Rosa is a 74 – year – old woman who presents with a complaint of itching and soreness in her left side and upper back.


Rosa is a 74 – year – old woman who presents with a complaint of itching and soreness in her left side and upper back. She tells you that she has been gardening and that she thinks she may have a spider or bug bite, but she cannot see this area. She felt an “irritation” 2 – 3 days ago with intermittent itching. She took some OTC Benadryl © without benefit. She now complains of intermittent “shooting pain” and “tingling” sensations. She has been wearing a camisole instead of a bra for comfort. She denies itching in any other location on the body and has no other dermatological complaints. She is not aware of any tick bites, and she denies recent trauma to the chest or back. She denies use of new shampoos, lotions, laundry products, clothing, perfumes, or topical agents.

Past medical history: Positive for hypertension (HTN); osteoarthritis (OA, primarily of the knees and fingers); gout; osteoporosis, and polymyalgia rheumatica (PMR).

Medications: Zestoretic, 1 tablet qd; Fosamax, 70 mg po, once per week; allopurinol, 200 mg po once per day; Prilosec, 20 mg po qd; and prednisone, 7.5 mg po qd. She has been taking these medicines for over 1 year (with varying prednisone dose adjustments).

Allergies: She denies any environmental, contact, or medication allergies.


Head: Abundant, slightly dry hair in normal distribution with no alopecia or breaking. Head is normocephalic and traumatic. Lymph nodes: No palpable lymphadenopathy in head, neck, thorax, or axilla. Skin: Pale with multiple scattered, small, bright – red, pinpoint papules over the chest and back, as well as several irregularly shaped, fat, light – brown macules. She has no visible rash, discoloration, or lesion in the affected area, and no obvious insect bite or entry wound. Her skin is very dry in all areas. Thorax: Exquisite tenderness on palpation in the left subscapular area, extending to the anterior axillary line, lateral to the left breast. Her remaining physical examination is within normal limits.






  1. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?

__ Erythrocyte sedimentation rate (ESR or “sed rate”)

__ Immunoglobin E titer

__ Immunoglobin G titer for varicella zoster

__ Metabolic (chemical) profile including LFTs, BUN/ creatinine, electrolytes, and TSH

__ Polymerase chain reaction testing

__ Skin biopsy

__ Skin scraping for microscopy

  1.  What is the most likely differential diagnosis and why?

__ Bug bite

__ Contact dermatitis

__ Eczema

__ Herpes zoster

__ Infestation (lice or scabies)

__ Medication – related adverse effects

__ Polymyalgia rheumatica (exacerbation)

__ Rib fracture

__ Seborrheic dermatitis

__ Systemic disease

__ Xerosis (dry skin)

  1. What is your management plan for Rosa?


  1.  Are any referrals appropriate at this time? Which of the clinical findings are consistent with normal aging changes?


  1. What are the most common causes of pruritus (itching) in older adults? What are the risks and benefits of antihistamine therapy for pruritus, such as diphenhydramine (Benadryl ©)?



  1.  If new lesions continued to appear after 1 week, what additional considerations would you address? Which specific vaccines’ dates of administration should be included in immunization documentation for older adults?


  1. List two additional questions the practitioner should consider to guide clinical care. These questions should be considered in your approach to all geriatric care, in tandem with the workup, diagnosis, and management of the presenting problem.

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