Diagnosis: Psoriasis
Differential Diagnosis: Seborrhea, atopic dermatitis

Include ICD-10 Code for diagnosis

Attached is template. use template exactly they way it is. Be sure to bold abnormal findings.

References no older than 3 years

THE HISTORY AND PHYSICAL (H&P)

1. Chief Complaint

“The skin on my right elbow is itchy. Rashes and red patches have developed in the area due to persistent scratching.”

1. History of Present Illness (HPI)

B.L. is a 16-year-old Caucasian male who has visited the clinic accompanied by his mother. B.L. is complaining of itchiness of the skin around his right elbow. As reported by B.L., red patches and rashes have developed on his elbow due to persistent scratching. These symptoms started about two weeks ago. The itchiness is mostly triggered by cold weather and subsides during hot weather. B.L.’s mother has indicated that his son has not used any medications to treat the condition since it started.

Location: The skin.

Quality: Persistent itchiness.

Quantity or severity: Severe to moderate itchiness.

Timing: The itchiness lasts for about 5 minutes before disappearing and then returns.

Setting: Anytime.

Aggravating or relieving factors: The itchiness is worsened by cold weather and it subsides during hot weather.

Associated manifestations: Scratching, rashes, red patches.

III. Past medical history (PHx)

1. Childhood illnesses

As reported by the mother, B.L. had measles and malaria at the age of 3 and 5 years respectively and was treated without hospitalization. Since then, he has not been diagnosed with any serious medical condition except fevers that come and go.

1. Immunizations

The mother has indicated that B.L. has received all immunizations according to schedule. He received 1^st and 2^nd doses of hepatitis B vaccine, 1^st and 2^nd doses of rotavirus vaccine, diphtheria, pertussis, and tetanus (DPT) vaccine, measles, mumps, rubella (MMR) vaccine, influenza vaccine, polio vaccine, varicella, hepatitis A, and pneumonia vaccine. He obtained his last influenza vaccine last year when he was 15 years old.

1. Adult Illnesses

B.L. has not been diagnosed with any serious medical condition during adulthood. The fevers that occurred were successfully treated without medication.

1. Operations

B.L. has not undergone any medical operation before.

1. Allergies

The mother denies drug or food allergies.

1. Medications

He is not under any medications at the moment.

1. Complimentary treatments

Denies use of complementary treatments

1. Family history

B.L. is the third born in a family of four children. His father is alive and currently aged 48 years old. His mother is 40 years old. Both parents are healthy with no history of serious medical conditions. His three sisters are also healthy. As reported by B.L.’s mother, his maternal grandparents are alive. Maternal grandfather has diabetes whereas grandmother is healthy. His paternal grandparents are also alive. Paternal grandfather is healthy while grandmother has high blood pressure.

1. Social history

B.L. is a student in his fourth year in high school. They are on holidays and are soon resuming learning. His father is a secondary school teacher while his mother is a flight attendant. His mother is not at home most of the time due to work-related commitments. His other siblings are still in school.  Neither B.L. nor his parents consume cigarettes, alcohol, or illicit substances like heroin and cocaine. As reported by B.L.’s mother, the family’s typical diet comprises of the five major food groups including carbohydrates, proteins, minerals, fruits, and vegetables. The parents are always committed to ensure that their children eat healthy and live in a clean environment whenever they are at home.

1. Review of Systems

General: Denies significant weight loss or weight gain in the recent months. Denies chills, fever, or nausea. Reports discomfort due to the itchiness on the right elbow. The mother reports that B.L. had his last medical examination by a physician at the age of 12 years.

Skin: Report itchiness, rashes, and red patches on the skin covering his right elbow. Denies rashes, redness, or bruises on other areas of the skin.

HEENT:

Head: Denies physical head injury. Denies a headache.

Eyes: B.L. had his last eye exam when he was 12 years. He denies redness or pain in the eyes. Denies vision-related problems. He has never been diagnoses with cataracts or glaucoma. B.L. does not use contact glasses. Does not report double vision or excessive tearing.

