Thursday, March 13, 2008

A little rash

NewFNP walked into clinic Tuesday - a different site from where she usually works - and her MA asked her to please take a gander at the little girl in room 3 with a rash.  

A rash??  Holy shit, and how!

This little girl's skin was fucking polka-dotted.  Ears, face, trunk, legs, arms, neck and -- hey there --palms and soles.  Did newFNP mention that this four-year old's temp was 103?  And that two of the lesions seemed purpuric.  And that she showed increased work of breathing?  And that she had conjuctivitis?  And coryza?

Inside, newFNP was like this: Shit!! What the fuck?  Help!  Inside, newFNP asked the mom about medications.  None.  Known allergies?  None.  Travel history?  None.  Pain?  None.  Vaccines?  No four-year old vaccines yet, but the girl was only two weeks past her fourth birthday.  Otherwise, up to date.  Onset? About twelve hours prior, as a single lesion on her arm.  Scared?  Yes.  The patient and newFNP.

NewFNP must admit that her differentials included holy shit, what the fuck is this? and who fucking knows but she's going to the ED.  NewFNP tried to calm herself down and think of what causes palmar rashes.  Syphilis.  Allergy.  Help!

NewFNP ruled out syphilis because, high risk though her clinic may be, no -- just no.  And her history didn't lend itself to the diagnosis of allergic reaction.

At this point, newFNP knew that she was dealing with a case requiring consultation.  She called Dr. Dual-Ivy-League-Degrees who raised the concern for meningitis and supported newFNP's decision to send the girl to the ED.  

The patient's mom offered to take the little girl on the bus.  Gold star for flexibility, not so much for public health.  NewFNP arranged alternative transportation and affixed a surgical mask to the girl's face in the off-chance that the rash was, in fact, meningeal.

NewFNP called the parents last night.  The little girl was being discharged after having been observed for twenty-four hours for suspicion of the very freaky Stevens-Johnson syndrome.  Apparently, she must not have had it or she wouldn't have been discharged, right?  NewFNP is dying to read the hospital notes.  

The ER docs attributed her reaction to a Motrin allergy.  Now, newFNP did not get this information in clinic and actually gave the patient a whopping dose of Motrin to bring that fever down.  Frankly, newFNP is suspicious of this diagnosis.  Sure, she won't give Motrin to this patient in the future, but a temp of 103?!?  Perhaps that is a confounder in this case.

Man, is newFNP ever lucky that this girl was her first patient of the day and not her last!  


nycpnp said...

could it have been HSP - not sure if that spares the palms and soles though....that would have freaked me out too.

npsusan said...

rocky mountain spotted fever?

Anonymous said...

Wow, I'm very impressed by the critical thinking but your profanity makes us all look ignorant! Your fellow nurse...