Nondistended, flat, soft abdomen. Genital/Rectal: Normal shaped male genitals. No visible hemorrhoids. No tenderness or discharge noted. Muscle strength 5/5 noted in all four extremities. Musculoskeletal: No limitation in range of motion of all four extremities. Neurological: Skin: Symmetric erythematous inflamed and uniform white scaly skin patches noted on elbows and knees skin surfaces. Diagnostics: Full physical exam including skin exam Auspitz Sign: bleeding is noted when lesion surfaces are scraped In severe cases: Skin biopsy, Phototherapy ASSESSMENT: 1) Priority Diagnosis: Erythrodermic Psoriasis – presents with red, inflamed, silvery-white scaly lesions in areas such as elbows, knees, extensor limbs, and scalp 2) Differential Diagnosis: - SLE (Systemic Lupus Erythematous):
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- Summer '15