1/
She had an itch for 10 years and then finally a dx was made.
Hope you don't get itchy reading this one.
<3 @rabihmgeha
She had an itch for 10 years and then finally a dx was made.
Hope you don't get itchy reading this one.
<3 @rabihmgeha
2/
PMD "How are you doing?"
Her "I am fine. My diabetes is under better control."
PMD "How are your kids?"
Her "My youngest just graduated college"
(10 minutes later)
PMD "Anything else bothering you?"
Her "I've had an itch all over for 10 years but no one can figure out why."
PMD "How are you doing?"
Her "I am fine. My diabetes is under better control."
PMD "How are your kids?"
Her "My youngest just graduated college"
(10 minutes later)
PMD "Anything else bothering you?"
Her "I've had an itch all over for 10 years but no one can figure out why."
3/
It often helps to know the general buckets that might cause symptoms before using clues to prioritize.
Pruritus buckets
1. Primary skin d/o
2. Systemic d/o
3. Neurologic
4. Pysch-related
It often helps to know the general buckets that might cause symptoms before using clues to prioritize.
Pruritus buckets
1. Primary skin d/o
2. Systemic d/o
3. Neurologic
4. Pysch-related
4/
Base-rate is queen and most often pruritus is d/t a primary skin d/o. So @ time point zero that is where your focus must be.
Base-rate is queen and most often pruritus is d/t a primary skin d/o. So @ time point zero that is where your focus must be.
5/
Before you get too detailed w/ HPI ask 2 questions and perform a skin exam.
1. How long have you had the itch?
2. Where do you itch?
Before you get too detailed w/ HPI ask 2 questions and perform a skin exam.
1. How long have you had the itch?
2. Where do you itch?
6/
Primary skin d/o often is responsible for acute (<6wk) pruritus and leaves a signature on the skin.
Be cautious as skin findings might be subtle in xerosis or scabies OR transient in urticaria AND furthermore, skin findings might simply reflect scratching-like excoriations
Primary skin d/o often is responsible for acute (<6wk) pruritus and leaves a signature on the skin.
Be cautious as skin findings might be subtle in xerosis or scabies OR transient in urticaria AND furthermore, skin findings might simply reflect scratching-like excoriations
7/
Chronic itch w/ no skin findings OR just skin findings secondary to scratching point to a systemic cause like CKD, cholestasis, thyroid d/o, underlying cancer (liquid > solid), drug (prescribed and illicit)
Chronic itch w/ no skin findings OR just skin findings secondary to scratching point to a systemic cause like CKD, cholestasis, thyroid d/o, underlying cancer (liquid > solid), drug (prescribed and illicit)
8/
Localized skin findings point to a neurologic cause (like postherpetic pruritus) or psychiatric (anxiety, depression, delusional parasitosis)
Some unique features like itch w/ shower might suggest P. vera
Or itchiness of palm/soles is often how cholestatic pruritus starts
Localized skin findings point to a neurologic cause (like postherpetic pruritus) or psychiatric (anxiety, depression, delusional parasitosis)
Some unique features like itch w/ shower might suggest P. vera
Or itchiness of palm/soles is often how cholestatic pruritus starts
9/
No etiology found check back periodically b/c the itch might be a paraneoplastic finding of Hodgkin lymphoma
No etiology found check back periodically b/c the itch might be a paraneoplastic finding of Hodgkin lymphoma
10/
Back to case
The chronic and generalized nature of her pruritus w/ the absence of skin findings pointed to a systemic cause.
The answer was staring us in the face for 10 yr. Abnormal LFTs. Diagnosed w/ PBC. Itch resolved w/ ursodeoxycholic acid.
Back to case
The chronic and generalized nature of her pruritus w/ the absence of skin findings pointed to a systemic cause.
The answer was staring us in the face for 10 yr. Abnormal LFTs. Diagnosed w/ PBC. Itch resolved w/ ursodeoxycholic acid.
11/
Before you judge these providers KNOW this could have happened to you too. There were a few reasons this dx was delayed that I will not dive into.
The purpose is to give you an approach to pruritus so you don't have the same delay in dx for your patient.
Before you judge these providers KNOW this could have happened to you too. There were a few reasons this dx was delayed that I will not dive into.
The purpose is to give you an approach to pruritus so you don't have the same delay in dx for your patient.
12/
Pruritus
Step 1 - look at skin
Step 2 - use tempo, location, and other factors to make progress
Step 3 - never close the door un itch of unknown etiology and check in periodically
Pruritus
Step 1 - look at skin
Step 2 - use tempo, location, and other factors to make progress
Step 3 - never close the door un itch of unknown etiology and check in periodically
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