PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Friday, March 16, 2007

Pustular Psoriasis

"This young man presented with this condition after being given some treatment for a his plaque psoriasis . Please examine his skin"

Suggested presentation
This febirle unwell-looking young man has generalised widespread creamy white pustules with an erythematous base. Some of the pustules have erupted, resulting in red oozing erosions . The palms and soles are also involved. He also has generalised onycholysis with discolouration and misshaped toes and fingernails.The patient has tenderness and warmth over both knee joints.

The diagnosis is pustular psoriasis complicated by gout. The likely cause for this presentation is massive intradermal steriod injection.

(Patient in this picture had pre-existing plaque psoriasis, so did his father and paternal grandfather. He was given Intradermal methylprednisolone 200mg daily instead of the recommended 10mg per month. Not shown inthe pictres, he had evidence of plaques on his elbows, hairlines and behind the ears)

Questions that may be asked
1. What differentiates this from skin infections?
The pustules are sterile on culture and the patient's white cell count may be normal

2. What is explanation for the patient's knee pain?
Psoriasis is a condition where there is increased cell turnover so there is hyperuricaemia, which results in crystal deposition in knee joins, giving rise to gout.

3, How would you manage this patient?
The patient should be managed like a exfoliative erythrodermic patient, paying close attention to barrier nursing, fluid replacement, prompt treatment of infections, adequate nutrition

4. Name me the definitive treatment for pustular psoriasis.
Acitretin, an oral retinoid.

Contributed by Giant Eagle

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