Case report: Related issues?

When a patient enters an examination room at our walk-in clinic, the nature of the problem often seems apparent. Crutches, limp, obvious fresh blood etc., point to a probable reason for the visit. But this is not always the case. Recently, a fit, healthy, 26-year-old, fair-skinned young man walked in holding his right arm protectively to his side. A splint and bandage were apparent on the hand. The patient reported just returning from a holiday in the Bahamas where he had slipped on a staircase, reaching for the railing and catching his right thumb—which he had forcibly and painfully hyperextended. With little time before his departure, he obtained a splint and bandage there, and carefully protected his right arm flying home. He had called his family physician and booked an appointment for a few days in the future where the physician planned to order an x-ray. Everything was taken care of. Read: Case report: TB or not TB However, to my surprise—since I always ask “What can I help you with?”—the patient had come because of a sore, itchy, red rash under his right arm. He wondered if it could be related to his hand injury. He had not treated it in any way. Examination of his hand and right arm revealed tender bruising but no abrasions or lacerations. He had an erythematous, widespread tender, pruritic rash in his right axilla (see picture). Mostly diffuse and macular, the rash had a few raised follicular lesions as well. Most axillary lesions that I have seen over the years, have been either secondary to a peripheral infection or due to fungus/yeast, especially in overweight or diabetic patients and rarely due to deodorant application. The current patient had none of these risk factors. The clues to the diagnosis of the rash lay in environmental and behavioural factors. Even for July, the weather both in the Bahamas and Southern Ontario, had been unusually hot. Since the hand injury, he had kept his right arm close to his side, avoiding contact with his painful hand. This had been obvious from the time I first saw him. He had been sweating profusely. I believe that the dermatitis was a combination of yeast (in a warm, moist environment) and simple inflammation from continual rubbing of skin in the axilla. The patient was advised to keep his arm away from his side. I prescribed Canesten Cream and a short course of Clavulin to cover the folliculitis. Hopefully his rash will have cleared by the time his hand injury is dealt with. Once again, I was reminded not to take problems at “face value” and always ask “How can I help you?” Dr. Robert Dickson is a family physician in Hamilton. This report is based on a real case from Dr. Dickson’s files.

Case report: Related issues?

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