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Under the radar

Maurer, Brian T. PA-C

Journal of the American Academy of Physician Assistants: April 2017 - Volume 30 - Issue 4 - p 58
doi: 10.1097/01.JAA.0000513355.83642.e5
The Art of Medicine

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

Figure

Figure

“Only in the place of healing do we dare show our wounds.”—Henri Nouwen

He sits on the edge of the examination table, this young man of 23 years: shoeless, sockless, his feet dangling down below the tattered hem of his worn trousers. A faded gray pullover is likewise threadbare. With one glance, I ascertain the reason for this visit: a cracked, peeling dermatitis of the third, fourth, and fifth toes on each foot.

“My goodness, how long have you had that?” I ask with a concerned smile.

“About 6 weeks,” the young man, who has all the appearance of a boy, says. A slightly oversized red-and-white baseball cap covers his head. Were it not for the support of his prominent ears, it would engulf his face down to the philtrum.

“That's a long time,” I muse. “What have you been doing for it?”

He shrugs his shoulders. “Not much,” he says.

“You haven't tried any over-the-counter creams or lotions? No foot soaks?”

“Nope,” he says. “Didn't know what it was. Figured I'd come in and have it looked at first. Figured you could tell me what to do about it.”

“I see,” I muse, and make my pronouncement. “It looks like you've got a good case of athlete's foot. You've probably heard of it. It's a fungal infection of the toes and forefoot.”

“Where could I have gotten it from?” he asks.

“You could have picked it up in the shower or in a locker room. Are you a member of a health club? Do you go to a gym to work out?”

“No.”

“Anybody else at home have anything like this?”

“Not that I know of.”

Another thought occurs to me. “Have you recently gotten a new pair of shoes?”

He points to the bright orange tennis shoes lying on the floor. “Been wearing those all summer,” he says.

I nod my head. “Well, in any case the treatment is fairly straightforward. Soak your feet in an Epsom salt solution, dry well between the toes, and apply an antifungal cream a couple of times a day.”

I jot down the instructions, add the name of an OTC cream, and hand him the note.

“You'll probably have to keep up with the treatment regimen for at least 3 weeks, maybe a bit longer, but it will settle down.”

The young man, who is really just a boy, accepts the scrap of paper. “Thank you, sir,” he says.

“You're welcome,” I say, somewhat taken aback by the formal response. “Any questions?”

“Just one,” he says, stuffing the note into his back pocket. “How long does it take folliculitis to go away?”

“Folliculitis?”

“Yeah, you know, infection of the hair follicles.”

“Usually we treat folliculitis with an antibiotic,” I explain. “Who has folliculitis?”

“I do,” he says. “At least, that's what the doctor at Planned Parenthood told me. I was there with my girlfriend. We got tested for STIs. Everything came back negative, but the doctor there said I've got this folliculitis. He said to keep it clean and it would go away, but it's been weeks and I've still got it.”

“Let's have a look.”

He drops his shorts and points to a cluster of papules partially obscured by his pubic hair. I don a pair of gloves and scan the area with the aid of an otoscope. Tiny dome-shaped papules pepper the skin surface. Under magnification, several of the lesions appear to be umbilicated.

“It looks like you've got a case of molluscum,” I inform him. “It's a viral wart, transmitted by skin to skin contact. Does your girlfriend have anything like this?”

“Not that I know of,” he says.

I explain the natural history of molluscum and offer some treatment options. The young man seems relieved. “Thanks again,” he says. This time the thank you is less formal, perhaps more genuine. He steps out the door with a smile on his face. I lower my head as I watch him go.

He may have used his tinea pedis to get a foot in the door, but behind closed doors the real reason for this young man's visit became apparent. He flew in under the radar and managed to score a hit.

Many times hidden agendas aren't revealed until those final moments when an otherwise routine visit draws to a close.

Copyright © 2017 American Academy of Physician Assistants