Page 20 of 21
DR2.1,DR3.1-3,DR4.1 | Papulosquamous & Pigmentary Disorders — Assignment
CLINICAL SCENARIO
You are the primary registrar in a dermatology outpatient clinic. A 40-year-old man presents with a 3-year history of recurrent, thick, scaly plaques over the elbows, knees, and scalp. He has recently developed joint stiffness in his fingers. Your attending asks you to work up and present this patient as a comprehensive clinical case. This assignment challenges you to integrate recognition, investigation, differential diagnosis, severity assessment, and treatment planning — the complete clinical skill-set for papulosquamous disease.
Instructions
Write a structured case-based report in the format below. Base your reasoning on evidence from your SDL modules and the cited reference texts (IADVL Textbook of Dermatology, Neena Khanna — Illustrated Synopsis of Dermatology, Roxburgh's Common Skin Diseases). Where clinical judgement is involved, justify your decisions explicitly. The assignment is submitted individually and then reviewed by a peer according to the rubric provided.
Length: 1,200–1,800 words for the main report (Sections 1–4), plus 200–300 words for Section 5 reflection. Tables and procedural lists are not included in the word count.
What to Submit
Describe the classic morphology of psoriatic plaques as you would document them in a case record. Name and explain at minimum three physical signs you would specifically look for, and state what each sign tells you pathologically. Distinguish the lesion morphology from two common differentials (you must include at least one differential that also produces scaly plaques). Include in your description the specific distribution pattern that would support your diagnosis.
Write a procedural note as if you are documenting a performed Grattage test. Describe: (a) your indication for performing the test in this patient, (b) step-by-step technique with the three endpoints you expect in correct sequence, (c) interpretation of each endpoint with its pathological basis, and (d) how the test result changes (or confirms) your diagnostic impression. Note any safety precautions and contraindications.
Calculate and state this patient's PASI category (justify your estimate based on the history given), DLQI impact (based on his occupation and joint symptoms), and classify the disease as mild, moderate, or severe. Then write a structured treatment plan with: (a) first-choice treatment for his severity, (b) monitoring plan including frequency and parameters, (c) counselling points about chronicity, relapse triggers, and treatment expectations. CRITICAL: explicitly address why systemic corticosteroids must NEVER be prescribed for this patient, and what could happen if they were.
A junior colleague suggests this patient might have lichen planus. Write a structured comparative table (minimum 5 rows) contrasting psoriasis with lichen planus across morphology, clinical signs, histology, distribution, and management. Then write a short paragraph (≥150 words) explaining why the Wickham striae and the character of the scale are the two most critical discriminators in your clinical examination.
During the examination you notice a separate, well-defined, milky-white patch on the patient's left hand with no change in sensation. Wood's lamp accentuates it brilliantly. Write a brief reflective note (≥200 words) addressing: (a) your diagnostic reasoning for the pale patch (vitiligo vs leprosy differential — be specific about the three tests or observations that distinguish them), (b) how you would counsel this patient about this additional finding, including prognosis and treatment options for stable limited vitiligo, and (c) what this finding teaches you about the importance of a complete skin examination in every dermatology patient.
Grading Rubric — Papulosquamous & Pigmentary Disorders Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Clinical Morphology and Recognition (DR3.1): Accuracy and completeness of lesion description, physical signs (Auspitz, candle-grease, Koebner), pathological correlation, and differential diagnosis reasoning | 25 pts | All three signs named and explained with precise pathological basis; differential includes two valid mimics with discriminating features clearly stated; distribution and morphology accurately described |
| Grattage Test Procedural Documentation (DR3.2): Correct sequential endpoints, pathological basis for each, interpretation, and procedural safety | 20 pts | All three endpoints in correct order (candle-grease → last membrane → Auspitz sign); pathological mechanism of each stated correctly; interpretation linked to diagnosis; safety/contraindication mentioned |
| Severity Assessment and Treatment Planning (DR3.3): Correct PASI/DLQI application, appropriate treatment selection, monitoring plan, and contraindication of systemic steroids clearly explained | 30 pts | PASI category justified with clinical reasoning; DLQI impact appropriately estimated; treatment tier correct and evidence-based; monitoring plan complete; systemic steroid contraindication explicitly stated with mechanism (rebound pustular/erythrodermic psoriasis) and consequence |
| Differential Diagnosis Table and Discrimination (DR4.1): Accuracy of psoriasis vs lichen planus comparison, quality of comparative reasoning about Wickham striae and scale character | 15 pts | Table has ≥5 rows with accurate, specific entries for both conditions across all domains; paragraph clearly explains why Wickham striae (hypergranulosis, lace-like) and scale character (silvery parakeratotic vs thin white) are discriminating; psoriasis-lichen planus steroid management contrast included |
| Reflective Clinical Reasoning — Pigmentary Differential and Holistic Examination (DR2.1): Depth of vitiligo vs leprosy differential reasoning, quality of counselling, and reflective insight | 10 pts | Three discriminating observations clearly stated (colour quality, sensation, Wood's lamp); counselling covers prognosis (chronic autoimmune), treatment options (topicals, NB-UVB, surgical for stable), and appropriate reassurance; genuine reflective insight about whole-skin examination |
PEER REVIEW
You will receive a classmate's assignment for review. Read the entire submission before making any comments. Using the rubric above as your framework, provide specific, evidence-based feedback on each section. Your review must include: (1) at least two specific strengths with examples quoted from the work, (2) at least two specific improvement suggestions per section (not just 'needs more detail'), and (3) a suggested score for each criterion with a one-sentence justification. Remember: constructive peer review is itself a learning activity — your goal is to help your peer improve, not simply to award marks. Avoid vague praise.