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Foot Pain Following a Car Crash
The radiograph demonstrates an acute fracture of the second, third, and fourth distal metatarsals. The third and fourth are mildly impacted.
In addition, there is a deformity noted within the medial cuneiform, strongly suggestive of a fracture. This was later confirmed by CT. Orthopedic consultation was obtained.
The radiograph demonstrates an acute fracture of the second, third, and fourth distal metatarsals. The third and fourth are mildly impacted.
In addition, there is a deformity noted within the medial cuneiform, strongly suggestive of a fracture. This was later confirmed by CT. Orthopedic consultation was obtained.
The radiograph demonstrates an acute fracture of the second, third, and fourth distal metatarsals. The third and fourth are mildly impacted.
In addition, there is a deformity noted within the medial cuneiform, strongly suggestive of a fracture. This was later confirmed by CT. Orthopedic consultation was obtained.
Following a motor vehicle collision, a 60-year-old woman is brought in by emergency medical transport. She was a restrained driver in a vehicle that went out of control, hit a tree, and ended up in a ditch. There was a prolonged extrication time (> 30 minutes) due to extensive damage to the front of the vehicle. On arrival, the patient is awake and alert, complaining primarily of pain in her left hip and right foot. Her medical history is unremarkable. She has an initial Glasgow Coma Scale score of 15. Her vital signs are: blood pressure, 154/100 mm Hg; pulse, 108 beats/min; respiratory rate, 16 breaths/min; and O2 saturation, 100% on room air. Primary survey is otherwise unremarkable. A series of radiographs are ordered; that of the right foot is shown. What is your impression?
Grad Student With Palpitations
ANSWER
The correct interpretation of this ECG includes sinus rhythm with marked sinus arrhythmia and a blocked premature atrial contraction (PAC).
Sinus rhythm is defined as a heart rate between 60 and 100 beats/min, with a P wave for every QRS complex, a QRS complex for every P wave, and a consistent PR interval between 120 and 200 ms.
A sinus arrhythmia is defined as a variation of the P-P interval ≥ 120 ms in the presence of normal P waves and a normal PR interval. The most common cause of a sinus arrhythmia is respiratory variation.
A blocked PAC is seen following the fifth QRS complex. Careful inspection of the terminal portion of the T wave reveals a P wave without a corresponding QRS complex. There is no QRS complex because the PAC occurs while the AV node is refractory. The subsequent pause occurs because the PAC blocks the sinus node and resets the sinus rate.
The palpitations were correlated to PACs observed on a continuous rhythm strip, and the patient was reassured.
ANSWER
The correct interpretation of this ECG includes sinus rhythm with marked sinus arrhythmia and a blocked premature atrial contraction (PAC).
Sinus rhythm is defined as a heart rate between 60 and 100 beats/min, with a P wave for every QRS complex, a QRS complex for every P wave, and a consistent PR interval between 120 and 200 ms.
A sinus arrhythmia is defined as a variation of the P-P interval ≥ 120 ms in the presence of normal P waves and a normal PR interval. The most common cause of a sinus arrhythmia is respiratory variation.
A blocked PAC is seen following the fifth QRS complex. Careful inspection of the terminal portion of the T wave reveals a P wave without a corresponding QRS complex. There is no QRS complex because the PAC occurs while the AV node is refractory. The subsequent pause occurs because the PAC blocks the sinus node and resets the sinus rate.
The palpitations were correlated to PACs observed on a continuous rhythm strip, and the patient was reassured.
ANSWER
The correct interpretation of this ECG includes sinus rhythm with marked sinus arrhythmia and a blocked premature atrial contraction (PAC).
Sinus rhythm is defined as a heart rate between 60 and 100 beats/min, with a P wave for every QRS complex, a QRS complex for every P wave, and a consistent PR interval between 120 and 200 ms.
A sinus arrhythmia is defined as a variation of the P-P interval ≥ 120 ms in the presence of normal P waves and a normal PR interval. The most common cause of a sinus arrhythmia is respiratory variation.
A blocked PAC is seen following the fifth QRS complex. Careful inspection of the terminal portion of the T wave reveals a P wave without a corresponding QRS complex. There is no QRS complex because the PAC occurs while the AV node is refractory. The subsequent pause occurs because the PAC blocks the sinus node and resets the sinus rate.
The palpitations were correlated to PACs observed on a continuous rhythm strip, and the patient was reassured.
