What’s the Diagnosis #18

An elderly patient with hypertension, hypothyroidism, and dementia is sent from the nursing home by ambulance for evaluation of a rash to her scalp. The patient’s nurse had noted the rash that afternoon while putting the beret in the patient’s hair and is sure that the rash wasn’t there two days ago when she last cared for the patient.

Scalp Rash BeforeThe patient was reportedly sleeping more than usual the day prior to her transport. The nursing director at the nursing home was concerned that the patient had developed shingles to her scalp.

A picture of the patient’s rash is to the right (unfortunately, not the best clarity).  What’s the diagnosis and what is the treatment for this condition?

Scroll down for the answer.















Answer: Acute Lipstick Misapplication

Scalp Rash AfterThe “rash” happened to be the same color as the patient’s lipstick. There were initially two spots. Both were removed with an alcohol wipe.
Treatment: Discharge with close follow up.

Wait … not so fast.
Upon learning of the patient’s imminent return, the nursing director from the nursing home called back the emergency department and stated that no one had addressed why the patient had slept more than usual. After all, the patient reportedly slept past breakfast the day prior to her transport.
There was a bit of a discussion between the nursing director and the emergency department nurse which then escalated to a discussion between the nursing director from the nursing home and the nursing director from the hospital. Eventually, the patient had several lab tests performed in the emergency department to rule out anemia, electrolyte abnormalities, and hypothyroidism as a cause of the patient’s acute transient hypersomnolence.
When the labs all came back normal (except a mildly low sodium), the patient’s doctor had to be contacted in order to tell the nursing director from both facilities that it was permissible to send the patient back to the nursing home.
The nursing home then had its transport van come to pick up the patient.

Wait … not so fast.
The transport van was not available. It only runs between 8AM and 2PM. It was 4:30 PM.
So an ambulance had to be called to transport the patient back to the nursing home at a cost of roughly $400 plus $37.50 per mile.

The final result was an awful expensive bit of lipstick

Discharge instructions nearly included an order to set the patient’s alarm clock for 15 minutes prior to breakfast each day, but the emergency physician decided that there were enough phone calls made to hospital administrators regarding this patient for the day.


This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

4 Responses to “What’s the Diagnosis #18”

  1. GrumpyRN says:

    What an appalling waste of time and money. Poor patient out of her environment for hours could not have been very therapeutic.

  2. TH says:

    Something similar to this happens in my ED at least once a month.

    “Poor feeding”
    Dx: “I didn’t like what they were serving.”

    “Won’t rouse for lunch.”
    Dx: “I’m awake all night because of my restless legs and I was pretendign to be asleep because I had actually been sleeping…”



  3. ThorMD says:

    I can’t tell you how many times I’ve “cured” a rash by using an alcohol wipe. Patients are mortified when this happens, but really, what was the emergency in the first place?

  4. SeaSpray says:

    Genius medical staff at nursing home.

    The poor lady ..and ED staff.

    A bit funny tho …

    Except for the waste of money/time and trouble for all.

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