Monday, April 14, 2008

Diagnose This!

You're a student on rotation at an academic medical center's walk-in clinic. A new patient presents with a one week history of pruritic 1-2 mm diameter vesicles and evidence of excoriation on the extensor surface of both hands that is most prominent between the metacarpophalangeal joint and the dorsal crease of the wrist. There are also some lesions at the proximal nail fold and distal phalanges. The interphalangeal skin and finger webbing is largely spared, except for the area surrounding the left 4th digit. There is no palmar rash. Upon closer inspection, the lesions have a diverse morphology, ranging from non-erythemetic fluid-filled indurated vesicles to bright red papules with a 3 mm diameter border to small salmon colored macules with crusted centers. A thorough skin inspection yields no other rashes. Complete physical exam is unremarkable except for dark circles under his eyes. The skin finding is shown below.

Further questioning reveals that this patient has developed irregular sleep habits over the past several months and has several other new stressors in his life, including physical relocation, new responsibilities at work, looming deadlines, personal grief, and a perception that his future depends on every daily task. He does report several adaptive behaviors to help manage this stress, including creative outlets that use all ten fingers... The rash has been refractory to cortisone and triamcinolone, and Actifed helps a little bit with the itching. He seems resigned to this condition, stating that his position will change in about a month.

After consulting your attending, you recommend which of the following therapies:
A) Bed Rest
B) Solar Therapy (Specifically In Zihuatanejo)
C) Desoximetasone Baths
D) Cutting Back On The Alcohol

Oh, I almost forgot: What's your diagnosis doctor?

1 comment:

Heidi said...

are you turning into a cheetah too?