RASHES

I make this no secret. I do not like rashes in any way shape or form. Unfortunately they are a common occurrence in the long-term care facility and I have to deal with them whether I like it or not. One rash in particular caught my eye (not in a good way) when I was on call one Saturday. Call on Saturday was from 0800 to 0800. I feel this is a long time to be on call, especially if there are a lot of “calls.” The answering service e-mails the information from the facility I need to call. I compare the on-call experience to telephone triage.

“Beep beep beep,” rang my pager. I looked at it and saw it was from one of the facilities I knew nothing about the patients. I looked at the brief explanation of the phone call. It read, “Patient with scabies.” I started to immediately itch. I wrote down the information and called the number given as I started scratching my arms. “I hate rashes, I hate rashes, I hate rashes,” I thought to myself.  

“Hi. This is the NP on call,” I said.

“Oh hi. This is Stephanie. One of the other NP’s new patients has a rash. She has had it before but it is looking worse. We think it might be scabies. We had an outbreak about two years ago here and I want to be safe,” she said.

“And it looks worse on a Saturday instead of a Friday?” I thought to myself. “And, oh yeah…I hate rashes.”

In order for me to fully assess the rash I needed to actually see the patient. Getting the description over the phone was not the best method because the LPN’s usually could not describe them. I got into my car and drove to the facility six miles away.

I walked onto the second floor of the facility and saw a girl in scrubs sitting in the nurse’s station I assumed to be Stephanie. She watched me and smiled because she knew I was probably the NP on call because of the identifying stethoscope around my neck and I was wearing regular clothes. I introduced myself and asked for the patient’s chart. Stephanie proceeded to tell me about the rash on Mrs. B. Mrs. B was waiting for me in her room. She was put on precautions and could not leave the room for fear of spreading the scabies to other residents including the staff who took care of her. According to Stephanie there were no other residents or staff who had a suspicious rash. That was a good sign.

I walked into the dimly lighted room with Stephanie. There sat a morbidly obese woman in a wheelchair smiling as I walked in. I looked at her arms and noticed she had a rash on both. I put on gloves as I tried to talk myself out of scratching in front of the patient. My head was itching and moving down my face. “I will need to take a very hot shower when I get home,” I thought to myself.

Stephanie introduced me as the NP who would be looking at her rash. I had the feeling it would not be a small rash considering what her arms looked like. There obviously was more to see. Stephanie then closed the door and told Mrs. B she would be lifting her gown so I could see the rash. Mrs. B was more than happy to allow Stephanie to lift her gown. As she lifted the gown I saw the rash covered her entire upper back, large abdomen, arms, and the outer portion of her breasts.

“Do you itch?” I asked Mrs. B.

“Oh yes. All of the time,” she responded as she sat in her wheelchair without an arm going anywhere on her body to scratch.

“I am itching more than you. And you have this global rash,” I thought to myself.

I felt the rash with my gloved fingertips to ascertain the raised and flat areas. They were erythematous patches and papules, some with crusts. I also noticed old scarring on her shoulders and upper back. I could see where the staff thought it would be scabies because of the shapes of the some of the old scars. Scabies had the distinctive linear ridges (burrows) with minute papules or vesicles and the end of the tunnel produced by the mite. The elevation at the end of the burrow is where the mite resides to lay their eggs. One hallmark symptom of having scabies is pruritis (itching). Mrs. B did not have what appeared to be scabies. I diagnosed her with dermatitis. I prescribed Lidex cream to put on the rash. The cause would have to be determined later in the week by the patient’s regular NP.

After a week I checked with the regular NP to see if the Lidex cream had worked and I did not mis-diagnose Mrs. B. I found out Mrs. B’s rash was almost gone. She had a dermatology appointment the following week to determine the cause of the rash and if further treatment was necessary. Me…well I itched despite my diagnosis for Mrs. B for three days. I called my diagnosis phantom psychoscabie-itis. You can use that too if you are itching after reading this post.