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Clinical Experience Week 5

This week’s clinical experience was great. I was able to see a lot more patients and chart on a ton. I was able to get very comfortable with charting and feel like I am getting better and better, with each clinical day. This week, I saw a lot of different things, I saw a lot of sinus infections, did a lot of covid swabs, urinalysis, sports physicals, medication refills, and so much more.

A patient that was particularly interesting came in today, with a rash that started on his left ankle and traveled up his left calf. He stated he went to Universal Studios yesterday and by the end of the day, he noticed a rash on his left ankle. By that night, he stated that the rash traveled up to his left calf. He presented here with the rash, no pain or itching, just slightly tender to the touch. The rash was large erythema and purpura patches. After doing some research with my preceptor and a fellow student, we found a condition called the “Disney rash”, which is also known as, exercise induced vasculitis. It is often misdiagnosed as an allergic reaction, insect bites, heart failure, or secondary to thrombocytopenia or other hematologic abnormalities. Exercise-induced vasculitis is not fully understood, but it is thought to be secondary to muscle fatigue in the lower extremities, resulting in venous pooling and complement activation during prolonged exercise and hot weather. This presents clinically as mild edema and a petechial rash to the ankle area, sparing the sock area (Morgan, 2020).

Exercise-induced vasculitis is a small-vessel vasculitis affecting the lower legs that occurs after strenuous sports activity such as running or hiking, particularly during hot weather. It is more common in women over 50 years of age and presents with petechial or urticarial rash with edema, itch or pain in an otherwise healthy patient. The skin area compressed by the sock cuff is characteristically spared. Exercise-induced vasculitis is self-limiting and resolves after a few days. Nonsteroidal anti inflammatory drugs, topical corticosteroids and elevation of the affected legs may reduce symptoms (Jud & Hafner, 2018).

Some possible differential diagnosis include cellulitis, allergic reaction, and PAD. Cellulitis is a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin (Centers for Disease Control & Prevention, 2020). Allergic reactions on the skin can be caused by a variety of factors. These include immune system disorders, medications and infections. When an allergen is responsible for triggering an immune system response, then it is an allergic skin condition (American Academy of Allergy, Asthma, & Immunology, 2020).Peripheral artery disease is a narrowing of the peripheral arteries that carry blood away from the heart to other parts of the body. The most common type is lower-extremity PAD, in which blood flow is reduced to the legs and feet (American Heart Association, 2020).

The patient was prescribed Doxycycline and a topical corticosteroid. The patient was provided a note for work, to work from home to stay off the leg and elevate it as much as possible. He was also referred to a vascular physician to get establish due to his Raynaud’s disease. He was educated to take his doxycycline with food to prevent upset stomach and also to take a probiotic or yogurt.

This week I learned more how to manage my time, chart more in depth and handle many patients at once. When the clinic was busy, I would have multiple charts at a time. I was able to multitask and manage my time, all while making sure my charts were all complete and charted correctly. I learned a lot more about the first line of therapy for different infections and conditions, I think that was very helpful and will stick with me.

References

American Academy of Allergy, Asthma, & Immunology. (2020). Skin allergy. American Academy of Allergy, Asthma, & Immunology. https://www.aaaai.org/Conditions-Treatments/Allergies/Skin-Allergy.

American Heart Association. (2020). About peripheral artery disease. American Heart Association. https://www.heart.org/en/health-topics/peripheral-artery-disease/about-peripheral-artery-disease-pad.

Centers for Disease Control & Prevention. (2020). Cellulitis. Centers for Disease Control & Prevention. https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html.

Jud, P., & Hafner, F. (2018). Exercise-induced vasculitis. CMAJ-JAMC, 190(7). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828891/.

Morgan, E. (2020). Quick consult symptoms: Edema, petechial rash on legs. Emergency Medicine News, 42(7), 25–26. https://journals.lww.com/em-news/fulltext/2020/07000/quick_consult__symptoms__edema,_petechial_rash_on.20.aspx.