A 24-year-old graduate student presents to the student clinic with a history of palpitations. He first noticed them while snowboarding two months ago, but says they’re now occurring daily and much more frequently. He is concerned about the risk for “another” episode of tachycardia, which, through careful questioning, you learn he has experienced twice before. He recalls that each of the episodes—which occurred while he was “pulling all-nighters” for final exams during his undergrad years—began abruptly and lasted for approximately an hour. He had no chest pain, symptoms of near-syncope, or syncope, but recalls feeling very “jittery,” which he attributed to drinking a full pot of coffee while studying. The patient has no prior cardiac or pulmonary history and considers himself to be in excellent health. He has run two half-marathons in the preceding six months and is an avid snowboarder. He also competes in local road cycling competitions with reasonable success. Medical history is remarkable only for fractures of the right ankle and the left clavicle. He takes no medications and has no drug allergies. Family history is significant for stroke (paternal grandfather), diabetes (maternal grandmother), and hypertension (father). He consumes alcohol socially, primarily on weekends, and does not binge drink. He smokes marijuana during snowboard season but denies use at other times of the year. A 12-point review of systems is positive only for athlete’s foot and psoriasis on both upper extremities. The physical exam reveals a healthy, athletic-appearing male in no distress. Vital signs include a blood pressure of 126/68 mm Hg; pulse, 78 beats/min; respiratory rate, 14 breaths/min; and O2 saturation, 99% on room air. He is afebrile. His height is 70” and weight, 158 lb. Auscultation of the heart reveals no murmurs, rubs, or gallops, but you do detect several pauses. As you listen, he emphatically states, “There’s one … there’s another.” Following the physical exam, the patient asks you to order an ECG. The resultant tracing reveals the following: a ventricular rate of 70 beats/min; PR interval, 178 ms; QRS duration, 90 ms; QT/QTc interval, 402/434 ms; P axis, 23°, R axis, 38°; and T axis, 31°. What is your interpretation of this ECG?
An Encounter With Unflattering Light
ANSWER
The correct answer is dermatoheliosis (choice “d”), also correctly termed photoaging. This condition manifests as a number of specific skin changes, including the items named (choices “a,” “b,” and “c”)—all of which were present on this patient.
DISCUSSION
The consequences of chronic overexposure to UV radiation constitute the most common reason patients present to dermatology practices in the United States. The bulk of this damage takes decades to appear, by which time patients have forgotten about their earlier sun exposure (in fact, they often deny any exposure) and even the painful sunburns that taught them to avoid the sun in the first place.
In general, the effects of sunburns sustained in childhood or young adulthood do not usually manifest until the patient is in his/her 50s or 60s, although patients who are less sun-tolerant (our definition of “fair”) may show signs of damage considerably earlier.
However, with the popularity of artificial tanning among teenagers (and even preteens in some cases), evidence of sun damage is being seen at younger ages than ever. Basal cell carcinomas, once unheard of in teenagers, are being found with increasing frequency in this age-group. In patients ages 12 to 15, there has been a 100-fold increase in the incidence of melanoma—theorized to be due, in part, to the effects of artificial tanning.
This particular patient is typical of cases in which sun damage was obtained more passively. At one time in the US, having a tan was decidedly unfashionable; it marked one as a member of “the lower classes.” But that all began to change after WWI: Hemlines and hairlines rose, Prohibition created a new generation of drinkers and scofflaws, clothing began to be more revealing, and suddenly it was fashionable for women to shave their legs and get a tan.
About that same time, many men began to ignore the long-held tradition of wearing hats and long sleeves when outside, inevitably tanned, and thus gained approval from the opposite sex. Most went off to war in the 1940s, many to the Pacific theater, where they had even more exposure to the sun.
Following WWII, a great number of these men returned to their jobs as farmers, ranchers, or construction workers. Golfing became the “in” sport during leisure time. It’s this generation we’re seeing now for sun-related pathology. Even if they had been inclined to use it, effective sunscreen was not generally available until the early 1970s.
The patient depicted here has a typical collection of the pre-cancerous sun damage known as dermatoheliosis: solar elastosis, actinic keratoses, telangiectasias, and solar atrophy (which affects the arms more than the face). The latter, along with the effects of wind, heat, cold, smoking, and drinking alcohol, constitute the main causes of extrinsic aging.
TREATMENT
Short of heroic efforts, not much will be done for this patient’s dermatoheliosis. However, he was strongly advised to return to dermatology twice a year to watch for the arrival of the basal cell and squamous cell carcinomas that are almost certainly headed his way.
ANSWER
The correct answer is dermatoheliosis (choice “d”), also correctly termed photoaging. This condition manifests as a number of specific skin changes, including the items named (choices “a,” “b,” and “c”)—all of which were present on this patient.
DISCUSSION
The consequences of chronic overexposure to UV radiation constitute the most common reason patients present to dermatology practices in the United States. The bulk of this damage takes decades to appear, by which time patients have forgotten about their earlier sun exposure (in fact, they often deny any exposure) and even the painful sunburns that taught them to avoid the sun in the first place.
In general, the effects of sunburns sustained in childhood or young adulthood do not usually manifest until the patient is in his/her 50s or 60s, although patients who are less sun-tolerant (our definition of “fair”) may show signs of damage considerably earlier.
However, with the popularity of artificial tanning among teenagers (and even preteens in some cases), evidence of sun damage is being seen at younger ages than ever. Basal cell carcinomas, once unheard of in teenagers, are being found with increasing frequency in this age-group. In patients ages 12 to 15, there has been a 100-fold increase in the incidence of melanoma—theorized to be due, in part, to the effects of artificial tanning.
This particular patient is typical of cases in which sun damage was obtained more passively. At one time in the US, having a tan was decidedly unfashionable; it marked one as a member of “the lower classes.” But that all began to change after WWI: Hemlines and hairlines rose, Prohibition created a new generation of drinkers and scofflaws, clothing began to be more revealing, and suddenly it was fashionable for women to shave their legs and get a tan.
About that same time, many men began to ignore the long-held tradition of wearing hats and long sleeves when outside, inevitably tanned, and thus gained approval from the opposite sex. Most went off to war in the 1940s, many to the Pacific theater, where they had even more exposure to the sun.
