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Psoriasis Case Study: Symptoms and Treatment

The patient is a 22-year-old male who presented with a chief complaint of multiple skin lesions all over his body and head for the past 2 months. Examination found plaque and scales present all over the body. Laboratory tests were normal. The assessment is psoriasis based on the skin findings and history. The patient is being treated with topical steroids, emollients and methotrexate. He was counseled on skin care and prevention of disease transmission.

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yasahswi91
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181 views9 pages

Psoriasis Case Study: Symptoms and Treatment

The patient is a 22-year-old male who presented with a chief complaint of multiple skin lesions all over his body and head for the past 2 months. Examination found plaque and scales present all over the body. Laboratory tests were normal. The assessment is psoriasis based on the skin findings and history. The patient is being treated with topical steroids, emollients and methotrexate. He was counseled on skin care and prevention of disease transmission.

Uploaded by

yasahswi91
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd

PSORIASIS

BY:

IP NO:
AGE: 22 YEAR
SEX: MALE

DATE OF ADMISSION:
DEPARTMENT : MEDICINE

SUBJECTIVE
Chief complaint:
c/o multiple skin lesion all over the body and head from 2 months.

Present complaint:
pt was apparently normal 2yrs back then he developed a papule and
plaque on the back it gradually increased and spreaded to all over the body
associated with itching.

Previous history:
no h/o DM, HTN, ASTHAMA, TB.
no h/o previous hospitalization

Family history:
no h/o DM, HTN, ASTHAMA, TB.

Personal history:
diet-mixed, Appetite-normal, Sleep-normal, Bowel & bladder-regular.

OBJECTIVE
Patient aged about 22yr moderately built and nourished conscious & co-operative.

PR: 80 bpm
BP: 120/80 mm Hg
RS: NAD
CVS:NAD
P/A:NAD

LOCAL EXAMINATION:
Hair plaque are present, multiply, asymmetrical scale plaque are present
all over the body.

Provisional diagnosis : psoriasis

INVESTIGATION AND LABORATORY


TEST
TEST VALUE
NORMAL VALUE
REPORT
FBS (mg/dl)

80

70-100

B.Urea (mg/dl)

18

15-40

Sr. cr (mg/dl)

1.1

0.9-1.5

Total bilirubin (mg/dl)

0.4

0.2-0.8

Direct bilirubin(mg/dl)

0.2

0.00-0.25

SGOT (IU/L)

36

UPTO 40

SGPT (IU/L)

61

UPTO 41

Alkaline phosphate (IU/L)

69

UPTO 115

Total protein (g/dl)

8.0

6.6-8.3

Albumin (g/dl)

5.2

3.5-5.0

Total cholestrol (mg/dl)

195

125-225

Triglycerides (mg/dl)

232

66-170

LFT

TEST

TEST VALUE

NORMAL VALUE

Hb (g/dl)

16.8

13-18

Total leucocytes
counts (cumm)

7500

4000-11000

N (%)

49.5

40-75

L (%)

40.1

20-45

E (%)

3.2

1-6

M (%)

6.1

2-10

B (%)

1.1

0-1

RBC count
(millions/cumm)

5.77

4.5-6.5

Urine routine
albumin

Nil

Urine sugar

Nil

Puscells

1.2/ hpf

E.P. cells

1-2/ hpf

ASSESSMENT
Based upon the subjective evidence
like skin lesions papule and plaque
associated with itching and objective
evidence hair plaque are present, multiply,
asymmetrical scale plaque are present all over the
body.

Medication chart
BRAND
NAME

GENEROIC
NAME

DOSE

FREQUENC
Y

Liquid
paraffin

DATE

DATE
END

3/1/12

T . CFM

Cefixime

200mg

1-0-1

3/1/12

10/1/1
2

INJ. Avil RC

Phenaramine

22.75m 1-0-1
g

3/1/12

Con

Dermadew
(soap)
T.Neotrexat
e

Methotrexate 2.5mg

Weekly
once(3dos
e)

5&11/1/
12

Halox lotion

Halobetasol
proprinate+s
alicylic acid

daily

4/1/12

Con

FUDIC
cream

Fusidic acid

T. CETREZOL

Cetirizine-5
mg
Diethyl

1-0-0

11/1/12

Con.

Planning
Advise to patient
Dont scratch the skin
Dont expose the skin directly to the sun light
Maintain good hygiene
Prevent direct contact with other peoples to

prevention of dieses

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