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Itching child

Clinical Discipline(s)/Organ System(s)
Dermatology, General Practice, Hauora Māori, Immunology, Infectious Diseases, Paediatrics
Progress Test Topic(s)
Skin
Description
An 8 year old Māori boy is admitted to the paediatric ward with an generalised itchy red scaly eruption. He has had atopic eczema since he was 3 months old and has required multiple courses of antibiotics and been admitted for incision and drainage of an abscess 10 months ago. He has previously experienced boils and he has had courses of antibiotics in addition to topical steroids and anti-scabies treatment without success. The boy's skin is dry, thickened and excoriated with crusted areas about the knees and ankles.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Multifactorial pathogenesis of atopic eczema: genetic and environmental triggers, association with food allergy
   - Immunology of eczema and atopy
   - Microbiology of infective exacerbations of eczema (bacteriologic, viral and parasitic) and impetigo
   - Pathogenesis of acute post-streptococcal skin infection
   - Pharmacology of topical anti-inflammatory corticosteroids
Clinical and Communication Skills 
   - Take a history that allows determination of risk factors for eczema, associated conditions, assessment of severity, current treatment including quantity and duration; assess possible 'steroid phobia'
   - Examine the skin and assess the extent and degree of involvement of the eczema; examine for clinical evidence of scabies, eczema herpeticum and molluscum contagiosum; establish if there is secondary bacterial infection and know features of impetigo and furunculosis
   - Describe the clinical features observed using dermatological terminology
   - Role and indications for bacterial and viral swabs
   - Management of mild to moderate eczema including use of emollients; appropriate use of topical steroid ladder; give family a clear explanation of how to apply topical preparations and appropriate quantities, and demonstrate where necessary
   - Understand the management of severe and refractory eczema e.g. the concept of 'wet wraps' and 'weekend treatment'; topical immunomodulators such as pimecrolimus; phototherapy; systemic agents (anti-inflammatory corticosteroids, azathioprine, methotrexate, ciclosporin)
   - Explain how to recognise skin infection and how to manage this within a household
   - Assess the impact of this chronic disease on the patient and family/whānau; establish a short term and then a realistic longer term goals of management with the patient and the family/whānau
Personal and Professional Skills 
   - Develop the ability to manage chronic disease and patient expectations
Hauora Māori 
   - Awareness of differing risk profiles for atopy between Māori (and other disadvantaged populations) compared with non-Māori in NZ
   - Acknowledgement of the disproportionate impact of illness on whānau employment/income, and therefore availability and models of caregiving
   - Ability to cater for differential health literacy needs of Māori patients and whānau
   - Understanding the role of kaupapa Māori services and research (e.g. Toi Tu service in Tamaki Makaurau)
Population Health 
   - Understand that atopic diathesis is prevalent in New Zealand and a significant disease burden, particularly among children
Conditions to be considered relating to this scenario
Common
atopic eczema (dermatitis), recurrent skin infection particularly furunculosis, cellulitis impetigo, scabies, contact irritation (in relation to scabies treatment)
Less common but 'important not to miss'
erythrodermic eczema, eczema herpeticum, immunodeficiency
Uncommon
ichthyosis or other genodermatosis