Following WWII, a great number of these men returned to their jobs as farmers, ranchers, or construction workers. Golfing became the “in” sport during leisure time. It’s this generation we’re seeing now for sun-related pathology. Even if they had been inclined to use it, effective sunscreen was not generally available until the early 1970s.
The patient depicted here has a typical collection of the pre-cancerous sun damage known as dermatoheliosis: solar elastosis, actinic keratoses, telangiectasias, and solar atrophy (which affects the arms more than the face). The latter, along with the effects of wind, heat, cold, smoking, and drinking alcohol, constitute the main causes of extrinsic aging.
TREATMENT
Short of heroic efforts, not much will be done for this patient’s dermatoheliosis. However, he was strongly advised to return to dermatology twice a year to watch for the arrival of the basal cell and squamous cell carcinomas that are almost certainly headed his way.
ANSWER
The correct answer is dermatoheliosis (choice “d”), also correctly termed photoaging. This condition manifests as a number of specific skin changes, including the items named (choices “a,” “b,” and “c”)—all of which were present on this patient.
DISCUSSION
The consequences of chronic overexposure to UV radiation constitute the most common reason patients present to dermatology practices in the United States. The bulk of this damage takes decades to appear, by which time patients have forgotten about their earlier sun exposure (in fact, they often deny any exposure) and even the painful sunburns that taught them to avoid the sun in the first place.
In general, the effects of sunburns sustained in childhood or young adulthood do not usually manifest until the patient is in his/her 50s or 60s, although patients who are less sun-tolerant (our definition of “fair”) may show signs of damage considerably earlier.
However, with the popularity of artificial tanning among teenagers (and even preteens in some cases), evidence of sun damage is being seen at younger ages than ever. Basal cell carcinomas, once unheard of in teenagers, are being found with increasing frequency in this age-group. In patients ages 12 to 15, there has been a 100-fold increase in the incidence of melanoma—theorized to be due, in part, to the effects of artificial tanning.
This particular patient is typical of cases in which sun damage was obtained more passively. At one time in the US, having a tan was decidedly unfashionable; it marked one as a member of “the lower classes.” But that all began to change after WWI: Hemlines and hairlines rose, Prohibition created a new generation of drinkers and scofflaws, clothing began to be more revealing, and suddenly it was fashionable for women to shave their legs and get a tan.
About that same time, many men began to ignore the long-held tradition of wearing hats and long sleeves when outside, inevitably tanned, and thus gained approval from the opposite sex. Most went off to war in the 1940s, many to the Pacific theater, where they had even more exposure to the sun.
Following WWII, a great number of these men returned to their jobs as farmers, ranchers, or construction workers. Golfing became the “in” sport during leisure time. It’s this generation we’re seeing now for sun-related pathology. Even if they had been inclined to use it, effective sunscreen was not generally available until the early 1970s.
The patient depicted here has a typical collection of the pre-cancerous sun damage known as dermatoheliosis: solar elastosis, actinic keratoses, telangiectasias, and solar atrophy (which affects the arms more than the face). The latter, along with the effects of wind, heat, cold, smoking, and drinking alcohol, constitute the main causes of extrinsic aging.
TREATMENT
Short of heroic efforts, not much will be done for this patient’s dermatoheliosis. However, he was strongly advised to return to dermatology twice a year to watch for the arrival of the basal cell and squamous cell carcinomas that are almost certainly headed his way.
During a recent trip, this 77-year-old man stayed in a hotel in which the bathroom lighting was considerably brighter than that at home—allowing him to see a number of skin changes he hadn’t noticed before. As a result, he presents to dermatology for an evaluation. The patient’s forehead, as well as his cheeks and nose, look curiously mottled (pink and white), with a rough, scar-like, pebbly surface that resembles chicken skin. There are also numerous 1- to 3-mm rough, scaly, papular lesions and multiple faint telangiectasias. In sun-exposed areas, such as his hands and arms, the skin is rough, dry, and exceptionally thin, with light and dark color changes; this is in sharp contrast to the relatively pristine texture and uniformly light color of the volar forearms and other areas that are not exposed to the sun. History taking reveals that, as a young man, the patient spent a great deal of time outdoors, both at work and in his free time. He never wore a hat or used any other form of sun protection. Since age 50, he has had several skin cancers removed from his face and back. Despite this, he is not seeing a dermatology provider regularly.
Drug Abuse Follows a Broken Heart
ANSWER
This ECG shows sinus tachycardia at a rate of 110 beats/min, evidenced by the presence of a P wave for every QRS complex with regular R-R intervals. Left atrial enlargement is evident from the presence of P waves ≥ 110 ms (admittedly difficult to see in this example) and a terminal negativity of the P wave in lead V1 ≥ 1 mm2. A rightward axis is evidenced by the presence of an R-wave axis of 96°; however, it does not meet criteria for a true right-axis deviation
(≥ 105°). Nonspecific T-wave abnormalities are observed in leads V5 and V6.
The most intriguing aspect of this ECG is observed in lead V3. Note the abrupt disruption of R-wave progression between leads V2 and V4. This was due to incorrect placement of the ECG electrode for V3, which occurred in the haste to obtain the ECG prior to the CT scan. This illustrates the importance of correct electrode placement for an accurate tracing.
