Download Erythroderma

Chronic inflammatory skin disease
FOR THE MEDICAL STUDENT
Remember the standard expected for this OSCE is of a competent PRHO. For this station you are
expected to take the role of a FY1 working in general practice.
Background Information
You are working in general practice. A man is consulting you for the first time. He has a new
rash on his elbows.
Task
 You will be asked to take a focused and relevant dermatological history from the patient.
 When you are ready, ask the examiner to show you the clinical photographs. You will
be asked to describe the signs and to discuss where else you might look to confirm the
diagnosis of psoriasis.
 You will be asked to explain the diagnosis of psoriasis to the patient and to agree a
management plan with the patient.
You do not need to remember these stages as the examiner will prompt you as you proceed
through the station.
Notes to the Patient
You have had a rash on your elbows for about 9 months-it is not going away and you are
becoming a little concerned. It is raised, red, scaly and slightly itchy. When you scratch, the skin
bleeds. You think it might be psoriasis (your aunt has this condition) but are also a bit worried it
may be contagious and that you are spreading the “infection” and making things worse when you
scratch. You noticed that it improved in the sun – became flatter, less itchy and scaly. You have
not used any treatments.
You aunt has very bad psoriasis and you know she has to see a dermatologist and has had a lot of
treatments. You are worried that your condition may be become just as bad, but you try not to
think about this and will not raise it unless the doctor asks you. You do want to know where to
find out more about psoriasis.
You are very fit and have no other medical problems (no joint disease, not taking any
medications). You are a banker commuting long distances and leading a fairly hectic life so you
do not have much time for treating your skin
The rash on your elbows does not really bother you that much and you are not keen on the idea of
greasy ointments - messy, will make your shirt sticky, stain clothes, smelly and may not work
(your aunt told you that). You have heard that steroid creams sometimes help. You might be
happy to leave it untreated if that is reasonable.
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Station Chronic inflammatory skin disease
EXAMINER FORM (complete both pages)
STUDENT NUMBER:
Which Learning Outcomes are being assessed in this OSCE station?
Students MUST be able to
 Take a dermatological history
 Describe cutaneous physical signs
 Explore a patient’s concerns and expectations
Students should be able to formulate a differential diagnosis, describe the investigation and
discuss the principles of care of patients with:
 A scaly erythematous rash (psoriasis)
Background for Examiner
You will briefly introduce a patient with a rash and ask the student to take a focused
dermatological history. You will show the student the clinical photographs and ask him/her to
describe the lesions that are present and where else to look. You will tell the student that he /she
is confident the patient has psoriasis and ask him to explain this diagnosis to the patient and
discuss management.
At the end of the whole exam session and not before, you will be feeding back to the student
about their performance. For most students, you may feel their performance was fine. Do not tell
them about pass/fail decisions. This feedback is about technique/approach.
Please start the exam off and indicate the next stages as appropriate as follows
Please tell the student: You are working in general practice. This patient is consulting you for
the first time about a rash on his elbows. Please take a focused and relevant dermatological
history from this patient.
After 5 minutes (if not already there) show the student the clinical photographs and say Please
describe the clinical signs. After 1 minute ask the student where else he would look for signs to
confirm the diagnosis of psoriasis.
Then say: You think this man has psoriasis affecting the skin on his elbows. You have found no
other evidence of disease. Please can you explain the diagnosis of psoriasis to your patient and
discuss options for management. Potent topical steroid preparations (Betnovate) are a
reasonable treatment for limited psoriasis.
Finally give the student a prescription form and ask the student to write a prescription for topical
betnovate.
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Station Chronic inflammatory skin disease
Assessment
COMPETENCE
Competence task
Completed
Comment
(only if reqd)
Student takes dermatological history for this case
including symptoms, duration, treatments used/response,
exacerbating factors, factors that make it better Shows
awareness of need to ask about psychological and lifestyle
impact /anxieties. Asks about family history, joint
disease/other medical problems/drugs
Student describes lesions present in the clinical photossymmetrical, well demarcated erythematous scaly plaques
(raised). Knows where to look for other signs-scalp, nails,
extensor surfaces
Student addresses patient’s anxieties-not contagious,
prognosis -may not spread, may go away, unpredictable,
will not necessarily be like the psoriasis in his aunt.
Explores what treatment the patient wants and how much
time he has for applying treatment
Discusses likely outcome of treatment - control not cure,
reduce redness and scaling.
No treatment is one option.
Good student may offer patient information leaflet, patient
support group, website
Negotiates management e.g. no treatment, topical steroid,–
Good student may explain how to use treatment (x2/day,
apply thinly) how long treatment might take to work (a
few weeks) and what outcome of treatment is likely to beflatten a bit, reduce scale, relieve itch, still have a red
mark , psoriasis returns when stops treatment
May discuss side effects –skin thinning,
May offer emollients-messy but can reduce scale and itch.
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Examiners should give a global assessment of each student’s performance at this station. The
standard expected for this OSCE is that of a competent FY1 working in general practice.
How do YOU feel the student has performed? You may take into account fluency and confidence
of answers given. Please underline the descriptor that best describes the performance of this
student:
CLEAR FAIL Student does not ask appropriate questions, cannot describe lesions and has
no knowledge of treatment
BORDERLINE Student takes history, but omits one aspect e.g. psycho-social aspects or
symptoms, describes signs but is uncertain how to confirm diagnosis, poor at counselling
patient or negotiating treatment.
CLEAR PASS Student covers points in history listed, describes signs correctly, responds
appropriately to patient’s questions and works with the patient to decide on treatment.
ABOVE EXPECTED STANDARD Student covers all points listed, shows insight into
indications for different treatments and handles discussion confidently and accurately
Finally, check the correct student details are at the top of the form.
check the correct student details are at the top of the form.
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