Ears: Denies hearing loss, ringing in the ears, ear infections, or pain in the ears.

Nose and sinuses: Denies nasal discharge or obstruction Does not report nasal stuffiness. Denies Does not report frequent colds or changes in smell. Denies a history of nasal polyps reported.

Mouth and throat: No mouth ulcers. Denies pyorrhea. Denies hoarseness of the throat. No history of bleeding gums or strep throats reported. Denies dental carries.

Neck: Denies the presence of lumps in the neck region. Does not swollen lymph nodes. Denies goiter or a history of thyroid enlargement.

Lymphatics: Does not report swollen axillae or lymph nodes in the inguinal and epitrochlear areas.

Breasts: Denies discomfort, pain, lumps, or discharge from both breasts.

Pulmonary: Denies breathing difficulties. Denies a cough. Does not report hemoptysis. Denies pleuritic chest pain, wheezing, cyanosis, recurrent pneumonia, or a history of tuberculosis.

Cardiovascular: Denies a history of cardiovascular problems. Does not report chest pain, shortness of breath, irregular heartbeat, or heart murmurs. No history of high blood pressure or rheumatic fever reported.

Gastrointestinal: Denies abdominal pain. Denies indigestion, dysphagia, or heartburn. Denies vomiting or nausea. No changes in bowel movements reported. Does not report diarrhea, constipation, excessive belching, a history of jaundice, or a history of gallbladder problems.

Urinary: Does not report pain in the genitals during urination (dysuria). Denies the presence of blood in urine (hematuria). Denies a reduction in urine volume. No history of urinary tract infections reported.

Genital tract (male): Denies a history of a sexually-transmitted disease (STD). Denies pain the genitalia.  Denies swelling in the testicles. No penile discharge or hernias reported.

Musculoskeletal: B.L. reports occasional stiffness on the right elbow joint. Reports mild swellings on the right elbow joint. Denies a history of fractures, backache, or limitations of motion.

Neurologic: Does not report blackouts or seizures. Does not report tingling, tremors, or numbness of limbs. Denies muscle atrophy, headaches, changes in memory, or dizziness.

Psychiatric: Denies nervousness, depression, insomnia, anxiety, or tension. B.L. denies suicidal ideation or a history of serious mental illnesses.

Endocrine: Does not report excessive thirst, abnormal sweating, or excessive hunger. No thyroid issues reported. Does not report heat or cold intolerance. No excessive urination reported.

Hematologic: B.L. denies easy bruising, anemia, or abnormal bleeding. His mother denies a history of blood transfusion or reactions.

VII. Physical examination

Vital signs: Temperature; 36.7 degree Celsius, Blood pressure; 128/85, respiratory rate; 19 breaths per minute, pulse; 90 beats per minute, weight; 132.4 lbs.

General appearance: B.L. looks attentive and keeps eye contact. He is neatly dressed and appropriately oriented to time, place, and person.

Skin: Skin on other areas of the body is warm, intact, and without rashes except on his right elbow. On the right elbow, there are red patches of skin with small scaling spots that resemble rashes. The skin in the area also appears dry and cracked with signs of bleeding. Nails are thickened and ridged.

HEENT:

Head: No evidence of trauma. It is normocephalic. Absence of depressions or palpable masses. Hair is of normal texture. No signs of alopecia.
Eyes: No evidence of lesions or swelling of the eyelids. No signs of hemorrhage of conjunctivae. No evidence of icterus on sclerae.

Ears: No evidence of discharge or blockage in the ear canal. No tenderness or edema on the external ear and ear canal. A pale grey color is observed in the tympanic membrane.
Nose: No signs of nasal hemorrhage. Nasal mucosa is hairy, pink, and moist. The nasal septum is at the midline positioned.

