A Systematic Approach to the Unknown Rash
Todd Way Jan 13, 2015
Goals
• Review some common ED rash presentations
• Provide a systematic way to identify rashes.
• Test our knowledge.
• Skin rash accounts for approx 2 % of ED visits
• In the top 20 of ED chief complaints
• National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary Pitts et al. Ø3000 dermatological diagnoses
Dermatology
• What is Dermatology?
• Dermatology is the study and treatment of the skin, hair and nails, as well as education related to sun protection and other aspects of skin health.
• Some common issues experienced with skin include acne, eczema, cold sores and various types of infections. The specialists for skin, hair and nail health are called dermatologists
• Courtesy Horizon Health Network Website
Dermatologists
Case 1
Case 2.
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
Case 12
Case 13
Case 14
Case 15
Case 16
Case 17
Case 18
Case 19
Case 20
Pictures are worth 1000 words… but some words help.
• Age of Patient • Duration of Rash • Associated Symptoms • (fever, itching, pain, swelling) •
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•
•
•
•
•
Travel / Location Sick Contacts Past Medical History New Medications Menstrual History Sexual History Vaccinations •Morphology •
•
•
•
Diffuse Erythematous
Maculopapular
Vesiculo-­‐Bullous
Petechiae / Purpura
•Vital Signs • Hypotension • Tachycardia • Fever • Mental Status Changes
Distribution
•
•
•
•
•
•
•
Central Peripheral Flexural Extensor Intertriginous (skin folds)
Dermatomal
Mucosal Surface Involvement Appearance
•
•
•
•
•
•
•
Scaly/Moist Color Honey Crusted Umbilicated
Blanching Palpable Hyper / Hypopigmented
Case 1
12 year old boy presents with 3 day history of non pruritic, non palbable rash.
Travel – none
Sick contacts – whole house fighting flu.
Allergies – none
Medications – none
Immunizations -­‐ UTD
PMHx-­‐ well, recent viral illness
Vital signs within normal limits.
Case 2.
19 y.o male presents with fever, and rash ongoing for 2 days. Recently travelled to visit sister in Boston
Allergies – none
Medications – none
Immunizations UTD
PMHx – well
Temp 38.4, HR 97, BP 121/77
No mental status changes.
Case 3
10 year old boy presents with Fever, Maculopapular rash to his extremities and mental status changes.
No allergies or medications
Otherwise well
No recent travel
Pt is hypotensive, tachycardic, and appears ill with a temp of 39C.
Case 4
6 y male with fever and rash since waking this morning. Diffuse, covers torso. Rough feeling.
PMHx – well, Immunized
Allergies / Meds – none
No recent travel
No sick contacts.
Vitals: HR 130; T 38 C; BP 110/60; RR 30 Case 5
35 yo woman presents to ER with red rash, and skin sloughing.
Meds –
Septra for UTI 2 weeks ago.
Naproxen for back pain
No sick contacts or travel
PMHx – chronic back pain
Temp = 39, HR88, BP 105/75, RR 20
Case 6
34 yo male who presents with itchy erythematous rash on upper torso, neck and face. Started after spending day mackerel fishing with friends on boat in Bay of Fundy.
Consumed alcohol during day, had mackerel for supper.
Nauseated
Afebrile
No travel
No allergies
No medications
Temp 37.1. HR 97, BP 114/72, RR 20
Case 7
7 y o boy presents with maculopapular rash over entire body. Started over 24 hour period
No recent travel/ sick contacts
Allergies – none
Meds – tylenol
Immunization – UTD, including varicella vaccine
Temp 38.4, other vitals normal.
Case 8
19 yo female with itchy vesicular rash on R wrist. It has gotten so bad that she can no longer wear her new watch. Otherwise well
No other sx
Vitals stable
Case 9
9 yo boy presents with painful maculopapular rash localized to flexor surfaces of both wrists
No sick contacts
Recently travelled to Moncton (visited relatives)
PMHx – well, Immunized
Allg – none
Meds – none
Vitals Normal, afebrile
Case 10
38 yo man presents with the following rash.
