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