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More Than Skin Deep: A Lesson From an Unusual Rash

It was my third day on my home dermatology elective, and I boldly volunteered to see a patient by myself. As a third-year medical student strongly considering dermatology for my future career, I had studied for weeks for this rotation, hoping to make an impression as a confident, knowledgeable and reliable doctor-in-training. Usually, medical students shadow for two weeks before seeing patients on their own, but I was eager to be more independent. This was my chance to demonstrate everything I was working toward. 

I was assigned to a new patient; a 53-year-old woman with a chief complaint of a leg rash. I entered the room, introduced myself and asked what brought her to see the dermatologist. Anxiously, she explained that she had been suffering from an itchy, swollen rash of both lower legs for the past few months. She pointed to the rash, with an intense grimace seemingly due to an unquenchable impulse to scratch, as she described that she has been unable to sleep due to intense pruritus.

I kneeled to observe the rash more closely, unsure of what the underlying diagnosis could be. What I did notice was that the rash was red, pebbly and firm, with overlaying scratch marks that had crusted over. After speaking with her for a few more minutes, I left the room puzzled, preparing my thoughts to present to the attending.

I reminded myself of the importance of morphology, reviewing the various rash descriptors in my newly learned lexicon. My physical exam description was my chance to impress, as offering a broad differential diagnosis was above what was expected of a student at my level. I mustered up the courage to present the case as the attending listened intently. Curiously, my description of erythematous indurated pebbly plaques seemed questionable, as a perplexed look appeared on her face.

“Um, okay. Why don’t we examine the patient together,” she said ambivalently. At this point, my small bit of confidence remaining evaporated as I thought how wrong I must be. I hoped she gave me some credit for trying.

We walked in to see the patient together, and I watched the encounter between my attending and the patient closely. The patient reported no known medical problems, yet recently had unexpectedly lost some weight and noticed she hadn’t been comfortable wearing sweaters due to feeling warmer than usual. As the attending continued to ask the patient more questions, she examined the patient, noting the rash and pointing out slightly protruding eyes. At this point she decides to take a punch biopsy.

During lunchtime, my attending asked that I briefly meet with her for feedback. I expected the worst. ‘You have to keep working on your morphology, Jonathan,’ is what I anticipated hearing. To my surprise, however, she complimented my description, admitting it was surprisingly accurate. Holding back my immediate desire to smile, I listened carefully.

She explained that stasis dermatitis was common and based on the history of a new onset itchy red rash, she was expecting to see thin scaly plaques with scattered hyperpigmentation and pitting edema. She stated that after talking to the patient and examining the rash herself, she realized I was actually on the right track. She explained how dermatologists frequently identify systemic disease and directed me to read more about cutaneous manifestations of systemic disease.

A week later, the pathology report confirmed her suspicion of pretibial myxedema associated with underlying Graves Disease. Since then, the attending trusted me to be more independent. My confidence grew, and I started to trust myself. At the conclusion of the rotation, I ultimately chose to pursue a research fellowship to expand my knowledge in dermatology, with the hopes of becoming a dermatologist.

As medical students, we are nurtured by our superiors to develop our own clinical acumen through observation and knowledge acquisition. This is a stepwise process for us, as we gradually gain more experience and responsibility with each year of medical school. We are told that gaining confidence in the clinical realm comes with experience and practice, so we look forward to getting there one day.

But let’s take the time to acknowledge and reflect upon our shining moments along the way. Take a few minutes to enjoy receiving positive feedback. It is important to introspect in these moments to fully appreciate the progress you are making, and what it means for your professional growth. Find opportunities to feel validated and recognized. Start trusting yourself, and build your confidence from within. 

Author’s note: Patient details changed to maintain confidentiality.

Jonathan Koptyev (1 Posts)

Contributing Writer

Rutgers-Robert Wood Johnson Medical School

Jonathan is a fourth-year medical student at Rutgers-Robert Wood Johnson Medical School in Piscataway, NJ, class of 2023. In 2017, he graduated from Columbia College with a Bachelor of Arts in Hispanic studies. He enjoys singing, playing chess, and spending time with his wife and two daughters. After graduating medical school, Jonathan hopes to pursue a career in dermatology.