For my final site evaluation, I presented on a case of a 55-year-old Caucasian male who was complaining of a rash on bilateral arms and legs and generalized bilateral foot pain that was localizing to the left heel, both for the past 2-3 months. Both of his complaints were of new onset. My patient did not have any significant past medical history except for some eczema in his childhood and was not taking any medications, vitamins, or supplements.

During the ROS and PE exams, I was able to document his rash as dry, scaly, erythematous macules and papules or coin like lesions along bilateral inner arms, inner legs up to the ankle area, and on bilateral lower back. I was also able to reproduce mild tenderness upon palpation of the left plantar heel. I believe that I gave a broad enough list of differentials that were reasonable for the rash, including nummular dermatitis (which we diagnosed him with), allergic contact dermatitis, pityriasis rosea, psoriasis, and tinea corporis. With each of these skin conditions, I was able to my patient the pertinent questions to help rule them in or out, in addition to knowing what these rashes looked like. As for the foot pain, I included differentials such as left sided heel spur, plantar fasciitis, plantar fasia rupture, tarsal tunnel syndrome, and osteomyelitis of the foot. Again, taking into account the onset of the foot pain (after frequently walking 20-25 miles for prolonged periods of time), the pattern in which he felt the pain (more so after walking a long time or during the end of the day), and him not feeling any numbness or tingling (to R/O nerve conditions), we diagnosed him with heel spur.

At the end of my presentation, Prof. Sadat said that he was not familiar with nummular dermatitis so I was able to explain more in detail the etiology, pattern, and treatment for nummular dermatitis. As for the need for better arch support, for the patient Prof. Sadat had personal experience with being semi-flat footed and because he used to play basketball often. He specified that arch support should consist of hard arch supports as opposed to the soft or gel in soles from Dr. Scholl’s. Prof. Sadat explained that soft/gel arch supports are not useful because they conform to the feet and the patient is once again, left without arch support since the gel only provides some padding. I did not specify the type of material or texture of the arch support so learning from Prof. Sadat was valuable. In my future patient interactions and H&Ps, I will make sure to note these little details that end up making a difference for my patients.

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