Solve the Medical Riddle: She Has Blisters in Her Mouth and on Her Body, First Week

By Marie Savard MD

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 the doctor and how the doctor proceeded with the examination. Next week, a specialist 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 specialist will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Zoe, age 53, recently developed blisters in her mouth and then on her body.

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 Zoe told the doctor:

“I have been getting blisters in my mouth for a number of months but thought nothing of it. I cook with spicy food so I thought I was just having a reaction to the hot spices. I wouldn’t even have come to the doctor if I hadn’t started to get blisters popping up all over my body over the past few weeks. They are painful but they’re not itchy. They look terrible, though! My daughter and her fiancé are getting married in four months, and I’d love to get my skin cleared up and make sure there is no connection between my mouth blisters and these new skin ones. To be honest, my hairdresser has been complaining when she does my hair about rough skin patches in my scalp as well.

“I’m going with my daughter to a trunk show next week so we can pick out her bridal gown and my mother-of-the-bride dress. I was thinking of something that’s not too matronly, maybe chiffon and sleeveless instead of a suit. I’ve been working out and I’ve lost ten pounds because I want to be a good-looking MOB! I hope you can figure out what’s wrong with me and help me clear up this skin condition as fast as possible. My health has been good until now, although thyroid disease runs in my family. I take a number of vitamins and supplements from health food store but no prescription medication.”

Zoe’s physician did a complete head to toe exam including a brief look at her genital area including the vulva and labia. The physical exam was normal except for Zoe’s skin, scalp, and oral mucous membranes.

In her scalp, she had multiple areas of excessive thickened/granulation tissue and crusting.

In her mouth she had a few open blisters along her gums.

Zoe’s skin had numerous blisters with surrounding redness. Very few of the blisters were unopened. They were primarily along her arms and legs with a few on her trunk. She had none in her armpits, groin creases and none in the vulva or labia area. Her fingernails were normal.

She did have a positive Nikolsky signin which firm sliding pressure with a finger peels away normal-appearing epidermis (outermost layer of skin), producing a blister.

The doctor referred Zoe to a dermatologist associated with a university and ordered comprehensive blood tests to check for thyroid disease, kidney, and liver function, among other conditions, to rule out autoimmune diseases and blood disorders.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the dermatologist continued the quest for a correct diagnosis of Zoe’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.

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