Are you certain it’s just a rash?

The Inquiry Committee recently reviewed a complaint alleging that a physician had underestimated the severity of a rash, missing a clinically important allergic reaction. The patient was admitted to hospital with a history of fever, cough, swelling of her face/lips and a widespread rash. Despite being seen by multiple physicians, specifics of the rash were never adequately documented. The rash was not described in sufficient detail anywhere in the record. 

The committee determined that the standard of care in this setting required a record of the onset of the rash, specific triggers, distribution, and presence or absence of pruritus and/or pain. A past history of similar rashes and allergic reactions should have been elicited. Associated symptoms such as gastrointestinal upset and difficulty breathing should have likewise been noted, and the physical characteristics of the rash should have been described, e.g. macular, papular, vesicular or purpuric. Whether the rash is generalized or localized should also be documented. 

Physicians should remain mindful that skin eruptions can be a sign of severe illness including anaphylaxis, meningococcal septicemia, and cellulitis. Documenting the specifics of rashes is just as important as other physical findings—arguably more so, given that even high-resolution imaging, which sometimes replaces skillful physical assessment in some clinical settings, will not provide a record of what was present.