States just getting over a flu, fever, body aches, tired. Denies respiratory symptoms.
PMHx – HTN
Meds –
HCTZ
Tylenol for fever
Allergies – none
Vitals entirely normal
Case 11
20 yo woman with rapidly progressive target lesions over legs, back of arms. Non pruritic. Feels achy, occasional fevers
PMHX – Herpes
Drugs – none
Allergies – none
No sick contacts / travel
Vitals are stable.
Case 12
26 yo male with red rash to chest noted on waking today. Afebrile today.
PMHx – well, just getting through cold sx.
Allergies – none
Medications – OTC cold medications Sick contacts – none/ no travel
Case 13
24 yo male with itchy / scaly rash to back and torso. Initially started with L picture and then became more diffuse.
Otherwise well, afebrile, not ill appearing. No travel / sick contacts
Case 14
33 yo diabetic woman presents with acutely painful rash over top of right shoulder which appeared after she was stung by a bee.
PMHx – diabetic
Medications – Lantus, humulog, Tylenol
LMP – 2 weeks ago
No travel / sick contacts
No allergies
Temp 37.8, BP 102/65, HR 104, RR 20.
Case 15
4 month old presents with diffuse erythematous rash, fever, and poor oral intake.
PMHx – term, no GBS, immunized fully
Allergies -­‐ none
Meds – Tylenol
Child febrile and appears ill.
Case 16
20 y.o. woman present to ED with fever, and red skin x 24 h.
Travel – none
Sick contacts – none
Allergies -­‐ 0 Meds -­‐ tylenol
LMP – currently menstrating
BP – 90/60, HR 115, RR 20, Temp 39.1
Case 17
68 yo woman with history of 2 months of itching followed by progressive formation of plaques then blisters to flexor surfaces of both arms.
PMHx – HTN, MI, Aortic valve replacement
Meds – ramipril, metoprolol, cholesterol drug, and something to thin her blood.
Allergies – none
No travel.
Case 18
A 36 y/o woman presents with a a burning, right-­‐sided chest & back pain with a vesiculobullous
rash
PMHx: well
Allergies: NKDA Immunizations: UTD no recent travel / sick contacts Vital Signs: BP 124/82; HR 90; RR 16; T 37.1
Case 19
30 y.o. man presents with rash to to his palms and soles as well as malaise, fever, joint pains and a rash.
PMHx – well
No recent travel or sick contacts
No medications or allergies.
Case 20
A 66 year old woman presents For the second time in 2 months complaining of a blistering type rash involving the mucosal surfaces and her scalp
PMHx – HTN
Meds – Ramipril, Septra for UTI.
Allergies – none
No travel/ sick contacts
RR = 22, HR = 102, T = 37.2, BP = 145/86 The Algorithms
•Morphology based
•
•
•
•
Diffuse Erythematous
Maculopapular
Vesiculo-­‐Bullous
Petechiae / Purpura
Case 1
12 year old boy presents with 3 day history of non pruritic, non palbable rash.
Travel – none
Sick contacts – whole house fighting flu.
Allergies – none
Medications – none
Immunizations -­‐ UTD
PMHx-­‐ well, recent viral illness
Vital signs within normal limits.
Case 2.
19 y.o male presents with fever, and palbable rash ongoing for 2 days. Recently travelled to visit sister in Boston
Allergies – none
Medications – none
Immunizations UTD
PMHx – well
Temp 38.4, HR 97, BP 121/77
No mental status changes.
Maybe Not So Well Named…
caused by infection with Rickettsia rickettsii
Transmission: American dog tick (Dermacentor variabilis) Oklahoma and North Carolina have the highest incidence.
Case 3
10 year old boy presents with Fever, palpable maculopapular rash to his extremities and mental status changes.
No allergies or medications
Otherwise well
No recent travel
Pt is hypotensive, tachycardic, and appears ill with a temp of 39C.
Case 4
6 y male with fever and rash since waking this morning. Diffuse, covers torso. Rough feeling.
PMHx – well, Immunized
Allergies / Meds – none
No recent travel
No sick contacts.