ANSWER
This ECG shows sinus tachycardia at a rate of 110 beats/min, evidenced by the presence of a P wave for every QRS complex with regular R-R intervals. Left atrial enlargement is evident from the presence of P waves ≥ 110 ms (admittedly difficult to see in this example) and a terminal negativity of the P wave in lead V1 ≥ 1 mm2. A rightward axis is evidenced by the presence of an R-wave axis of 96°; however, it does not meet criteria for a true right-axis deviation
(≥ 105°). Nonspecific T-wave abnormalities are observed in leads V5 and V6.
The most intriguing aspect of this ECG is observed in lead V3. Note the abrupt disruption of R-wave progression between leads V2 and V4. This was due to incorrect placement of the ECG electrode for V3, which occurred in the haste to obtain the ECG prior to the CT scan. This illustrates the importance of correct electrode placement for an accurate tracing.
ANSWER
This ECG shows sinus tachycardia at a rate of 110 beats/min, evidenced by the presence of a P wave for every QRS complex with regular R-R intervals. Left atrial enlargement is evident from the presence of P waves ≥ 110 ms (admittedly difficult to see in this example) and a terminal negativity of the P wave in lead V1 ≥ 1 mm2. A rightward axis is evidenced by the presence of an R-wave axis of 96°; however, it does not meet criteria for a true right-axis deviation
(≥ 105°). Nonspecific T-wave abnormalities are observed in leads V5 and V6.
The most intriguing aspect of this ECG is observed in lead V3. Note the abrupt disruption of R-wave progression between leads V2 and V4. This was due to incorrect placement of the ECG electrode for V3, which occurred in the haste to obtain the ECG prior to the CT scan. This illustrates the importance of correct electrode placement for an accurate tracing.
A 26-year-old man is brought to the emergency department (ED) by three friends who hadn’t seen him for two days and went to his apartment to check on him. They found him unconscious on the floor with four empty syringes on the coffee table beside him. The patient was aroused with difficulty but remained incoherent. Rather than call 911, they carried him to their car and brought him to the ED. According to his friends, he has been an IV drug abuser since breaking up with his girlfriend two years ago. He has been increasingly despondent over the past few days after seeing her with anoth-er man. The friends state that they know he has used heroin, cocaine, marijuana, and methamphet-amines in the past, but do not know what he used on this occasion. He has not had any prior illnesses, surgical procedures, or medical conditions that they are aware of. They do not know whether the patient is taking any prescription medications, nor whether he is aller-gic to any medications. According to one of the friends, the patient works with him as a welder at a local factory. He states the patient has been absent from work since last seeing his ex-girlfriend. You are unable to obtain a review of systems. A cursory examination reveals a thin, disheveled male who is unconscious but arousable. Blood pressure is 102/62 mm Hg, and pulse, 110 beats/min. Res-pirations are shallow at a rate of 20 breaths/min-1. Examination of the skin is remarkable for multiple recent and mature needle tracks in both upper ex-tremities, as well as multiple excoriations and shallow ulcers on both lower extremities. The EENT exam is remarkable for constricted pupils that react to light. Corneal reflexes are intact. The teeth are in poor repair with multiple caries and missing teeth. The neck veins are not distended, the thyroid is normal, and there are palpable lymph nodes in the left anterior cervical chain. The lungs have diffuse, scattered dry rales. The cardiac exam reveals a regular rate at 110 beats/min with a soft, early systolic murmur best heard at the left upper sternal border. A rub is also present. Peripheral pulses are equal bilaterally in both upper and lower extremities. The abdomen is soft and nontender. The liver edge is palpable 2 cm below the right costal margin, and a firm spleen is palpable on the left. The neurologic exam reveals hyperactive deep tendon re-flexes in all four extremities. Laboratory samples are drawn; results are positive for cocaine, cannabis, and methamphetamine. Stat blood cultures are positive for Staphylococcus aureus, and the white blood count is 21,000/μL. A bedside echocardiogram performed in the ED shows evidence of a pericardial effusion and a perivalvular abscess on the septal side of the mitral valve, consistent with endocarditis. Prior to the patient’s transport to radiology for a CT scan, a quick ECG is performed. It reveals a ven-tricular rate of 110 beats/min; PR interval, 130 ms; QRS duration, 76 ms; QT/QTc interval, 352/476 ms; P axis, 59°; R axis, 96°; and T axis, 106°. What is your interpretation of this ECG?
Wife Wants Husband’s “Zits” Gone!
ANSWER
The correct answer is dilated pore of Winer (choice “b”), a hair structure anomaly discussed below. Sebaceous cysts (choice “a”) often present with a surface punctum, but the depth and appearance of this pore are not consistent with a simple punctum. The same could be said of the other two choices: ice-pick scar secondary to acne (choice “c”) and ingrown hair (choice “d”).
DISCUSSION
Dilated pore of Winer is actually a tumor of the intraepidermal follicle and related infundibulum of the pilosebaceous apparatus, a fact confirmed by immunohistochemical studies. It has no implication for health, but its appearance is occasionally distressing. Unfortunately, this patient has matching dilated pores on either side of his nose.
These scar-like pits are most commonly seen on the face, especially the maxillae. Even though they resemble one another, dilated pore of Winer differs significantly from a simple comedone: The former is considerably deeper, as well as markedly different in structure.
