Advance Health Assessment of Hair, Nail and Skin, SOAP Psoriasis

SOAP Psoriasis
Patient Information:
Initials: Ms. H     Age: 31 years old    Sex: Female     Race: Caucasian
SUBJECTIVE DATA:
Chief Complaint (CC): Itchy red rash on arms and legs: #2
History of Present Illness: Ms. H is a 31 years old woman and complains of an itchy, red rash on her arms and legs that has persisted for three months. The rash is gradually spreading. Ms. H has a long history of scalp dandruff and frequently uses anti-dandruff shampoos. She denies news exposures or travel, recent illness and fever, and says she feels well. Ms. H says that she has had a similar rash on her knees and elbows in the last few years that resolved in the summer months, but the rash has persisted this time.
Current Medications:
1 Oral contraceptives
2 Over-the-counter hydrocortisone cream (0.5%)
Allergies:
Does not have any drug, food or insect allergies
Past Medical History (PMH):
No history of major illness and no history of surgeries and received influenza vaccine two years ago
Social History
Ms. H does not smoke, takes 1-2 alcoholic drinks per week, married five years ago with two children. She works as a full-time secretary and avoids social gathering as she feels self-conscious.
Significant Family History:
Her father has spinal arthritis, and the mother and siblings are all healthy
Review of Systems:
General: denies chills and fevers, denies significant weight loss
Skin: lesions present in arms and legs, bleeding points where she has scratched
HEENT: She does not have a headache, dizziness or syncope. She does not have any notable change in his hearing and no tinnitus. She does not have any notable change in his vision. Nose not assessed. She describes a lump in his throat associated with dysphagia.
Neck: No assessment
Cardiovascular: No chest pain or palpitations
Respiratory: Denies chest pains, lung injury, lung disease, allergies, and asthma
Gastrointestinal: Complaints of vomiting, nausea, dysphagia or change instool pattern, consistency or color.
Genitourinary: Denies dysuria, discharge, and hematuria
Neurological: Does not have numbness and tingling or incoordination
Musculoskeletal: No muscle or joint pain
Hematologic: Denies ease of bleeding, bruising and no history of blood transfusion.
Lymphatics: known diabetes, denies thyroid problems, cold/heat intolerance
Psychiatric: No hx of anxiety or depression; Denied suicidal/homicidal hx; disturbance in sleep when symptoms started
Allergic/Immunologic: No known allergies
OBJECTIVE DATA
Physical Examination:
General: Ms. H is a well-developed white lady appears alert, oriented and cooperative.
Vital signs: Ht 5’5” Wt 130lbs HR 73 RR 18 BP 129/80 Temp 37 degrees, BMI = 22.4
Skin: Physical exam reveals small plaques with whitish or silvery scale, involving approximately 9% body surface area (BSA).Lesions are mainly on the arms and legs with some buttock involvement. There are no visible nail changes. There are several bleeding points where she had been scratching.
HEENT: movements are smooth with a wide visual field, and the conjunctiva is clear. Pup...