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You are an Fy1 working in the Acute Medical Unit in your hospital. Mr Ben Penn is a 29 year old gentleman who has been admitted to the ward just now, with an itch. He describes the itch as running across his abdomen and it is the ‘itchiest thing I have ever experienced in my entire life’. He also has been experiencing some weight loss. Mr Penn, who is otherwise well, is not currently on any regular medications. He recently had a viral illness, around one month ago, which has since resolved. Ben is very concerned about this itch and would like you to resolve this problem for him as soon as possible.

Please take a history from Ben and perform the appropriate examination. Ensure that you undertake a relevant history of presenting complaint and address his concerns.

You are Ben Penn, a 29 year old man who works as an architect. You recently moved to this area from your home town in Ireland, where you graduated as an architect. This is your first week on the job so were really keen that everything would go smoothly.

HPC: Unfortunately, things have been disastrous. You have had an absolutely insufferable itch across your abdomen for the past 3 days now. It has got progressively worse and now you are covered in numerous scratch marks. Aside from the scratch marks, you notice a lot of little red lumps and bumps across your abdomen.

When pressed about how your health has been recently, you realise that things have not been quite right for some time. You had noticed that you had lost around 2 stone in the last 2 months. Originally, you had been trying to lose weight, but have long since stopped this attempt. Your bowels have been a little loose recently, and been quite foul smelling. They have also been quite hard to flush away. The bowel problems have been going on for about one month.

You have not been vomiting and have not had any reflux either. This is the first time any of this kind of thing has happened. You don’t think that you have changed your diet much recently, apart from eating a bit more fast food of late.

ICE: Understandably, this has caused a lot of stress for you at work. You’re very keen to solve this itching problem with some kind of subtle cream, and potentially have some tablets to take the foul smell away from your stools. You odn’t have any idea where this rash could have come from. You haven’t changed anything you do, you haven’t got any new pets. You’ve recently moved home so are hoping the new flat doesn’t have bed bugs or something else sinister!

PMH: You’ve always been quite healthy: you’ve never even had a sick day off of university! You don’t take any regular medication.

SH: You currently live alone in a one bedroom flat in a new city, so are keen to get around and get to know the local area. You didn’t plan for that to include the hospital, however! You don’t smoke and haven’t drunk much since some binge drinking in your student days. At most you have one pint of cider when out with friends at home, but that is once a month, at a maximum.

FH: You don’t remember anyone in your family being unwell recently. Your mum has extensive psoriasis, but you haven’t tried any of her creams, as you are worried about taking other people’s medicaitons. Your dad has fibromyalgia and takes a special kind of pain killer for this.

The student should demonstrate a clear history of the rash and enquire about the abdominal symptoms Ben has been experiencing. In terms of examination, a dermatological exam would be appropriate, however good candidates would undertake an abdominal exam if they identify the cause of the rash. The student’s differential diagnosis should sound something like:

My differential diagnosis would include an abdominal cause, more specifically Coeliac disease, presenting with dermatitis herpatiformis. I would also want to include other abdominal causes, such as inflammatory bowel disease. Dermatological causes of pruritic rash may include an atopic rash or a viral rash. Example for discussion may include:

  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • What is the rash that this patient presenting with?
  • What is the cause of coeliac disease?
  • Who would be involved in the care of a patient with coeliac disease?
  • What would encourage you to refer this patient to a dermatologist?