Republic of the Philippines

Department of Health
SOUTHERN PHILIPPINES MEDICAL CENTER
Davao City

DERMATOLOGY CLINIC FORM

Name: _____________________ Age: 54 Sex: M HRN: ______
Date of Birth: __________________ Place of Birth: __________________
Civil Status: ____________ Occupation: PUJ Driver
Address: Davao City Date: November 16, 2021

Chief Complaint: Papules and plaque with scales

History of Present Illness:

3 years prior to consultation, the patient had an onset of a lesion in the scalp which
started as small, erythematous macules with dry silvery scales described as dandruff. The
lesions are associated with mild pruritus. The patient tried using different anti-dandruff
shampoos but afforded no relief. There were no medications taken and no consultation was
done. The patient tolerated the condition.
1 year year prior to consultation, the same lesion spread into the abdomen and back
described as multiple, erythematous plaque with a silvery scale and constantly increasing in
number and size. The patient also noticed the appearance of the lesions on previously
unaffected skin after scratching it. The patient self medicated with BL cream and the lesions
have spontaneously resolved. However, the lesions recurred after a few months. No
consultation was done.
6 months prior to consultation, the lesions persisted with associated nail changes
wherein there is visible white discoloration. Persistence of the above symptoms prompted the
patient to seek consultation.

Review of Systems:
General: (-) fever, (-) weakness
Skin: (-) jaundice,
HEENT: (-) headache, (-) epistaxis, (-) dysphagia
CVS: (-) chest pain, (-) palpitation
Respiratory: (-) dyspnea, (-) cough
GI: (-) abdominal pain, (-) diarrhea
GU: (-) polyuria, (-) painful urination
Musculoskeletal: (-) myalgia, (-) joint pain
Peripheral vascular: (-) leg pain, (-) varicose veins
Neurologic: (-) numbness, (-) paralysis
Endocrine: (-) excessive thirst, (-) excessive sweating
Hematologic: (-) easy bruising (-) easy bleeding
Past Medical History:
(-) Medical Illness
(-) Allergies
(-) Hospitalizations/ Surgeries
(-) Medications

Family History:
(-) History of skin conditions

Personal & Social History:

(-) Non-alcoholic drinker
(-) Non-smoker
The patient works as a PUJ Driver

PHYSICAL EXAMINATION:

Head: multiple, annular, well-demarcated, erythematous plaque with silvery white scale that
extend beyond the hairline; (-) male pattern hair loss
Skin: multiple, annular, well-demarcated, erythematous plaque with silvery white scale
Nails: (+) nail pitting, (+) distal onycholysis
Extremities: multiple, annular, well-demarcated, erythematous plaque with silvery white scale;
(+) Auspitz sign

ASSESSMENT:
Initial Impression: Psoriasis vulgaris
Differential Diagnoses:

Seborrheic dermatitis
Rule in: (+) erythematous plaque with scales
Rule out: (-) severe itching, (-) yellow, greasy appearance, (-) spread beyond the hairline, (-)
involvement of the eyebrows, face

Pityriasis rosea
Rule in: (+) papules with scales, (+) pruritus,
Rule out: (-) christmas tree distribution of lesions, (-) duration is only 5-8 weeks

Tinea corporis
Rule in: (+) plaque with scales, (+) pruritus
Rule out: (-) central clearing, (-) lymphadenopathy, (-) broken-off stumps of hair, (-) alopecia;
Perform KOH examination to totally rule out
Atopic dermatitis:
Rule in: (+) erythematous papules, (+) pruritus
Rule out: (-) personal or family history of allergic rhinitis, asthma, atopic dermatitis, (-)
lichenification in flexural areas

Psoriasis vulgaris
Rule in: (+) erythematous plaque with silvery white scale, symmetric lesions, (+) Auspitz sign, (+)
Koebner phenomenon, (+) Nail pitting
Rule out: Cannot be totally ruled out

Final diagnosis: Chronic Plaque-type Psoriasis

PLAN:
● Manage as outpatient
● Medications:
○ Topical corticosteroid Clobethasone Propionate cream 0.05%
○ Vitamin D Calcipotriene 0.005%
● Daily bathing with mild cleanser
● Use of emollients creams after bath
● Refer for phototherapy
● Follow-up after 2 weeks to reassess response to therapy
● Advise and educate the patient regarding the benefits of not smoking, avoiding excessive
alcohol intake, and maintaining a healthy weight and blood pressure.
 SOUTHERN PHILIPPINES MEDICAL CENTER
J.P. Laurel Avenue, Bajada, Davao City

OUT- PATIENT DEPARTMENT

NAME: ______________________________________________________________________
AGE: 54 SEX: M

Date: November 18, 2021

Rx
Clobetasol Propionate Cream 0.05%
Sig: Apply to affected areas on the scalp, trunk and extremities twice daily for 2 weeks

Calcipotriene 0.005%
Sig: Apply to affected areas on the scalp, trunk and extremities twice daily

CHRISTINE LORRAINE S. FERENAL, MD

SPMC DERMATOLOGY
LIC. # 01010100