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Solve the Medical Riddle: She Itches All Over Even Though She has No Rash or Hives, First Week

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the doctor will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Nancy, age 58, woke up in the middle of the night about two months ago with the sensation of itching all over her body. The symptoms have continued even though she has been to a dermatologist. She decided to make an appointment with her primary care physician.

As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Nancy told her PCP:

“When I woke up itching all over in the middle of the night after enjoying an evening on our deck with my husband, I thought I must have been bitten by mosquitoes. We had used citronella candles, but they don’t always work. Anyway, I went into the bathroom and turned on the light to check for bites. I saw nothing at all – no bites, no rash, no hives. I rubbed on some Calamine lotion that I had in the medicine cabinet. It didn’t help. After I went back to bed, I slept in fits and starts because of the itching.

“In the morning, I told my husband what was going on. He insisted that I see a dermatologist. I made an appointment for the next day. The dermatologist couldn’t find anything specific. He said I probably just had dry skin. He did prescribe a lotion, so I was happy that I might get some relief. No such luck. In fact over the past few weeks the itching, which has been generalized and not limited to one area of my body, has been getting worse. It’s intense, and scratching doesn’t help. That’s why I decided to come to see you. Maybe I’m going crazy! Could this be all in my head?”

The doctor asked Nancy to identify the lotion her dermatologist had prescribed. Wisely, she had brought it with her to the appointment. She showed it to the doctor. It was a mild steroid cream and topical moisturizer.  The doctor told Nancy that the past weeks of sudden onset pruritus – the medical term for itching – might well be caused by dry skin as the dermatologist had suspected. However, since dry skin is more common in the winter than during the warner months, and because the topical lotion had been ineffective and no rash was evident, the doctor wanted to rule out other possibilities.

He took a thorough medical history with emphasis on drug exposure, travel history to exclude endemic parasitic infections, unexplained weight loss, night sweats, contact with environmental irritating and sensitizing substances, lifestyle including diet, substance abuse such as opioids, work activity, and hobbies. She had no history of allergies to drugs or to environmental allergens, she had not been traveling, and she had not been taking any new medications. She was not taking painkillers and her lifestyle had not changed in the past few weeks. Her weight had remained stable. She did report some night sweats, but she attributed those to menopause.

The doctor then asked her some questions about her mental state and concluded that she was probably not “going crazy” since she did not appear to have symptoms of an anxiety disorder. However, he said that he might refer her to a psychiatrist if no physical cause of the pruritis could be found.

Because Nancy had no idea that a complete physical exam to detect a systemic condition might be necessary, she had only booked a brief appointment. The doctor did a physical examination limited to the skin, which was normal except for some areas of excoriation where she had scratched too hard.

The doctor ordered the following lab tests: comprehensive blood work, total and differential blood count, liver and renal function tests, lactate dehydrogenase, serum glucose, iron, ferritin, thyroid function tests, erythrocyte sedimentation rate, protein electrophoresis, and urinalysis. He also ordered a chest X-ray, ultrasound examination of abdomen, and stool examinations for occult blood, ova, and parasites (although the latter were unlikely since she hadn’t traveled recently).

He asked Nancy to come back for a complete physical after the results of the tests were available. In the meantime, he suggested that Nancy should try over-the-counter allergy medications such as Claritin or Allegra. She could also try Benadryl, but only in the evening because that medication can cause drowsiness.

Come back to ThirdAge.com next Thursday to learn how the doctor continued the quest for a correct diagnosis of Nancy’s condition . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Pleas visit DrSavard.com.