TREATMENT
The only effective treatment for dilated pore of Winer is surgical excision, which is easily accomplished under local anesthesia. A 4- to 5-mm punch biopsy tool is introduced into the skin at the same angle as the course of the pore, then taken down to adipose tissue, which ensures complete removal. Two interrupted skin sutures serve to convert the round punch defect into a linear wound, preferably matching skin tension lines. The tissue thus removed is always sent for pathologic examination to rule out basal cell carcinoma.
But for the vast majority of patients affected by dilated pore of Winer, the best treatment is to leave the lesions alone.
ANSWER
The correct answer is dilated pore of Winer (choice “b”), a hair structure anomaly discussed below. Sebaceous cysts (choice “a”) often present with a surface punctum, but the depth and appearance of this pore are not consistent with a simple punctum. The same could be said of the other two choices: ice-pick scar secondary to acne (choice “c”) and ingrown hair (choice “d”).
DISCUSSION
Dilated pore of Winer is actually a tumor of the intraepidermal follicle and related infundibulum of the pilosebaceous apparatus, a fact confirmed by immunohistochemical studies. It has no implication for health, but its appearance is occasionally distressing. Unfortunately, this patient has matching dilated pores on either side of his nose.
These scar-like pits are most commonly seen on the face, especially the maxillae. Even though they resemble one another, dilated pore of Winer differs significantly from a simple comedone: The former is considerably deeper, as well as markedly different in structure.
TREATMENT
The only effective treatment for dilated pore of Winer is surgical excision, which is easily accomplished under local anesthesia. A 4- to 5-mm punch biopsy tool is introduced into the skin at the same angle as the course of the pore, then taken down to adipose tissue, which ensures complete removal. Two interrupted skin sutures serve to convert the round punch defect into a linear wound, preferably matching skin tension lines. The tissue thus removed is always sent for pathologic examination to rule out basal cell carcinoma.
But for the vast majority of patients affected by dilated pore of Winer, the best treatment is to leave the lesions alone.
ANSWER
The correct answer is dilated pore of Winer (choice “b”), a hair structure anomaly discussed below. Sebaceous cysts (choice “a”) often present with a surface punctum, but the depth and appearance of this pore are not consistent with a simple punctum. The same could be said of the other two choices: ice-pick scar secondary to acne (choice “c”) and ingrown hair (choice “d”).
DISCUSSION
Dilated pore of Winer is actually a tumor of the intraepidermal follicle and related infundibulum of the pilosebaceous apparatus, a fact confirmed by immunohistochemical studies. It has no implication for health, but its appearance is occasionally distressing. Unfortunately, this patient has matching dilated pores on either side of his nose.
These scar-like pits are most commonly seen on the face, especially the maxillae. Even though they resemble one another, dilated pore of Winer differs significantly from a simple comedone: The former is considerably deeper, as well as markedly different in structure.
TREATMENT
The only effective treatment for dilated pore of Winer is surgical excision, which is easily accomplished under local anesthesia. A 4- to 5-mm punch biopsy tool is introduced into the skin at the same angle as the course of the pore, then taken down to adipose tissue, which ensures complete removal. Two interrupted skin sutures serve to convert the round punch defect into a linear wound, preferably matching skin tension lines. The tissue thus removed is always sent for pathologic examination to rule out basal cell carcinoma.
But for the vast majority of patients affected by dilated pore of Winer, the best treatment is to leave the lesions alone.
A 52-year-old man self-refers to dermatology, at his wife’s insistence, for evaluation of “big black-heads” that have been present on his maxillae for as long as he can remember. Periodically, he ex-presses cheesy, odoriferous material from them. He denies ever experiencing trauma in the area, and there is no history of other skin problems (eg, acne). His wife wants him to get these “black-heads” removed, because there is “dirt” in them. Small “holes” are seen on each side of the nose, about 3 cm lateral to midline. Each lesion is 2 to 3 mm wide and obviously deep. There is no comedonal material or protruding hair seen in the lesions; the surrounding skin is unchanged. Induration is absent in or around the lesions. No signs of active acne are seen elsewhere.
Cough and Back Pain in a Man With COPD
ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.
Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.
In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.
ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.
Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.
In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.
ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.
Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.
In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.
A 60-year-old man presents for evaluation of fever, cough, and back pain. His symptoms have been intermittent but have worsened over the past month or so. He has had no treatment prior to today’s visit. His medical history is significant for hypertension, COPD, and chronic renal insufficiency. He denies any history of tobacco use. On physical exam, you see an older man in no obvious distress. His vital signs are stable. He is afe-brile, with a blood pressure of 150/90 mm Hg, a heart rate of 66 beats/min, and a respiratory rate of 18 breaths/min. His O2 saturation is 98% on room air. His neck is supple, with no evidence of ade-nopathy. Lung sounds are slightly decreased bilaterally, with a few crackles heard. The rest of his physical exam, overall, is normal. You order preliminary lab work as well as a chest radiograph (shown). What is your impression?
Hand Slammed in Door
ANSWER
The radiograph shows a comminuted fracture of the proximal fifth phalanx. Soft tissue swelling is noted as well. The patient’s hand was splinted, and arrangements for outpatient orthopedic follow-up were made.
ANSWER
The radiograph shows a comminuted fracture of the proximal fifth phalanx. Soft tissue swelling is noted as well. The patient’s hand was splinted, and arrangements for outpatient orthopedic follow-up were made.
