MBBS Short case: Psoriasis vulgaris

Jul 30, 12 MBBS Short case: Psoriasis vulgaris

For undergraduate medical students

 

 

Requested and specially dedicated to my ex-students from Universiti Malaya.

 

 

 

Question: Please examine the skin of this patient.

Scenario: Patient with plaques on the elbow

Objectives:

1. Demonstrate that it is indeed psoriasis plaques

– Demonstrate the typical morphology of psoriatic plaque

– Demonstrate the typical distribution of psoriatic plaque

2. Look for other system involvement

– psoriatic nail changes

– psoriatic arthropathy

3. Look for other associated condition

– Metabolic syndrome (diabetes mellitus, hypertension, central obesity)

– Ischaemic heart disease

– Psychiatry disorder (alcohol addiction, tobacco usage, depression etc)

4. Look for common treatment complications

– Methotrexate complication

 

General observation

– Central obesity

– Any glaring abnormalities

Examination of the skin lesions

– Description of the skin lesions

  • well defined
  • erythematous
  • silvery scale

– Description of the typical distribution

  • Extensors
  • look out for Koebnerisation (psoriatic plaque over trauma/scar area)

– Examination of other ectoderms

  • Nails (Look for psoriatic nail changes- oil-spot signs, subungual hyperkeratois, nail pitting, total nail dystrophy
  • Mucous membrane
  • Hair

Examination of the joints

– Look for medium joint effusion/pain/tenderness (most common arthropathy is the oligo/mono-arthritis involving medium joint)

– Look for small joint involvement (for rheumatoid arthritis like arthritis, DIP joint involvement or arthritis mutilans)

ps: note if the arthritis is active or quiescent (active- tenderness, effusion and increase in temperature as opposed to quiescent- only deformities)

Complete the examination

– Examine the spine for spondyloarthropathy

– Examine the blood pressure (hypertension)

– Examine the fundus for diabetic and hypertensive changes

– Examine the GI system for inflammatory bowel syndrome (associated disease)

– Examine the lungs for pulmonary fibrosis, liver dysfunction, haematology system (side effect of methotrexate)

 

Conclusion

Patient has

– Psoriasis vulgaris

– with nail/joint involvement (p.s. if joint, what type of joint involvement, if there are functional limiting deformities)

– with other associated disease on examination

– with other conditions associated with treatment of psoriasis

 

Example:

Mr X has psoriasis vulgaris with nail involvements as well as active oligoartritis of his knee and ankle joints. He also has central obesity and median sternotomy scar suggesting a possible previous cardiac bypass surgery. Both conditions are associated with psoriasis vulgaris.

 

 

 

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