Office Visit Note
Narrative: Diagnosis: Psoriasis flare Diagnosis History: 1. Medical History: History of psoriasis with previous flares, no major flares in the past year. Psoriasis flares have previously been triggered by streptococcal infections. No mention of other chronic illnesses, surgeries, allergies, or lifestyle factors. Family recently had a viral infection. 2. Medication History: Currently using topical anti-inflammatory medications for psoriasis as prescribed by dermatologist. No oral therapies or biologic agents have been used. No reported medication allergies or side effects. Subjective: Patient presents with a flare of psoriasis that began approximately two weeks ago. No sore throat, no fever. Voice is a little hoarse. No cough or nasal congestion. Patient appears happy and smiling. Objective: Physical examination reveals widely distributed, small, diffusely scattered psoriatic lesions, with none on the scalp. Throat is clear. Neck is supple. No signs of pharyngitis. Rapid streptococcal antigen test is negative. Primary Diagnosis: - Assessment: Psoriasis flare. - Suspected Diagnosis: Possible viral etiology for immune flare considered due to recent family viral illness and absence of streptococcal infection. Plan: - Prescription: - Continue topical anti-inflammatory therapy for psoriasis as previously prescribed. - Next Steps/Examination: - Advised to reconnect with dermatology to assess for new therapy options. No additional laboratory or imaging studies ordered at this time. - Follow-up Treatment Plan: - Consideration of added or alternative therapy for psoriasis depending on dermatology assessment. Monitor for any new symptoms or worsening of current flare.