ANSWER
The radiograph shows a comminuted fracture of the proximal fifth phalanx. Soft tissue swelling is noted as well. The patient’s hand was splinted, and arrangements for outpatient orthopedic follow-up were made.
A 48-year-old woman presents to the urgent care center with complaints of right hand pain second-ary to an injury she sustained earlier in the day. Her hand was accidentally caught in a metal door as it was being shut by someone else. The door struck her in the middorsal aspect of her hand. She is now complaining of pain and swelling. She is healthy except for mild but well-controlled hypertension. Her vital signs are normal. Examina-tion of her right hand shows mild to moderate soft tissue swelling and some early bruising. There is extreme tenderness over the fourth and fifth metacarpal bones. Good capillary refill time is noted, and sensation is intact. She is able to flex her fingers somewhat, although this is limited by the swelling. Radiograph of the right hand is obtained. What is your impression?
Do Nausea and Vomiting Have Cardiac Cause?
ANSWER
The correct interpretation of this ECG includes normal sinus rhythm, left atrial enlargement, and nonspecific T-wave abnormalities.
Normal sinus rhythm is evidenced by an atrial and ventricular rate of 77 beats/min with one-to-one association. Left atrial enlargement is evidenced by the presence of a biphasic P wave in lead V1 with a negative terminal portion of the P wave ≥ 1 mm2. (P waves in lead I ≥ 110 ms are also seen in left atrial enlargement, but are not evident in this ECG.) The small or inverted appearance of T waves in the inferior and lateral leads indicates nonspecific T waves.
These ECG findings are typical of patients with mitral valve disease, but were of no benefit in diagnosing acute pancreatitis in this patient. By the time she had the ECG done, she had been given sedation sufficient to reduce her heart rate from the 118 beats/min it had been at the time of examination.
ANSWER
The correct interpretation of this ECG includes normal sinus rhythm, left atrial enlargement, and nonspecific T-wave abnormalities.
Normal sinus rhythm is evidenced by an atrial and ventricular rate of 77 beats/min with one-to-one association. Left atrial enlargement is evidenced by the presence of a biphasic P wave in lead V1 with a negative terminal portion of the P wave ≥ 1 mm2. (P waves in lead I ≥ 110 ms are also seen in left atrial enlargement, but are not evident in this ECG.) The small or inverted appearance of T waves in the inferior and lateral leads indicates nonspecific T waves.
These ECG findings are typical of patients with mitral valve disease, but were of no benefit in diagnosing acute pancreatitis in this patient. By the time she had the ECG done, she had been given sedation sufficient to reduce her heart rate from the 118 beats/min it had been at the time of examination.
ANSWER
The correct interpretation of this ECG includes normal sinus rhythm, left atrial enlargement, and nonspecific T-wave abnormalities.
Normal sinus rhythm is evidenced by an atrial and ventricular rate of 77 beats/min with one-to-one association. Left atrial enlargement is evidenced by the presence of a biphasic P wave in lead V1 with a negative terminal portion of the P wave ≥ 1 mm2. (P waves in lead I ≥ 110 ms are also seen in left atrial enlargement, but are not evident in this ECG.) The small or inverted appearance of T waves in the inferior and lateral leads indicates nonspecific T waves.
These ECG findings are typical of patients with mitral valve disease, but were of no benefit in diagnosing acute pancreatitis in this patient. By the time she had the ECG done, she had been given sedation sufficient to reduce her heart rate from the 118 beats/min it had been at the time of examination.
A 58-year-old woman presents with epigastric pain that began gradually about four hours ago, re-maining constant for the past two. She describes it as a “dull, steady, aching” pain directly beneath her lower sternum. It is neither exacerbated by exertion nor relieved by rest, but it does improve if she bends from the waist. She denies radiation of pain into her neck or upper extremities but describes a band of pain radiating to her back. Additionally, she has experienced nausea and vomiting, starting about 12 hours before her pain, with a single episode of emesis immediately upon presentation. She has a history of mitral valve prolapse, which was surgically corrected with a mechanical heart valve two years ago. She also has a history of paroxysmal atrial fibrillation for which she has been cardioverted on two separate occasions. Her last episode was six months ago. Social history reveals that she is divorced, has smoked one pack of cigarettes a day for the past 30 years, and is a heavy alcohol user. She states she went on a binge last weekend (72 hours ago), drinking one bottle of whiskey and half a bottle of vodka over the course of one day. She has tried heroin, cocaine, and methamphetamines in the past and currently uses marijuana when she can get it. The patient has a primary care provider who prescribed aspirin, atorvastatin, clonidine, gabapentin, metoprolol, and warfarin; however, she hasn’t taken or refilled any of these prescriptions for approx-imately six months. She is allergic to codeine, erythromycin, and azithromycin. The review of sys-tems is positive for difficulty sleeping, anxiety, diffuse abdominal pain not related to her current symp-toms, dyspnea on exertion, “typical smoker’s cough,” and burning with urination. The physical examination reveals an unkempt, thin woman who is restless and easily agitated. Her weight is 125 lb, and her height, 64”. Her vital signs include a blood pressure of 168/102 mm Hg; pulse, 118 beats/min; respiratory rate, 14 breaths/min-1; and temperature, 99.9°F. She has poor den-tition. There is no thyromegaly or jugular venous distention. Her respirations are shallow, and there are coarse rhonchi in both bases that change with coughing. The cardiac exam reveals a regular tachy-cardia with mechanical heart sounds and a grade II/VI systolic murmur. A well-healed median ster-notomy scar is present. The abdominal exam is remarkable for tenderness to palpation in the epigas-trium, with no evidence of rebound. There are no palpable masses. Bowel tones are present in all quadrants. The extremities are positive for 2+ pitting edema to the knees bilaterally. The neurologic exam is grossly intact. Following acute management of her pain, laboratory blood work, abdominal ultrasound and CT, chest x-ray, and ECG are ordered. The ECG is the last test to be obtained and reveals the following: a ventricular rate of 77 beats/min; PR interval, 142 ms; QRS duration, 104 ms; QT/QTc interval, 402/454 ms; P axis, 66°; R axis, 57°; and T axis, –11°. What is your interpretation of this ECG?
