Case study prompts: Integumentary Function:
K.B. is a 40-year-old white female with a 5-year history of psoriasis. She has scheduled an appointment with her dermatologist due to another relapse of psoriasis. This is her third flare-up since a definitive diagnosis was made. This outbreak of plaque psoriasis is generalized and involves large regions on the arms, legs, elbows, knees, abdomen, scalp, and groin. K.B. was diagnosed with limited plaque-type psoriasis at age 35 and initially responded well to topical treatment with high-potency corticosteroids. She has been in remission for 18 months. Until now, lesions have been confined to small regions on the elbows and lower legs.
Case Study Questions
1. Name the most common triggers for psoriasis and explain the different clinical types.
2. There are several types of treatments for psoriasis, explain the different types and indicate which would be the most appropriate approach to treat this relapse episode for K.B. Also include non-pharmacological options and recommendations.
3. Included in question 2
4. A medication review and reconciliation are always important in all patient, describe and specify why in this particular case is important to know what medications the patient is taking?
5. What others manifestation could present a patient with Psoriasis?
C.J. is a 27-year-old male who started to present crusty and yellowish discharged on his eyes 24 hours ago. At the beginning he thought that washing his eyes vigorously the discharge will go away but by the contrary increased producing a blurry vision specially in the morning. Once he clears his eyes of the sticky discharge her visual acuity was normal again. Also, he has been feeling throbbing pain on his left ear. His eyes became red today, so he decided to consult to get evaluated. On his physical assessment you found a yellowish discharge and bilateral conjunctival erythema. His throat and lungs are normal, his left ear canal is within normal limits, but the tympanic membrane is opaque, bulging and red.
Case Study Questions
1. Based on the clinical manifestations presented on the case above, which would be your eyes diagnosis for C.J. Please name why you get to this diagnosis and document your rational.
2. With no further information would you be able to name the probable etiology of the eye affection presented? Viral, bacterial, allergic, gonococcal, trachoma. Why and why not.
3. Based on your answer to the previous question regarding the etiology of the eye affection, which would be the best therapeutic approach to C.J problem.
SOLUTION TO CASE STUDIES
Psoriasis triggers and the clinical types
Psoriasis is a chronic recurrent illness that affects the skin and joints and is mediated by the immune system. Adequate evidence suggests that the disease has no cure. As such, the resulting impact on individuals varies from emotional, social, and psychological to physical. Nair and Badri (2022) note that heredity significantly contributes to its development; however, several modifiable factors also trigger psoriasis. Nair and Badri (2022) document the common triggers such as medications, including antihypertensive, lithium, and antimalarial drugs. Extreme weather conditions such as cold and hot weather trigger psoriasis. Stopping corticosteroid medications suddenly also triggers psoriasis. Other triggers include excessive alcohol consumption, skin injury, and throat infections.
Various clinical types of psoriasis have distinct signs to set them apart. First, plaque psoriasis is the most common. It clinically manifests as dry, scaly, and itchy plaques on the knees, lower back, scalp, and elbows. Post-inflammatory hyperpigmentation in the affected skin areas is common in dark and brown skin. Guttate psoriasis commonly affects children and young adults. Studies indicate that throat infections are the most common triggers of guttate psoriasis. The patches here are scaly, small, and drop-shaped, usually found on the legs, trunk, and arms.
Knowing a patient’s current or previous treatment regimen is necessary to establish an alternate effective regimen with a different pharmacological approach. Griffiths et al. (2021) state that the first-line treatment of mild and moderate psoriasis is topical pharmacological agents such as retinoid, dithranol, coal tar, vitamin D analogs, and corticosteroids. The topical agents are used with moisturizers to enhance skin barrier function and maintain hydration. The second line treatment is methotrexate. When patients do not respond positively to methotrexate, they are treated using biological agents or a combination of the two.
Non-pharmacological treatment methods include phototherapy through solar or ultraviolet radiation. Stress reduction techniques are also effective for psoriasis treatment (Griffiths et al., 2021). Since K.B. had already used the first-line pharmacological agents, the second line would be more suitable for him. Therefore, it would be more appropriate to treat him with methotrexate and enroll him in stress reduction programs.
Other clinical features that define psoriasis include generalized exfoliative erythroderma, nail involvement as in psoriatic arthritis, and development of a lesion at the site of injury (Nair & Badri, 2022).
I would diagnose C.J. with acute bacterial conjunctivitis with otitis media infection. The yellowish eye discharge and bilateral conjunctival erythema suggest a bacterial infection. The ear examination shows a painful, red, bulging tympanic membrane. These features are suggestive of otitis media.
Based on a review by Pippin and Le (2021), patients diagnosed with bacterial conjunctivitis present with tearing eye redness, and yellowish discharge from both eyes. The color of the eye discharge varies depending on the causative agent. In this scenario, the eye infection is of a bacterial origin based on its color and the symptoms suggesting a bacterial ear infection.
The most appropriate treatment approach for C.J. would be an ophthalmic and a systemic antibiotic to clear the eye and ear infection, respectively. According to Azari and Arabi (2020), C.J. would benefit from besifloxacin, 1 drop three times a day for a week, and amoxicillin-clavulanate 1g two times a day for five days.
Azari, A. A., & Arabi, A. (2020). Conjunctivitis: A Systematic Review. Journal of ophthalmic & vision research, 15(3), 372–395. https://doi.org/10.18502/jovr.v15i3.7456
Griffiths, C. E., Armstrong, A. W., Gudjonsson, J. E., & Barker, J. N. (2021). Psoriasis. The Lancet, 397(10281), 1301-1315.
Nair PA, Badri T. (2022). Psoriasis. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448194/
Pippin, M. M., & Le, J. K. (2021). Bacterial Conjunctivitis. In StatPearls [Internet]. StatPearls Publishing.
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