SUBJECTIVE DATA: Chief Complaint (CC):Painful rash and joint pain History of Present Illness (HPI):During the day, AB a 23-year-old lady was presented to the clinic with an onset of painful plague like rashes and pain her joints that started two weeks ago. She added that the rashes started on her knees and later to her elbows and scalps. She further reported the rashes are itchy and sore and complained her joints have painful for the past three weeks. The condition makes her annoyed and worsens as the days go by. More importantly, she added she takes painkillers (Ibuprofen 400mg three times a day) to relieve the pain as well change her laundry detergent with no improvement on her condition. Onset - Rashes three days Location - Knee Duration - Three weeks ago Character- gradual Associated symptoms - none Relieving factors - Painkillers Treatment - None Severity - 6/10 Medications: Takes Ibuprofen 400mg three times a day as prescribed in her local pharmacy. Multivitamin for women I tablet daily Allergies:Denies drug or food allergies.
DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS3 Past Medical History (PMH): Frequent Tonsillitis Past Surgical History (PSH): Tonsillectomy 2006 Caesarian section 2014 Sexual/Reproductive History: In a monogamous relationship Menarche 9 years and 8 months Gravida 1, Parity 0 She experiences regular menstruation Denies any history of sexually transmitted diseases She is on Nexplanon contraception for 3 years now She has her last pap smear in 2018 and results were normal Social History: Denies smoking and ETOH intake or substance abuse. She maintains a balanced diet and exercises when she can. Immunization History: AB is immunization is up to date according to the World Health Organization. She had a flu vaccine towards the end of last year and her Tdap in 2017 does not fulfill the standards for pneumonia immunization.
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