When our nurses put a patient into the examining room, they record the appropriate vital signs and write a brief chief complaint at the top of the chart explaining why the patient is coming to the office. This is placed outside the room for us to review before we enter to see the patient. One of the more challenging complaints is "rash", because quite often the diagnosis is not so clear cut. Sure, some of the rashes are so classic that they can be diagnosed before you even sit down. All too often however, there are some rashes that test one's clinical skills and investigatory prowess. Only after much detective work is a diagnosis finally made. Some rashes are ultimately referred to a dermatologist for a second...or third opinion. It is particularly vindicating when the dermatologist calls back to say, "I'm not sure what this rash is"!
Such was the case on a Tuesday morning when Mrs. X. brought her 16 month old daughter, Samantha, to the office with a chief complaint of "rash for 2 days". Accompanying mom and Sam was the oldest daughter, Jennifer, who is 9 years old. Jennifer had on a bathing suit that she wore under an oversized T-shirt. In the corner by the diaper bag was a large duffel bag that was filled with beach towels, water bottles, sun hats, and assorted snacks.
As the exam got under way, mom assured me that Sam was fine with the exception of the rash that started on Sunday night. There was no fever, cough, vomiting, or diarrhea. She wasn't fussy, didn't pull at her ears or have any problem sleeping. Mom, who was a very experienced mother of three girls, offered all of this information in a succinct manner simply after I asked when the rash started.
Mom was duly prepared and informed me that her middle daughter was allergic and had excema--as a result she had already looked at ALL of the possibilities in depth. Before I could ask my next question, she produced a notebook with her notes and in rapid fire proceeded to tell me, "Sam has not had any new or exotic foods, she did not use any detergent other than the hypo-allergenic one that we had recommended for her allergic daughter, and she never uses fabric softener"! As I took in a breath to speak, she interrupted me by saying, "I know what you are going to say, and the answer is no! Her grandmother did not do her laundry. Only I do her laundry at our house...and we do NOT use bubble baths".
As I gathered my thoughts, I was impressed how well prepared mom really was. She touched on all of the pertinent points. As I examined Samantha, I was struck by the appearance and distribution of her rash. It was a dry, red and slightly rough rash that was evenly spread on her trunk and extremities. Her diaper area was spared. There were superficial scratch marks to suggest that it did itch her. When I suggested to mom that this looked like a contact dermatitis, meaning that it was due to something that had irritated her skin, mom shook her head and scoffed, "Impossible", she said.
While she had given a convincing account of all of the things that it couldn't be, a piece of the puzzle was being overlooked. Then it came to me in a flash. I asked Jennifer where they were going after the appointment. With a big smile she told me that they were going to the beach. With the confidence of a prosecuting attorney who surprises a witness on the stand with a loaded question, I turned to mom and asked, "What kind of sun screen have you been using on Sam, and when did you start using it?"
There was a long pause and mom threw her head back and rolled her eyes. "That's it! I ran out of the kids' screen on Friday and used my sun screen on them Saturday and Sunday. I feel so foolish, but it was so obvious".
It was nice to solve the puzzle and find the cause of little Sam's rash, but this encounter drove home a bigger point that is applicable to parenting as a whole. As parents we sometimes fall into the trap of making assumptions or pre-conceived notions about many issues. This applies to behavioral matters, discipline, school performance, teachers, other children and their parents. Instead of stepping back and looking at all the facts, the "whole picture", with an open mind, we tend to zero in on our snap judgment. When our notion doesn't quite fit, we try to bolster our position with mis-directed facts. When challenged, we take a defensive posture and dig in deeper to defend our position. At this point, we lose all perspective and objectivity.
Parenting requires objectivity, open-mindedness and a willingness to look at all of the facts. We must be open to constructive advice and be able to appreciate another's point of view. Invariably, the answer is obvious and right in front of our eyes providing we are prepared to receive it.