Momwithastethoscope's Weblog

September 16, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:22 am
Tags: , , ,

Reason Number 16:  Ah Ha! Moments.  This was a piece that I intended to submit for a recent Grand Rounds, but didn’t get it finished on time. 

A mother of a three year old called my office one afternoon with a rash.  She described her daughter’s skin as blue bordering on purple and appearing suddenly on the arms and legs.  Several thoughts went through my head as I cued Colleen, my nurse, to bring this patient in for an appointment at 2:15.  Colleen assured me that the child was in no distress other than her mother’s angst.

Is this cyanosis?  Was there occult congenital heart disease?  Is this poisoning or methehemoglobinemia?  My mind raced to make a differential.  I googled cyanosis. I searched for pictures of children with acute purple extremitites.

Jennifer, my young patient, hopped onto the papered exam table with her usual vim and vigor.  She didn’t appear to be in any acute distress of pain.  Her mother pulled off her coat, and continued pull the layers of socks and leggings and tops. 

I reached out to touch her legs. No texture.  No signs of trauma or bruising.  Not tender or sensitive.  Just blue as a blueberry.

“Any fever?”

“No.”  Her mother answered.

“Sore throat?”

“No.”

“Does it itch?”

“No.”  mother and daughter offered.

For a full five minutes, I touched, I examined, and pondered.

“Hmm.” I mindlessly reached into the drawer of the exam table and pulled out an alcohol wipe.  It could have been a throat culture had I touch that first. I was just looking for a way to solve the mystery.  I ripped open the package and wiped it over Jennifer’s leg.  A streak of normal skin appeared where I swiped.  The pad turned more and more blue with successive swipes.

“You’re kidding me!”  Jennifer’s mom gasped.  “It’s just some kind of dye?”

“Yea.  That’s all it is. Has she worn anything new and blue?”  Jennifer’s mom couldn’t recall any exposure to blue anywhere. No blue bubble bath.  No blue markers.  No blue bath crayons.  No new blue jeans.

“How did you know to try to wipe it off?”  Colleen asked me afterward.

“I don’t know.  It just felt like the right, least invasive thing to try first.”

Still trying to figure out how to ICD code that visit…

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1 Comment »

  1. Last year I admitted a girl with what we thought was breast cellulitis. Turns out it was breast “rouge” – discovered when the surgeon went to clean off the area prior to doing a biopsy. She rouged up her boob because she didn’t want to go to band practice. *siiiiigh*

    Comment by Beth — September 16, 2009 @ 9:53 pm | Reply


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