Station 72

Emily Barratt 

Age: 34 year old female

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s Name: Emily Barratt 

Age: 34-year-old female

Past Medical History:

  • Childhood Eczema

Drug and Allergy History:

  • Not on any current medication
  • No known drug allergy

Recent Consultation: 

  • Nil 

Patient has sent in the below photograph and have booked an urgent telephone appointment to discuss her concerns regarding the image

Patient's Story (Role player’s brief)

Patient’s Story 

You are Emily Barratt, a 34-year-old woman attending a telephone consultation after sending in a photo of a rash on your hand.

You first noticed the rash 2 days ago, about a week after returning from a camping trip. You recall being bitten by a tick during that trip, and you’re now worried the rash may be related to Lyme disease, particularly as it appears to be spreading and present on both hands.

The rash is itchy, red, and scaly. You have not used any new soaps, detergents, fabrics, or skincare products recently. There is no other rash elsewhere on your body, and you have no additional symptoms such as fever, joint pain, headache, fatigue, or flu-like illness.

You have a history of childhood eczema but have been free of any significant skin problems in recent years.

If asked about any other symptoms, respond: “No.”

Social History: You work as a graphic designer, mostly indoors. No recent travel to areas known for Lyme disease outbreaks. You are a non-smoker, and do not drink alcohol. You are recently married, hoping to start a family within the next couple of years

Ideas: You are concerned this rash could be Lyme disease, due to the timing and the recent tick bite. 

Concerns: You’re worried that if this is Lyme disease as you have read online that it could become serious if left untreated.

Expectations: You would like the GP to confirm if this is Lyme disease, and if so, start antibiotics promptly. 

Question for the Doctor: You are due to travel to Montenegro tomorrow and would like to know if it is safe to travel with this rash, or whether you should delay the trip.

Marking Scheme

Data Gathering and Diagnosis 

  • Ask about the onset of the rash
  • Ask about the location of the rash — for example: “Thanks for sending the picture. Is the rash just on the hand shown, or is it affecting both hands or any other areas of your body?“
  • Ask whether the rash is getting worse, improving, or staying the same
  • Ask if the rash is itchy or painful
  • Ask if the rash is scaly, cracked, or weeping
  • Ask whether the patient has noticed a bull’s-eye or circular pattern typical of early Lyme disease
  • Ask how many ticks were noticed and whether they were attached for a long period and whether the tick was removed fully
  • Ask about any systemic symptoms that could suggest Lyme disease, such as fever, muscle or joint aches, headache, numbness or tingling, fatigue, or changes in vision.
  • Acknowledge her history of childhood eczema and ask when she last experienced a flare-up, and whether this current rash feels or looks different from her usual eczema.
  • Ask about any recent environmental changes — new job, stress, new skincare, laundry detergents, or living environment
  • Explore ICE — ideas, concerns, and expectations
  • Ask about smoking, alcohol intake, and how the rash is affecting daily life
  • Give a working diagnosis of likely hand dermatitis or eczema, with Lyme disease less likely based on history and clinical features. 

Example of explanation to patient​

Thanks for explaining all that and sending over the photo, Emily. 

I’ve had a good look at the picture, and I completely understand why you’re concerned, especially after being bitten by a tick during your camping trip.

From what you’ve described, a red, itchy, scaly rash on both hands, and the fact that you’re otherwise feeling well in yourself, I think this is more likely to be a flare-up of eczema or skin irritation, rather than something like Lyme disease.

You mentioned you had eczema as a child, and it’s not unusual for it to come back later in life, especially after exposure to irritants like cold weather, washing hands a lot, certain materials or products while camping or even just stress.

Does that all make sense so far? 

I can see you’re understandably worried this might be Lyme disease, and it’s great that you’ve picked up on the tick bite, as we always take that seriously. But typically, with Lyme disease, we would expect to see a particular type of rash that often starts as a round patch and expands over time, and people often feel quite unwell, with things like tiredness, muscle aches, fever, or feeling generally run down. Since you’ve not had any of those symptoms, and your rash doesn’t look like the typical Lyme rash, that’s really reassuring.

To help with the rash, I would suggest we start with a mild steroid cream and a moisturiser to help soothe and calm the skin. I would also recommend keeping a note of when the rash flares up, sometimes there are small triggers, like soaps, cleaning products, or even certain fabrics, that are worth spotting.

In terms of your plans to travel to Montenegro tomorrow, from everything you’ve told me, I don’t see any reason to delay your trip. You’re feeling well in yourself, and the rash, while uncomfortable, isn’t something that would stop you from travelling. I would suggest arranging travel health insurance before you go, just to be on the safe side. That way, if the rash spreads or you start feeling unwell while you’re away, you’ll be able to get medical advice or treatment without any difficulty

We can catch up again once you’re back from your trip, just to make sure everything is settling as expected

Does that all make sense so far? Are you happy with that plan?



Management

Management

  • Reassure the patient that based on the current appearance, distribution, and absence of systemic symptoms, Lyme disease is unlikely. 
  • Offer emollients and a mild topical steroid, such as hydrocortisone or a moderate-potency corticosteroid (Eumovate), to treat likely hand eczema
  • Advise keeping a symptom diary to help identify any potential triggers, including new products, materials, or environmental exposures
  • Reassure the patient that it is safe to proceed with her travel plans but recommend arranging travel health insurance in case any issues arise while she is away, so that she can access medical care if needed.
  • Arrange a follow-up in 2-3 weeks to review progress and response to treatment
  • Safety net: Advise the patient to recontact the surgery sooner if symptoms worsen or if she develops new systemic symptoms such as fever, generalised body aches, fatigue, or joint pain, at which point blood tests and further investigations for Lyme disease may be considered

Learning point from this station: ​

This case highlights the importance of managing diagnostic uncertainty in general practice, where decisions are often made based on a thorough history and clinical reasoning, rather than immediate access to definitive investigations. In this scenario, the patient was understandably concerned about Lyme disease following a tick bite. However, the absence of typical features, such as a bull’s-eye rash or flu-like symptoms, alongside the appearance and behaviour of the rash, pointed more towards hand dermatitis or eczema, particularly given her history of childhood eczema.

As GPs, we frequently make decisions using the most likely diagnosis, guided by good clinical history-taking and pattern recognition. While Lyme disease is unlikely, it is important to acknowledge the patient’s concerns, provide clear reassurance, and offer appropriate safety netting, advising the patient what to look out for, when to seek help, and arranging follow-up, in case the initial working diagnosis proves incorrect.

Further reading