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.