Throat: No evidence of sores, lesions, or ulcers in the oral mucosa. Oral mucosa oa moist and pink with good dentition on the gums. The pharynx is pink in color without with signs of edema or tonsillar exudates.

Neck: No evidence of abnormal pulsations or masses. Trachea is positioned midline. The neck is supple without lesions or bruits.

Nodes: The inguinal, axillary, and epitrochlear nodes do not have signs of swelling.

Chest: No crackles, wheezes, rhonchi, or rubs. Normal breath sounds noticed.

Heart: Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. No noise on a bilateral basis. Midclavicular PMI visible, 5th intercostal region, no heaves, lifts, or excitement. No evidence of edema on the periphery. Varied bilateral peripheral pulses, capillary refill less than 3 seconds.

Abdomen: No evidence of tenderness, pain, or distention. No scars, no bowel sounds.

Back/spine: Back and neck have no signs of deformity. No signs of trauma or external skin changes observed. B.L. has an upright posture with a steady gait within normal limits. No curvature of the spine noticed. No tenderness on the back and spine.

Extremities, including exam of pulses: Evidence of stiffness, tenderness, and swelling of the right elbow joint. Lower extremities are without trauma. Evidence of palpable pulses in the upper and lower extremities.

Genitalia/Rectal: Hair is evenly distributed on the pubic area. No lesions or masses observed on the penis. No signs of suprapubic pain on palpation. The testes are non-tender and without lesions. No evidence of rectal hemorrhoids.

Neurologic:

Mental status: B.L. is attentive and able to concentrate. His level of consciousness is good. No issues with language, speech, or memory.

Cranial nerves: Crania nerves II-IX are intact. Full EOM’s observed. Evidence of visual fields.

Motor: No signs of muscle rigidity. Normal gait and good balance. All other joints except the right elbow joint have a muscle strength of 5/5. Muscle strength of right elbow joint is 3/5.

Sensory: Reflexes are 2+ on upper and lower limbs. Lower and upper limbs are sensitive to touch and pricking.

VIII. Problem list

B.L. is a 16-year-old Caucasian male who has visited the clinic accompanied by his mother. His primary complaint is itchiness on his right elbow, scratching, rashes, and red patches. These symptoms began about two weeks ago and are worsened by cold weather and subside during hot weather. The problematic symptoms that signify the presence of a health problem include; itchiness on his right elbow, scratching, rashes, and red patches as reported by the patient. B.L. further reports occasional stiffness and swelling on the right elbow joint. Problematic objective findings include red patches of skin with small scaling spots that resemble rashes on the right elbow. The skin in the area also appears dry and cracked with signs of bleeding. Nails are thickened and ridged. Furthermore, there is evidence of stiffness, tenderness, and swelling of the right elbow joint. Muscle strength of right elbow joint is 3/5 which signifies reduced motor activity is another objective finding that should guide decision-making.

1. Differential diagnosis

1. Psoriasis (primary diagnosis)

ICD 10 code: L40.9: Psoriasis

1. Seborrhea

ICD 10 code: L21.9: Seborrhea

1. Atopic dermatitis

ICD 10 code: L20.9: Atopic dermatitis

 

 

 

 

 

 

 

 

References

American Academy of Family Physicians. (2020). Atopic dermatitis: Diagnosis and treatment. https://www.aafp.org/afp/2020/0515/p590.html

 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.

Bickley, L. (2018). Bates guide to physical examination and history taking (12th ed.). Philadelphia, PA: Wolters Kluwer.

Mayo Clinic. (2020). Seborrheic dermatitis. https://www.mayoclinic.org/diseases-conditions/seborrheic-dermatitis/diagnosis-treatment/drc-20352714

Mayo Clinic. (2021). Psoriasis. https://www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840

Rachna, J. & Yogesh, J. (2021). The importance of physical examination in primary health care provided by NPHW is being threatened in COVID19 times. Journal of Family Medicine and Primary Care, 10(1), 19-21 doi: 10.4103/jfmpc.jfmpc_1932_20