Unresponsive Woman Extricated From Car
ANSWER
The radiograph shows a right acetabular fracture that is mildly displaced. In addition, the right hip and femoral head are dislocated. Orthopedic consultation was made to reduce the hip and evaluate the fracture.
ANSWER
The radiograph shows a right acetabular fracture that is mildly displaced. In addition, the right hip and femoral head are dislocated. Orthopedic consultation was made to reduce the hip and evaluate the fracture.
ANSWER
The radiograph shows a right acetabular fracture that is mildly displaced. In addition, the right hip and femoral head are dislocated. Orthopedic consultation was made to reduce the hip and evaluate the fracture.
An unidentified female is brought in as a trauma code. She was apparently in a motor vehicle crash, the specific details of which are unclear. Emergency medical personnel describe extensive damage to her vehicle, which resulted in a pro-longed extrication time. Due to unresponsiveness at the scene, she was intubated in the field. The patient is probably in her late 30s to early 40s. She has two large-bore IV lines with normal saline infusing at a wide-open rate. Blood pressure is 90/60 mm Hg and heart rate, 140 beats/min. She has several superficial lacerations on her head, her pupils are fixed and dilated, and there is minimal withdrawal to pain in her extremities. No other trauma is im-mediately evident. Portable radiographs of her chest and pelvis are obtained prior to sending her for CT. Pelvis radiograph is shown. What is your impression?
After 15 Years, Still Losing Hair, Only Faster
ANSWER
This is a classic clinical picture of androgenetic alopecia (choice “a”). See discussion for more details.
Alopecia areata (choice “b”) usually manifests acutely and leads to complete hair loss in a well-defined, annular pattern. It typically resolves on its own, with or without treatment.
Telogen effluvium (choice “c”) involves generalized hair loss without a pattern. The hair is actually “lost,” meaning markedly increased amounts of hair are seen in the comb, brush, sink, or shower. This results in an increasingly visible scalp.
Without a clear clinical picture of alopecia, a biopsy might have been indicated—primarily to rule out conditions such as lupus erythematosus (choice “d”), which can involve hair loss of various kinds. The negative ANA result obtained by the patient’s primary care provider helped rule out this diagnosis.
DISCUSSION
Androgenetic alopecia (AGA) affects both men and women, though the latter begin to develop it about 10 years later, on average, than men do. Among women, 13% develop AGA before menopause, while 75% note its appearance postmenopausally.
In both sexes, AGA results from the gradual conversion of terminal hairs to vellus hairs, with miniaturization of the follicles. Hair loss in men starts in the vertex, followed by bitemporal recession. In women, AGA primarily affects the crown of the scalp, often with partial preservation of the frontal hairline.
Dihydrotestosterone (DHT) appears to be the main culprit; testosterone is converted to DHT by means of the enzyme 5α-reductase. One of the most effective medications for AGA in men has been finasteride, which blocks the effects of 5α-reductase and can at least slow the rate of hair loss. Unfortunately, finasteride does not appear to be effective in treating AGA in women.
Women do, however, appear to respond to minoxidil, a topically applied solution, better than men. The response is moderate at best, and any hair gained is lost if the treatment is discontinued. Interestingly, the stronger 5% solution of minoxidil in women does not produce any demonstrable improvement over that seen with the 2% solution.
From a practical diagnostic standpoint, it is quite common for women with longstanding mild to moderate AGA to present with an acute episode of telogen effluvium (TE), in which hair all over the scalp falls out. Careful history taking is necessary to tease these stories apart, since TE will typically resolve on its own. The most common causes of TE, in my experience, are stress, extreme weight loss, and as a consequence of general anesthesia. For unknown reasons, TE is almost nonexistent in men.
TREATMENT
This patient chose to use 5% OTC minoxidil, an antihypertensive with an unknown mode of action in AGA. She’ll confine its application to the affected areas of the scalp, since unwanted hair growth has been reported on the face with the use of this medication.
ANSWER
This is a classic clinical picture of androgenetic alopecia (choice “a”). See discussion for more details.
Alopecia areata (choice “b”) usually manifests acutely and leads to complete hair loss in a well-defined, annular pattern. It typically resolves on its own, with or without treatment.
Telogen effluvium (choice “c”) involves generalized hair loss without a pattern. The hair is actually “lost,” meaning markedly increased amounts of hair are seen in the comb, brush, sink, or shower. This results in an increasingly visible scalp.
