29 year old male with chief complaints of skin lesion since 2 month

29 year old male patient with chief complaints of Itching of skin, skin lesions since 2 months

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

History of present illness:

Patient was apparently asymptomatic 2 months back later  he developed assymptomatic skin lesions over hands and itchy skin lesions over the back

History of using clotrimazol 1% cream                         N/K/C/O - hypertension, diabetes, Asthma , Epilepsy

Past History:                                                                 No similar case in the past 

Family History:                                                             No significant family history

Personal History:

Diet: mixed 
Appetite: normal 
Sleep: adequate 
Bowel: regular 
Micturition: normal 
Addictions: No
Allergies: No

General examination:
Patient is conscious coherent and co-ordinated and checked in well ventilated area

Pallor present 
No Icterus 
No clubbing of finger 
No cynosis
No Lymphadenopathy 
No pedal  edema 

Vitals:
Temperature - afebrile
Pulse - 74
Respiration rate - 16/min
BP - 110/74 mmhg

Systemic Examination :

CNS examination
GCS: 15/15
The patient is conscious. 
Speech: normal
Cranial nerves: intact 
Seonsory system: normal 
Motor system: 
                       UL                       LL
Tone R INCREASED       INCREASED
          L INCREASED       INCREASED

POWER
          R      5/5                        5/5
          L       5/5                        5/5


REFLEXES           R                       L
BICEPS               2+                      2+
TRICEPS             1+                      1+
SUPINATOR        0                         0
KNEE                    0                         0
ANKLE                  0                         0
PLANTAR             E                         E


RESPIRATORY SYSTEM EXAMINATION 
-Bilateral air entry is present, normal vesicular breath sounds heard. 

CARDIO VASCULAR SYSTEM
S1 and S2 are heard. No murmurs are heard

ABDOMINAL EXAMINATION:
Soft, non-tender. 
No organomegaly
Bowel sounds are normal

Skin
Multiple pinpointed coloured papule of 1.5-2 mm diameter size noted over dorsal aspect of hand 
Multiple poly sized hyperpigmented scaly plague noted over a back and knee


Diagnosis
Psoriasis vulgaris 

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