The problems are three in number. Two are skin deep; the third lies deeper.
This teenager shows me the rash around her right wrist. She’s had it since Christmas, she says. Little red bumps that itch. Several are grouped into small clusters. Ringworm, the school nurse said. Better go see your doctor and have it checked out.
I turn her hand over, rotating the wrist to study the eruption, all the while conjuring up mental images of skin lesions that I have seen in the past. This rash doesn’t fit the criteria for ringworm, yet I am at a loss to explain it.
“She also needs this form filled out to exempt her from swimming class,” the mother explains, handing me a paper. “She’s sensitive to the chlorine, breaks out in rash from head to toe if she gets in the pool. It’s just like the metal allergy she’s got.”
“Metal allergy?” I ask.
“Yes, she breaks out when metal touches her skin. Belt buckles, cheap earrings and such.”
“It looks like some sort of contact dermatitis,” I muse, still studying the eruption.
The mother opens her purse and pulls out a shiny bracelet. “She got this for Christmas—from her brother,” she says.
I reach for the bracelet and run it through my fingers. “You’ve been wearing this bracelet on that wrist?” I ask.
The girl nods her head.
“Metal allergy,” I say, this time as a pronouncement, not as a question. “I’ll give you a prescription for an ointment to use.”
“Then there’s the pain in her stomach,” the mother says.
“Tell me about it,” I say to the girl.
“Not much to tell,” she says. “It hurts right here in the middle.” She points to the pit of her stomach. “Anytime I eat something, it sets it off.”
“How long does it last?”
“A couple of hours, then it goes away.”
I pose a few more questions and ask the girl to lie down on the exam table. I listen to her abdomen, feel her belly, ask her to take a deep breath while I push in with my hand.
“Any stomach problems in the family?”
“I had ulcers when I was young,” the mother says.
“I’m not convinced it’s an ulcer, but I do think she’s got some hyperacidity. I’ll prescribe a pill for you to take every morning before breakfast. Let’s see if that doesn’t help.”
I write out the prescriptions, explaining the directions as I do so. I sign the form to exempt her from swimming class. “Has she been under any duress lately?” I ask, as I hand the papers to the mother.
“Lots of stress,” the girl answers. “Mid-term exams….”
“And my son,” the mother says.
“Your son? How so?”
“He was in the Marines, over in Iraq. He came home with PTSD. He yells a lot. It bothers her—and me.”
“Is he getting some help?”
“He goes to see somebody. The state pays for some of his care. But he can’t hold a job.”
“How long has he been home?” I ask.
“Two years—” she says in a halting voice. “He came back when he was twenty-two, and he’s twenty-four years old now.” Her face turns red, her eyes well up with tears; yet she continues to smile. “I tell my daughter it’s just how things are right now with our family. This is our life now together.”
I offer her a tissue. She dabs the tears on her cheeks. For the moment, the surge has settled.
“Thank you for seeing my daughter.” The mother shakes my hand and turns to go.
This family—a mother, a daughter, a son. The problems are three in number. Two are skin deep; the third lies much deeper.