421.A 43-year-old insulin-dependent diabetic woman presents with an
intensely pruritic rash across her back for the last several days. She reports
a recent trip to the Caribbean with her family last week, none of whom has
similar symptoms. She denies any insect bites, new detergents, soaps, or
clothes and has otherwise been at her baseline of health with no constitutional
symptoms. The patient is on insulin glargine for her diabetes and reports a
hemoglobin A1C of < 7 mg/dL. Upon physical examination, the patient has
small vesicular lesions on an erythematous base with no visible purulence.
The rash does not follow a dermatome distribution and is clustered across
her back. Which of the following is the most appropriate treatment choice
for this patient?
a. Calamine lotion
b. Acyclovir
c. Chlorhexidine lotion
d. Benadryl
e. Parenteral antibiotics
422.A 32-year-old otherwise healthy man develops dizziness, nausea, and
confusion after running a race. Emergency medical services (EMS) are avail-
able on-site and the patient is given intravenous (IV) fluids. He is oriented to
person and time, but not place. He appears generally confused and it is dif-
ficult to obtain contact information from him. The patient is brought to the
ED whereupon his symptoms generally resolve, except for diffuse muscle
fatigue. Laboratory tests are drawn at this time, which are essentially normal,
except for minimally elevated hepatic transaminases. Given this patient’s
symptoms and laboratory evaluation, what is the most likely diagnosis?
a. Heat syncope
b. Heat edema
c. Rhabdomyolysis
d. Heat stroke
e. Heat exhaustion
462 Emergency Medicine