Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Doctor working in a GP practice. Your next patient is a 19-year-old female (Sarah Jane) who presented with a rash. Please take history and perform a relevant examination.
Patient History:
Sarah Jane, 21-year-old student.
Since the past week, you have developed an itchy rash at skin creases at the elbows + behind the knees + ankles + neck started which is also getting worse. You tried to put on some moisturising cream which helped a little, and you hope to see if there's a stronger cream for your skin. Because of the itchiness, you have been scratching your skin constantly throughout the day and left quite a few scratch marks. Some spots were bleeding due to the constant scratching. Your skin has also gotten redder and drier than usual and is becoming slightly more swollen.
You remember you had a similar episode when you were a child but do not quite remember what happened during that time – you just remember your skin was very itchy. Since then, you have had a few intermittent episodes. For this episode, this is at its worst, and that's why you are now here to see a doctor. You do not know what might have triggered this as you haven't done anything unusual in the past few weeks. You think stress usually triggers the flares.
Ideas, Concerns, Expectations:
You think this might be psoriasis; as you remember your mother has similar symptoms. You are concerned as this is affecting your ability to study as you have been scratching your skin all the time! You hope to receive some good cream to help control your itchiness and dryness of the skin.
Past Medical History:
Asthma + hayfever
Family History:
Psoriasis + eczema
Drug History:
Salbutamol inhaler PRN
Allergic to penicillin and seafood
Social History:
Non-smoker – you are never going to smoke as your parents both smoked a lot when you were a child, and you hated the smell of cigarettes.
You drink maybe 1-2 pints of beer over the weekend with friends.
You are currently a student – studying biomedical science – you hope to apply to medicine next year!
You currently live with your mates in a house.
Examination Findings:
Visible dry/ erythematous and sore patches of skin over flexor surfaces of elbows and knees – might include the face and neck. Features might include crusting/ scaling/ cracking + swelling + poorly demarcated redness (no vesicles). Scratch marks (excoriations) were noted on flexor surfaces and the neck. Lichenification (thickened skin) may be present.
No signs of eczema herpeticum e.g. punched-out erosions/ clustered blisters or infected skin
Differentials:
Atopic Eczema
Psoriasis
Other forms of eczema e.g. allergic/ contact/ seborrheic/ discoid
Lichen simplex
Investigations:
Clinical diagnosis
Observations
Skin-prick testing/patch/allergy testing(check for reactivity to allergens e.g. food, pets, dust mites may trigger eczema)
Consider bloods + culture / wound swabbing (for signs of infection/ discharge)
Consider immunoglobulin E (IgE) / RASTs
Consider skin biopsy (if diagnosis unsure)
Management (Eczema):