Without a clear clinical picture of alopecia, a biopsy might have been indicated—primarily to rule out conditions such as lupus erythematosus (choice “d”), which can involve hair loss of various kinds. The negative ANA result obtained by the patient’s primary care provider helped rule out this diagnosis.
DISCUSSION
Androgenetic alopecia (AGA) affects both men and women, though the latter begin to develop it about 10 years later, on average, than men do. Among women, 13% develop AGA before menopause, while 75% note its appearance postmenopausally.
In both sexes, AGA results from the gradual conversion of terminal hairs to vellus hairs, with miniaturization of the follicles. Hair loss in men starts in the vertex, followed by bitemporal recession. In women, AGA primarily affects the crown of the scalp, often with partial preservation of the frontal hairline.
Dihydrotestosterone (DHT) appears to be the main culprit; testosterone is converted to DHT by means of the enzyme 5α-reductase. One of the most effective medications for AGA in men has been finasteride, which blocks the effects of 5α-reductase and can at least slow the rate of hair loss. Unfortunately, finasteride does not appear to be effective in treating AGA in women.
Women do, however, appear to respond to minoxidil, a topically applied solution, better than men. The response is moderate at best, and any hair gained is lost if the treatment is discontinued. Interestingly, the stronger 5% solution of minoxidil in women does not produce any demonstrable improvement over that seen with the 2% solution.
From a practical diagnostic standpoint, it is quite common for women with longstanding mild to moderate AGA to present with an acute episode of telogen effluvium (TE), in which hair all over the scalp falls out. Careful history taking is necessary to tease these stories apart, since TE will typically resolve on its own. The most common causes of TE, in my experience, are stress, extreme weight loss, and as a consequence of general anesthesia. For unknown reasons, TE is almost nonexistent in men.
TREATMENT
This patient chose to use 5% OTC minoxidil, an antihypertensive with an unknown mode of action in AGA. She’ll confine its application to the affected areas of the scalp, since unwanted hair growth has been reported on the face with the use of this medication.
ANSWER
This is a classic clinical picture of androgenetic alopecia (choice “a”). See discussion for more details.
Alopecia areata (choice “b”) usually manifests acutely and leads to complete hair loss in a well-defined, annular pattern. It typically resolves on its own, with or without treatment.
Telogen effluvium (choice “c”) involves generalized hair loss without a pattern. The hair is actually “lost,” meaning markedly increased amounts of hair are seen in the comb, brush, sink, or shower. This results in an increasingly visible scalp.
Without a clear clinical picture of alopecia, a biopsy might have been indicated—primarily to rule out conditions such as lupus erythematosus (choice “d”), which can involve hair loss of various kinds. The negative ANA result obtained by the patient’s primary care provider helped rule out this diagnosis.
DISCUSSION
Androgenetic alopecia (AGA) affects both men and women, though the latter begin to develop it about 10 years later, on average, than men do. Among women, 13% develop AGA before menopause, while 75% note its appearance postmenopausally.
In both sexes, AGA results from the gradual conversion of terminal hairs to vellus hairs, with miniaturization of the follicles. Hair loss in men starts in the vertex, followed by bitemporal recession. In women, AGA primarily affects the crown of the scalp, often with partial preservation of the frontal hairline.
Dihydrotestosterone (DHT) appears to be the main culprit; testosterone is converted to DHT by means of the enzyme 5α-reductase. One of the most effective medications for AGA in men has been finasteride, which blocks the effects of 5α-reductase and can at least slow the rate of hair loss. Unfortunately, finasteride does not appear to be effective in treating AGA in women.
Women do, however, appear to respond to minoxidil, a topically applied solution, better than men. The response is moderate at best, and any hair gained is lost if the treatment is discontinued. Interestingly, the stronger 5% solution of minoxidil in women does not produce any demonstrable improvement over that seen with the 2% solution.
From a practical diagnostic standpoint, it is quite common for women with longstanding mild to moderate AGA to present with an acute episode of telogen effluvium (TE), in which hair all over the scalp falls out. Careful history taking is necessary to tease these stories apart, since TE will typically resolve on its own. The most common causes of TE, in my experience, are stress, extreme weight loss, and as a consequence of general anesthesia. For unknown reasons, TE is almost nonexistent in men.
TREATMENT
This patient chose to use 5% OTC minoxidil, an antihypertensive with an unknown mode of action in AGA. She’ll confine its application to the affected areas of the scalp, since unwanted hair growth has been reported on the face with the use of this medication.
A 43-year-old woman presents to dermatology with the extremely common complaint of hair loss. The problem is not new; she first noticed it 15 years ago. But the loss has now progressed to such an extent that the patient consulted her primary care provider. Blood tests were ordered, including complete blood count, antinuclear antibody (ANA), and thy-roid-stimulating hormone; all results were within normal limits. And so she decided to seek a specialist’s assessment. The patient is going through menopause—without the aid of medication—and claims to be otherwise healthy. She denies finding increased amounts of lost hair in her comb, brush, shower, or sink. She further denies any symptoms in her scalp. Her mother and one sister had similar problems with their scalp hair. Examination reveals extensive thinning of hair, which is almost totally confined to the crown of her scalp, with faint but obvious preservation of a thin band of the frontal hairline. There is no appreciable disruption of the skin surface in the scalp (eg, scaling, redness, edema, or scarring).
