I saw an old lady a few weeks ago who was complaining about a rash that first appeared when she was in the hospital for a gall bladder operation about a month ago. (She’d had to stay a little longer than necessary because they’d had to convert a laparoscopic procedure to an open one.) It happened to be located on her butt.
She told me it had been very painful at the time. It still hurt when she sat on it, producing a tingling sensation, so now it was mainly annoying. She’d been given a cream in the hospital (“diaper rash cream, like for a baby”) but it hadn’t done anything.
“May I look at the rash?” I asked.
“Certainly,” she replied. She dropped trou (hiked up her skirt, actually), bent over, and showed me the area in question.
On her right buttock only was a neatly circumscribed area of clusters of healing, crusted vesicles (blisters). The other side was as smooth and clear as a baby’s bottom, if you’ll excuse the expression.
“Did anyone in the hospital actually look at this rash?” I asked.
No one had. Apparently the protocol was: old person in hospital; rash on butt; throw some diaper rash cream on it. I suppose some doctors must feel that inspecting nether regions is beneath them. As for the nurses, if you don’t know what zoster looks like, get someone to show you.
Listen up, everyone. Dr. Bob and I (and others) have been beating this drum for some time now, but it doesn’t seem to be sinking in:
YOU HAVE TO MAKE AN ACCURATE DIAGNOSIS
IN ORDER TO PROVIDE APPROPRIATE TREATMENT.
I gave her my spiel on shingles and explained that there wasn’t any specific treatment to provide this far into the course. The rash was indeed healing, and the annoying tingling pain may or may not go away. She graded the pain as 1 of 10, so she’s not a candidate for heavy-duty post-herpetic neuralgia treatments. She was content with my care and went on her way.
Come on, people! At least TRY to make a diagnosis. You’ll be amazed how much more effective your treatment can be.
Musings of a Dinosaur 
I agree with you! Nothing irks me more than a doctor that won’t EXAMINE me but just asks me questions. Yes, I get that the questions are important, too, but so is actually looking at the patient. You miss more by not looking than by not knowing…
By: Jon on September 21, 2010
at 7:16 am
Unfortunately this is all too common among nurses and physicians. As a geriatric nurse practitioner, I have had multiple patients seen by home healthcare nurses who misidentify a vesicular rash (aka zoster) with a “rash” or “allergic reaction” and then provide no explanation of what they are seeing. Even if they could say there is a vesicular rash across area X that is in a band, would allow me to start the antivirals within the required time (within 72hrs). It’s an unfortunate short-coming, but one I am about to start a research project on to improve home healthcare nurses identification of certain common conditions present in the elderly.
Happy Hospitalists’ father in law just got antivirals from his internal med doc for a case of herpes zoster that was well over 72hrs old after a misdiagnosis by an occupational health nurse (see http://thehappyhospitalist.blogspot.com/2010/09/diagnosed-with-shingles-vs-spider-bite.html ). Goes to show that health professions for some reason have significant trouble with their members performing appropriate practice and treatment!
By: Ab Brody on September 21, 2010
at 10:41 am
Your description also fits herpes. A culture would tell the difference, if you can get some oozing lesions to culture. Same treatment really…but if herpes, I give her refills for future outbreaks.
Great post, doc!
By: Peggy Polaneczky on September 21, 2010
at 12:47 pm
pff. I knew it was probably Zoster as soon as you said the rash was painful. Shame on whoever didn’t bother to look.
By: whitecap nurse on September 21, 2010
at 1:18 pm
I get a lot of pissed off patients when I’m on call who tell me they have a “Rash”. Since I can’t see it on the phone I have to ask to see their doctor the next day (or Urgent Care when it is Friday night at midnight when they usually call). They argue with me on why they have to be seen, why can’t I just call something in, etc. etc.
I can’t diagnose it over the phone. It could be malpractice to do so if I called in the wrong meds.
Good medical care requires that a doctor examines the “rash” prior to providing treatment. Period.
By: Hashmd on September 21, 2010
at 2:50 pm
@Peggy: Not HSV. Beautifully contained within the sacral dermatome. VZV.
@hashmd: actually, camera phones make “telephone” diagnosis of rashes just a tad less ridiculous. Rarely have sufficient resolution, but if they want to get a little more adventurous and use a better camera, then email me the image, we’re into full-blown telemedicine.
By: notdeaddinosaur on September 21, 2010
at 3:53 pm
Well, yeah. Someone would have actually had to LOOK at pasty old-lady butt to make an accurate diagnosis.
Thankfully, you’re willing to do so. There are a Hell of a lot of doctors and nurses who would rather not.
By: CalvinsMom on September 21, 2010
at 6:11 pm
but wouldn’t it be interesting to get a primary outbreak of HSV in that patient… imagine the counseling opportunities!
By: medstudentitis on September 21, 2010
at 10:33 pm
Dino, thanks for pointing this out. ITA that docs and nurses seem to have lost the art of physical assessment. Patient report and test results are PART of health care…but actually LOOKING at pasty white butts is called proper assessment.
My LPN students had their very first ever clinical day this week, after being taught and tested on a complete head-to-toe assessment in skills lab.
We documented multiple bruises and lacerations on a little gentleman who fell and broke his hip. All notes read “skin dry and intact, no lesions, edema, or bruising noted.”
He had a black eye……….
By: Pattie, RN on September 22, 2010
at 7:49 am
I have been seeing a lot of articles lately on how the physical exam is still necessary and important. This post shows why those articles are necessary.
By: Sandra on September 22, 2010
at 10:01 am
We also had a young lady getting the big abdominal pain work-up recently until the gown was pulled up to reveal … ta da! zoster on the skin. You MUST LOOK.
By: whitecap nurse on September 22, 2010
at 1:00 pm
[…] DIAGNOSIS. It works, bitches. […]
By: Quick Links | A Blog Around The Clock on September 23, 2010
at 11:47 am
this happened to me, and the irony was that i was an ed nurse and 3 of the docs i worked with looked at it (it was on my neck) and told me it was just my idopathic uticaria. i went to my pcp, he consulted his derm reference and together we came to the dx of shingles. i was lucky in that it was a mild case and i had very little pain. the only trauma was my neck was scabbed for my daughter’s wedding.
By: susan on September 25, 2010
at 11:45 am
Good post. I guess none of her caregivers wanted to get ‘behind’ in their work.
By: Michael Kirsch, M.D. on September 26, 2010
at 8:41 am
You’re describing HSV.
Single patch, no hyperaesthesia along rest of dermatome, fairly common site (lip, genitals,cheek, buttock are the biggies,IME)
Just discovered this site..love it!
I too am a dinosaur..graduated 1969.
By: Andrew Loewy MD on September 28, 2010
at 1:20 am