Solve the Medical Riddle: She Had a Rash on Her Arms and Then New Patches Started Appearing on Her Legs, First Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told the doctor and how the doctor proceeded with the examination. Next week, the doctor will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!]

The Patient Reports Her Symptoms

Cynthia, age 63,went to Urgent Care on a Saturday morning because she woke up with patches of a red rash all over her body and her doctor’s office was closed.

As always in ThirdAge Medical Riddles, the healthcare professional will use the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Cynthia told the doctors at Urgent Care:

“Last weekend I visited some friends who live in Montana. The weather was chilly but sunny so we hiked in a wooded area. I live in Philadelphia and it was a treat for me to get out into nature for a few days. But right after I got back, I broke out with an ugly rash on my arms. It had red bumps that itched.

“I was guessing I might have been allergic to something in the woods. I Googled and found out about a fairly rare allergy to a plant native to Western U.S. and Canada called a sword fern. I remembered my friend pointing out sword ferns the previous year when I visited and we went on a hike. I had grabbed onto one at a certain point when the trail got narrow and I was afraid I was going to fall and I did the same thing this year. I had started sweating in spite of the cold weather – I swear I still have hot flashes! – so I took off my coat and tied it around my waist. When I wrapped my arms around the ferns, I was only wearing a T-shirt so my arms were bare. The ferns are huge, almost as big as trees. But I didn’t break out in a rash the first time I touched the ferns so maybe that’s not the cause after all.

“Anyway, I decided to put baking soda paste on the rash and hope it would go away. I didn’t want to take any over-the-counter medications or use OTC ointments if I could help it. I’m always leery of using OTC meds without a doctor’s approval.

“Then this morning, two days after the rash on my arms appeared, I woke up with patches of rash on my legs and torso. By the time I had finished my coffee, several new patches had shown up. That’s why I figured I’d better come here for an examination. Why would I keep getting new patches even though I’m nowhere near a sword fern? Maybe it wasn’t the fern after all. Maybe I’m allergic to something in my own home. I just hope this isn’t anything serious!”

The doctor at Urgent Care was visibly startled at how bad Cynthia’s rash was but  he said he had been trained in emergency medicine so that just by seeing Cynthia’s rash, he could reassure her that the rash was not life threatening. However, he said she should definitely see a dermatologist. He got on the phone right away and booked an appointment with a top dermatologist for the first thing Monday morning.

The Urgent Care doctor recommended that Cynthia should take Claritin or Allegra, which are OTC antihistamines. He explained that the body releases histamine, a chemical found in many cells, in reaction to an allergen and that this can cause a variety of symptoms from rashes to runny noses. The doctor also said he could give Cynthia a scrip for a prescription-strength topical corticosteroid ointment and a scrip for Prednisone, an oral steroid. However, he suggested that if Cynthia could stand the itching for one more day until Monday morning, he would prefer not to treat the rash because he wanted to let the dermatologist see it “while it’s on fire”. Cynthia said she was fine with that and she even decided to postpone taking an antihistamine.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the dermatologist used  S=Symptoms or Chief Complaint; O, Objective Findings; and A=Assessment or Analysis, in her quest for a correct diagnosis of Cynthia’s complaint . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com http://www.drsavard.com/index.php.