Scabies, Abbreviations, and Workflow
The clinic surprisingly busy even without the van and with the sub for our usual Nurse Practitioner, I began to understand why medical personnel try to be efficient but come off as curt. Susan was very thorough and had great rapport with patients, but her pace was just too slow for the number of patients we had today. The center who was loaning us their office was closing at 12, so it was a balance of rushing someone along and trying to get everything we needed. Waiting is one of the most irritating things to do, and we had a couple who was becoming disgruntled because they only wanted medication refills, and a mother of 2 small children who were becoming agitated and whiny. I can only imagine how much more hectic it gets at a bigger place. It seems like what the clinic needs is more personnel and at least one more room to take vitals. Oftentimes, the line gets backed up if one person takes too long, and due to privacy concerns, you can’t ask most of the questions pertaining to medical history in open space.
What would be excellent would be a reception area and 2 exam rooms. If there’s really only one NP or doctor onsite, then they can be examining one person while someone else takes vitals and the chief complaint of the next person in another room. Their chart would be handed off to the NP/MD when they were finished with the first patient.
I recorded medications for a patient today, and I made a mistake I’ll never make again. I wrote down “QID” instead of “QD”. The bottle read “take once a day”, and I had confused the Latin abbreviations to write down “four times a day”. And here we have Johns Hopkins’ list of banned medical abbreviations with QOD and QD written on there as well. Not to worry in this case, I had my work checked there immediately so there were no consequences except an embarrassing and important lesson learned.
I love technology, but after having to deal with cuffs the wrong size and the batteries running out of a scale, I’m becoming more inclined towards manual tools.
And one can never underestimate the importance of sugar-free lollipops for the upset children needing to satisfy their oral fixations.
Today, we saw a young child (~1 y/o) with bite-like bumps over his face, trunk, and limbs. There was no fever, other rash, or redness apparent anywhere else besides the bumps themselves. He was well-developed, with full range of movement and motor skills. There were no other complaints besides these bites which had been present and itching for about 3 weeks. No one else in the family was affected. The mother thought it was chiggers, but wasn’t sure. The only suspicious activity he had been engaging in recently was playing in tall grass. He was not only any medication. The mother had recently started applying calamine lotion to alleviate itching.
What are chiggers?
They are a type of mite that are found in grass or low, damp areas. They don’t burrow but attach themselves onto the skin and suck up digested tissue using enzymes. The enzymes used by chiggers cause intense itching, which can lead to increased risk for secondary infection. They usually bite people from the waist down. The bites are described as 1-2mm diameter papules that are intensely pruritic. You may get more eruptions in 2 days and sometimes the papules can persist for up to 3 weeks. Chiggers are removable by hot soapy baths or showers.
Susan found it highly unusual that the bites covered the head and neck. The time frame led her to think it might be a case of scabies, although the upper body involvement would still be a little unusual then as well.
Another type of small mite that burrows into the skin. They also cause intense itching, and the symptoms are classically made worse by heat and in the evening. You can often see the burrowing trails in the shapes of S’s. They’re usually found in the crevices of bodies like the webs of hands, under the breast, and in the inguinal region. Typical sites of infestation for children are palms and soles. Symptoms begin 2-6 weeks after infestation and can persist for weeks even when the mites are killed.
I really can’t say what I thought the child had. In order to diagnose a scabies infestation, you need a microscope to find the mite. We didn’t have one on hand. It’s suggested that you might be able to see the burrows with the naked eye. I didn’t get that close but on general examination, I didn’t see any burrows. Judging from these photos, they seem easy to miss. Chiggers seem less likely since the mother probably bathed the child several times in the span of 3 weeks, but he is still itching.
So another thing to add to the list is a small light microscope, slides, and immersion oil.
Scabies can be treated with Permetherin, Lindane, Ivermectin, or Crotamiton.
Permetherin prolongs sodium-channel activity and is the treatment of choice because it’s shown to be the most effective. Interestingly, it’s toxic to cats but not dogs.
Lindane is a GABA-inhibitor and has some neurotoxicity. It has some pretty unpleasant side effects. Given you have a range of medications to choose from, I’d stay away from using Lindane.
Ivermectin is not used for children under the age of 5.
Crotamiton is preferred for children but is not as effective as permetherin.
This child got a crotamiton lotion.
Johns Hopkins. Medical Abbreviation Policy. 2003. Available at: http://www.hopkinsmedicine.org/gynecology_obstetrics/education/medstudents/_docs/Learning_Mtls/abbrev-prohibited.pdf
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Steen CJ. Carbonaro PA. Schwartz RA. Arthropods in Dermatology. J Am acad Dermat. ;50:819-842. (http://www.dermatology.ucsf.edu/pdf/arthropods%20in%20derm.pdf)
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Principles of Pediatric Dermatology. Available at: http://www.drmhijazy.com/english/chapters/chapter12.htm
Naynaber S. Wolff H. Diagnosis of scabies with dermoscopy. Canadian Medical Association Journal. 2008;178:1540-1541. (http://www.cmaj.ca/content/178/12/1540.full)