Mendoza, T., Mindanao, A., Miranda, M., Molina, M., Monzon, J., Morales, A., Musni, M., Nallas, A., Naval, A., Nepomuceno, J., Nerpiol, C., Ng, C., Ng, P., Niere, J.,

Millicent Tan Ong, MDHelmar Soldevilla, MD

3C-MED

Medicine II –Module 4Clinical Case: Psoriasis

Psoriatic ArthritisCellulitis

OBJECTIVES• Present a case of a 28 y/o male with

Psoriatic Arthritis (PsA)

• Differential Diagnoses

• Pathophysiology of PsA

• Approach to a Patient with PsA

• Complications, Outcome and Prognosis of PsA

MEDICAL HISTORY• 28 year old male, catholic, married,

tricycle driver, residing in Caloocan City

• Chief Complaint:

History of Present Illness

7 Yrs PTA

Diagnosed with Psoriasis based on the following:• Flaky white scales on the scalp• Pustules, papules plaques topped with scales at the back, trunk, upper and lower extremities and his face • Punch biopsy: Psoriasis Rx: Psoralen + Ultraviolet A (PUVA) therapy Methotrexate (2.5mg) at 12 hr intervals for three doses each week Dermovate (unrecalled dose) with Petroleum Jelly and LCD Hydroxizine (Iterax) for pruritus 3x/day prnFull resolution of skin lesions

Diagnosed with Psoriasis based on the following:• Flaky white scales on the scalp• Pustules, papules plaques topped with scales at the back, trunk, upper and lower extremities and his face • Punch biopsy: Psoriasis Rx: Psoralen + Ultraviolet A (PUVA) therapy Methotrexate (2.5mg) at 12 hr intervals for three doses each week Dermovate (unrecalled dose) with Petroleum Jelly and LCD Hydroxizine (Iterax) for pruritus 3x/day prnFull resolution of skin lesions

2 Yrs PTA

• Recurrence of skin lesions• Pain and swelling of all the digits of both hands• Rx: Naproxen (550mg/tab) BID prn • Asymmetric oligoarthritis polyarthritis involving the DIPs and PIPs of both hands, BKJ• Consult to Rheumatologist• Rx: Celecoxib (unrecalled dose)

• Recurrence of skin lesions• Pain and swelling of all the digits of both hands• Rx: Naproxen (550mg/tab) BID prn • Asymmetric oligoarthritis polyarthritis involving the DIPs and PIPs of both hands, BKJ• Consult to Rheumatologist• Rx: Celecoxib (unrecalled dose)

1 month PTA

• persistent swelling on BKJ with↑ pain (VAS 9/10)• persistent swelling on BKJ with↑ pain (VAS 9/10)

1 week PTA

• Non-radiating pain (VAS 7/10) on the low back, hips, and BAJ• More difficulty in ambulation

• Non-radiating pain (VAS 7/10) on the low back, hips, and BAJ• More difficulty in ambulation

5 days PTA

• Consult to Orthopedic Surgeon; diagnosed with BKJ effusion & advised arthrocentesis• Consult to Orthopedic Surgeon; diagnosed with BKJ effusion & advised arthrocentesis

4 days PTA

• Undocumented fever temporarily relieved by Cefuroxime and Paracetamol (unrecalled dose)• Consult at FEU Hospital: (X-Ray of leg: soft tissue swelling)• Advised admission but refused due to financial constraints• Transferred to USTH for further evaluation & management

• Undocumented fever temporarily relieved by Cefuroxime and Paracetamol (unrecalled dose)• Consult at FEU Hospital: (X-Ray of leg: soft tissue swelling)• Advised admission but refused due to financial constraints• Transferred to USTH for further evaluation & management

ADMISSION

1 Yr PTA• Pain and swelling on both knee joints (BKJ) limping• Relieved by various unrecalled NSAIDs• Pain and swelling on both knee joints (BKJ) limping• Relieved by various unrecalled NSAIDs

Past Medical History• (-) DM

• (-) HPN

• (-) Joint surgery

• (-) history of trauma

• (-) Allergy

• Diagnosed with dengue fever (2nd year high school)

