Who you are:
FY2 in the GPWho the patient is:
37-year-old Donald Bloom came to the clinic with some complaints.What you should do:
Talk to the patient, assess, and address his concerns.
Psoriasis (Positive Findings):
- Dry skin lesions, known as plaques, that are covered in scales.
- Normally appear on elbows, knees, scalp and lower back, but can appear anywhere on your body.
- The plaques can be itchy or sore, or both.
- In severe cases, the skin around joints may crack and bleed.
Presenting complaint (P1) (ODIPARA):
D: Hello I am one of the doctors in the GP clinic. You must be Donald?
P: Yes.
D: Can I get your full name and D.O.B. please before we begin the consultation?
P: (Confirms details)
D: So, Donald, I can see that you have been having a rash?
P: Yes, doctor.
D: Tell me more about this rash. (Open question)
D: When exactly did it start?
P: Well, doctor, it has been going on for the past 3 months (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It’s there all the time.
D: Can you tell me exactly where it is? (Site)
P: It’s on my knees and elbows.
D: The size, shape and colour of the rash?
P: It’s mostly red in colour but there are also white patches as well.
D: Any discharge, bleeding, pain?
P: No, doctor, but it’s itchy and a bit sore.
D: Have you noticed any fever along with it?
P: No, doctor.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving factors)
P: No doctor, I have been using petroleum jelly (Vaseline) on the rash but that is not very helpful.
D: Any injury to skin (Cut, insect bite, sun exposure)?
P: No doctor.
D: Any recent stressors?
P: I have been a bit stressed because of my job, I have been jobless now for some time.
D: How is this affecting your life?
D: Anything else?
D.Ds
- Seborrheic dermatitis
- Fungal skin infection
- Candida intertrigo
- Eczema
Past medical conditions (P2)
D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
D.E.S.A:
Any smoking?
What about alcohol?
M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Is there anyone in your family with similar problems or other medical conditions?
P: No, doctor.
D: How has it been impacting you? Is it affecting your life in anyway? (Psychosocial)
D: Anything else.
Expectations?
D: Anything specific on your mind that you are expecting from us today?
P: Something to get rid of it, doctor.
Examination:
- Observations (Check vitals)
- General physical examination
- Examination of the rash
Idea
D: Do you have any idea what might be causing this?
P: No, doctor.
Suspected diagnosis:
Donald, you told me that you have got these lesions on the skin that are scaly and are itchy. Having had a look at the lesions I am suspecting a condition called psoriasis. It is related to a problem with the immune system. The immune system is your body’s defence against disease and infection, but it attacks healthy skin cells by mistake.
Psoriasis can run in families and sometimes symptoms start or become worse because of a trigger. Possible triggers of psoriasis include an injury to your skin, throat infections and using certain medicines.
Concern
D: Apart from this, do you have anything else that’s concerning you?
P: It looks really bad, doctor and I am worried that my partner might get it from me.
D: We’ll try some things to see if we can relieve it. Please don’t worry about anyone catching it, it’s not contagious, your partner can not get it from you.
Management:
- Senior
- Investigations
A biopsy might be required sometimes by the specialist if the diagnosis is not clear. - Symptomatic management
General lifestyle advice to reduce the risk of exacerbations, such as advice on:
– Smoking cessation if appropriate.
– Drinking alcohol within recommended limits.
– Weight loss if the person is overweight or obese.
– Assess for associated stress, distress, anxiety and/or depression, and manage appropriately. - Definitive management
- Topical – Creams & Ointments.
– Emollients (Moisturiser) apply directly to the skin.
– For mild to moderate psoriasis, topical corticosteroids can be applied.
– Vitamin D analogues cream
– Calcineurin inhibitors (Tacrolimus)
– Coal tar – can be used if other topical treatments are not effective. - Phototherapy – Skin exposed to certain UV light.
– Psoralen plus UV A (PUVA) - Systemic – Oral and Injected Medications.
– Non biological medications – Methotrexate, Ciclosporin
– Biological treatments – Etanercept, Adalimumab, Infliximab - The patient should be reviewed after 4 weeks of initiation of treatment.
- Specialist: Refer to the dermatology department.
- Safety net
- Unexplained joint pain or swelling (Psoriatic arthritis)
- Heart failure - due to increased skin blood flow, blood volume, and cardiac output.
- Dehydration
- Hypothermia
- Malabsorption