Vitals: HR 130; T 38 C; BP 110/60; RR 30 Case 5
35 yo woman presents to ER with red rash, and skin sloughing.
Meds –
Septra for UTI 2 weeks ago.
Naproxen for back pain
No sick contacts or travel
PMHx – chronic back pain
Temp = 39, HR88, BP 105/75, RR 20
Case 6
34 yo male who presents with itchy erythematous rash on upper torso, neck and face. Started after spending day mackerel fishing with friends on boat in Bay of Fundy.
Consumed alcohol during day, had mackerel for supper.
Nauseated
Afebrile
No travel
No allergies
No medications
Temp 37.1. HR 97, BP 114/72, RR 20
Case 7
7 y o boy presents with maculopapular rash over entire body. Started over 24 hour period
No recent travel/ sick contacts
Allergies – none
Meds – tylenol
Immunization – UTD, including varicella vaccine
Temp 38.4, other vitals normal.
Case 8
19 yo female with itchy vesicular rash on R wrist. It has gotten so bad that she can no longer wear her new watch. Otherwise well
No other sx
Vitals stable
Case 9
9 yo boy presents with painful maculopapular rash localized to flexor surfaces of both wrists
No sick contacts
Recently travelled to Moncton (visited relatives)
PMHx – well, Immunized
Allg – none
Meds – none
Vitals Normal, afebrile
Case 10
38 yo man presents with the following rash.
States just getting over a flu, fever, body aches, tired. Denies respiratory symptoms.
PMHx – HTN
Meds –
HCTZ
Tylenol for fever
Allergies – none
Vitals entirely normal
Case 11
20 yo woman with rapidly progressive target lesions over legs, back of arms. Non pruritic. Feels achy, occasional fevers
PMHX – Herpes
Drugs – none
Allergies – none
No sick contacts / travel
Vitals are stable.
Case 12
26 yo male with red rash to chest noted on waking today. Afebrile today.
PMHx – well, just getting through cold sx.
Allergies – none
Medications – OTC cold medications Sick contacts – none/ no travel
Case 13
24 yo male with itchy / scaly rash to back and torso. Initially started with L picture and then became more diffuse.
Otherwise well, afebrile, not ill appearing. No travel / sick contacts
Case 14
33 yo diabetic woman presents with acutely painful rash over top of right shoulder which appeared after she was stung by a bee.
PMHx – diabetic
Medications – Lantus, humulog, Tylenol
LMP – 2 weeks ago
No travel / sick contacts
No allergies
Temp 37.8, BP 102/65, HR 104, RR 20.
Case 15
4 month old presents with diffuse erythematous rash, fever, and poor oral intake.
PMHx – term, no GBS, immunized fully
Allergies -­‐ none
Meds – Tylenol
Child febrile and appears ill.
Case 16
20 y.o. woman present to ED with fever, and red skin x 24 h.
Travel – none
Sick contacts – none
Allergies -­‐ 0 Meds -­‐ tylenol
LMP – currently menstrating
BP – 90/60, HR 115, RR 20, Temp 39.1
Case 17
68 yo woman with history of 2 months of itching followed by progressive formation of plaques then blisters to flexor surfaces of both arms.
PMHx – HTN, MI, Aortic valve replacement
Meds – ramipril, metoprolol, cholesterol drug, and something to thin her blood.
Allergies – none
No travel.
Case 18
A 36 y/o woman presents with a a burning, right-­‐sided chest & back pain with a vesiculobullous
rash
PMHx: well
Allergies: NKDA Immunizations: UTD no recent travel / sick contacts Vital Signs: BP 124/82; HR 90; RR 16; T 37.1
Case 19
30 y.o. man presents with rash to to his palms and soles as well as malaise, fever, joint pains and a rash.
PMHx – well
No recent travel or sick contacts
No medications or allergies.
Case 20
A 66 year old woman presents For the second time in 2 months complaining of a blistering type rash involving the mucosal surfaces and her scalp
PMHx – HTN
Meds – Ramipril, Septra for UTI.
Allergies – none
No travel/ sick contacts
RR = 22, HR = 102, T = 37.2, BP = 145/86