A Lousy Diagnostician

The tall, youthful seventy year old woman wore her strikingly white hair in a tight bun. She was dressed like a Donald Fagen song – in jeans and pearls (”Maxine”, 1982).

She had an intense burning, itching sensation on the left side of her neck and occiput. Looking closely at her neck and hairline, I saw a couple of small, red papules. A few of them looked like early blisters.

I suspected herpes zoster and offered her a generic antiviral. The earlier you start it, the better your chances of avoiding long lasting pain afterward, I explained.

A week later, there were some red blotches and several scratch marks. Her burning and itching were worse.

I prescribed gabapentin and told her how to titrate herself up from 100 mg at bedtime to 300 mg three times a day.

The following week she still had red blotches and scratch marks and felt no better. I frowned.

She said “My granddaughters have head lice, so I asked my daughter to check me, but she couldn’t find any. Would you check me, just to make sure?”

I leaned close and removed my -11 diopter glasses. My focal point is about one finger length from my corneas.

It took me a while, but I found half a dozen nits, enough to be sure she had the real thing.

Didn’t I feel a little sheepish. Seventy year old woman with burning and itching scalp? Must be zoster, right? Head lice is more of a pediatric problem, right?

Wrong. I narrowed my differential diagnosis too quickly.

And, I didn’t take my glasses off the first time.

1 Response to “A Lousy Diagnostician”

  1. 1 habasar December 9, 2017 at 3:45 am

    Yes, lousy diagnostician, but hopefully it was one mistake and you learned.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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