• Excision of cyst at the back (2007)

Family History• (+) Myocardial Infarction – father

• (+) DM – father

• (-) HPN

• (-) stroke

• (-) Psoriasis

• (-) Cancer

• (-) Arthritides

Personal & Social History• Smoker: 0.6 pack years

• Occasional Alcoholic Beverage Drinker

• Denies Illicit Drug Use

• 3 past sexual partners, all protected

• Tricycle driver

• No history of travel outside manila

Review of Systems• No wt. loss, no loss of appetite

• No hearing loss, no nasal congestion, no cough

• No dyspnea, orthopnea, cyanosis

• No chest pain, palpitations

• No abdominal pain, diarrhea, constipation

• No dysuria, frequency, change in character of urine

PHYSICAL EXAMINATIONGeneral Survey• Conscious, coherent, oriented as to time, place and

person, not in cardio-respiratory distress

Vital Signs• BP 120/70 mmHg Wt: 70 kgs • PR 83 bpm Ht: 1.62 m• RR 20 cpm BMI : 26.5 kg/m2

• T° = 36.6 °C

Skin(+) generalized erythema w/ multiple well- to

ill-defined papules and plaques topped with whitish scales over the scalp, trunk and extremities

(+) onychodystrophy, nail pitting, oil spots of all nails of the hands and feet

HEENT• Pink palpebral conjunctivae, anicteric sclerae, no naso-

aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged

Neck• Supple neck, trachea midline, no palpable cervical lymph

nodes, thyroid gland not enlarged

Cardiovascular• Adynamic precordium, AB at 5th LICS, MCL; no murmurs• All pulses full and equal

Respiratory• Symmetric chest expansion, no retractions, clear breath

sounds on all lung fields, no crackles, no wheezes

Abdomen• Flat abdomen, NABS, soft, nontender, no masses

Musculoskeletal

Hand• (+) sausage-shaped 2nd and 4th digit

of the right hand & 4th & 5th digits of the (L) hand

• (+) Flexion contracture of the DIPs of the 2nd, 4th and 5th digits of the (R) hand & 5th digit of the (L) hand

• (+) tender, swollen, erythematous DIPs and PIPs of the 2nd, 4th and 5th digits of the ® hand and DIP of the 4th and 5th digit of the (L) hand

• All Active Range of Motion (AROM) of bilateral hands are within normal limits EXCEPT:

(L) hand

(R) hand

(R ) DIP PIP

2nd digit 45-45° 0-30°

4th digit 45-45° 0-45°

5th digit 30-30° 0-50°

Passive Range of Motion (PROM) not assessed due to tenderness of the affected joints

(L) DIP PIP

4th digit 0-45° 0-45°

5th digit 50-50° 0-40°

Landmark: Medial Tibial Plateau

RIGHT LEFT DIFFERENCE

3 inches 40.5 cm 38 cm 2.5 cm

6 inches 40.5 cm 37.5 cm 3 cm

9 inches 30.5 cm 28 cm 2.5 cm

BKJ•(+) swelling, warmth, tenderness•PROM within normal limits

Legs •swollen, warm, tender, erythematous (R) leg

Limb Girth Measurement

AROM (R) (L)

BKJ 0-100° 0-125°

SALIENT FEATURES

• 28 y/o male• History of Psoriasis• Asymmetric oligoarthritis polyarthritis of the

affected DIPs and PIPs of both hands, BKJ, and (BAJ)

• (+) Flexion contracture of the DIPs of the affected digits

• (+) sausage-shaped digits• Limited AROM of the affected joints• BKJ effusion• swollen, warm, tender, erythematous (R) leg • Undocumented fever

Pertinent (+)

SALIENT FEATURES

• No history of morning stiffness of joints

• No hx of bacterial infection or serious chronic illness

• No hx of infection before onset of arthritis

• No family history of arthritides

Pertinent (-)

OBJECTIVES• Present a case of a 28 y/o male with

Psoriatic Arthritis (PsA)

• Differential Diagnoses

• Pathophysiology of PsA

• Approach to a Patient with PsA

• Complications, Outcome and Prognosis of PsA

THANK YOU