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Worsening Symptoms in Woman with Cystic Fibrosis
ANSWER
The correct interpretation is sinus tachycardia with a short PR interval. This ECG illustrates a physiologic sinus rate response to hypercarbic respiratory failure secondary to an infectious exacerbation. A shortened PR interval occurs with an otherwise healthy conduction system in response to a rapid sinus tachycardia.
ANSWER
The correct interpretation is sinus tachycardia with a short PR interval. This ECG illustrates a physiologic sinus rate response to hypercarbic respiratory failure secondary to an infectious exacerbation. A shortened PR interval occurs with an otherwise healthy conduction system in response to a rapid sinus tachycardia.
ANSWER
The correct interpretation is sinus tachycardia with a short PR interval. This ECG illustrates a physiologic sinus rate response to hypercarbic respiratory failure secondary to an infectious exacerbation. A shortened PR interval occurs with an otherwise healthy conduction system in response to a rapid sinus tachycardia.
A 23-year-old woman with cystic fibrosis presents to the pulmonary medicine clinic for follow-up to a hospitalization one month ago for an infectious exacerbation of her condition. She has had four hospital admissions over the past year and is known to be chronically colonized with multidrug resistant Pseudomonas. Two days ago, she began feeling significantly more short of breath, with increasing home oxygen requirements (4 L at baseline, up to 10 L by nasal cannula), as well as increasing phlegm production and a fever of 100°F. She states she feels dehydrated, sleepy, and nauseous. In addition to cystic fibrosis, her medical history is remarkable for pancreatic insufficiency, diabetes, chronic sinus infections, and bronchiolitis obliterans syndrome. Family history is positive for hyperlipidemia and congestive heart failure. No other family members have a diagnosis of cystic fibrosis. Her medication list includes azithromycin, insulin glargine, insulin isophane, insulin lispro sliding scale, insulin regular, loratadine, omeprazole, pancrelipase, prednisone, simvastatin, sulfamethoxazole-trimethoprim, and a tobramycin inhaler. She is allergic to cephalosporin antibiotics. A quick review of systems reveals no other issues. Physical examination reveals a woman in extreme distress who is able to nod to questions and answer briefly but is unable to speak in full sentences. Her blood pressure is 136/82 mm Hg, with a mean arterial pressure of 99 mm Hg; pulse, 170 beats/min and thready; respiratory rate, 40 breaths/min-1; and temperature, 39.2°C. O2 saturation is 89% on 10 L of oxygen via facemask. The pulmonary exam reveals coarse bilateral crackles, worst at the bases, with associated intercostal and supraclavicular muscular retractions. The cardiac exam reveals no jugular venous distention. Her rate is rapid and regular with no murmurs, rubs, or gallops. The abdomen is soft and nontender, with normal bowel sounds. The extremities are warm, well perfused, and without edema. The neurologic exam is grossly normal without focal signs. A stat arterial blood gas reveals respiratory acidosis with a pH of 7.32 and a pCO2 of 83 mm Hg. A complete blood count reveals a white blood cell count of 34 x 109/L. You decide to admit her to the medical intensive care unit. You are concerned that her heart rate of 170 beats/min may be atrial flutter and obtain an ECG, which reveals the following: a ventricular rate of 177 beats/min; PR interval, 88 ms; QRS duration, 60 ms; QT/QTc interval, 238/408 ms; P axis, 67°; R axis, 76°; and T axis, 73°. What is your diagnosis?
What is the Next Step in Dealing With This Lesion?
DISCUSSION
Punch biopsy confirmed the clinical impression of lichen aureus. This is one of several types of pigmented purpuric dermatoses, all of which involve extravasation of red blood cells and marked localized deposition of hemosiderin.
Some researchers consider all other forms to represent variants of the most common type, Schamberg’s disease, which typically begins with symmetrical involvement of the lower portions of both legs, slowly ascending to mid-thigh or (less often) to the waistline, then just as slowly descending—resolving, in most cases, in months to years. The hallmark of most types of pigmented purpuras is an orange-brown, speckled macular cayenne pepper–like discoloration.
Lichen aureus, one of the least common types, usually appears on the legs of adolescents and young adults. It presents as a solitary copper-colored macule or patch that is nonblanchable on digital pressure, confirming the presence of extravasated red blood cells.
Biopsy shows a T-cell infiltrate centered in the walls of small blood vessels, with endothelial cell swelling, narrowing of vessel lumens, extravasation of red blood cells, and marked hemosiderin deposition in macrophages.
The cause of the pigmented purpuric dermatoses is unknown. However, the predominately lower-leg involvement and hemosiderin deposition strongly suggest a role for venous stasis, gravitational dependence, increased activity while upright, or all three.
In addition to lichen aureus and Schamberg’s disease, several other forms of pigmented purpura have been noted. These include:
• Purpura annularis telangiectodes (Majocchi’s disease): Small annular plaques with prominent telangiectasias start, as does Schamberg’s, on bilateral distal extremities and spread proximally. The lesions tend to become targetoid (displaying concentric light and dark rings). This type is more common in young women and can occur in areas other than the legs.
• Eczematid-like purpura of Doucas and Kapetanakis: This condition involves pruritic eczematous papulosquamous annular lesions with sparse petechiae and hemosiderin staining. Histologically, it is characterized by the presence of spongiosis (intercellular edema of the epidermis). It must be distinguished from cutaneous T-cell lymphoma, which it can resemble both clinically and histologically.
• Gougerot-Blum syndrome: This condition, also known as pigmented purpuric lichenoid dermatitis, starts with lichenoid papules that fuse into reddish-blue to purple plaques. It is notable among the various pigmented purpuras for the presence of underlying induration, caused by a brisk lymphocytic infiltrate
The differential in this case also includes leukocytoclastic vasculitis, which was successfully ruled out with the biopsy, as were drug rash and contact dermatitis.
TREATMENT
Unfortunately, no good treatment exists for lichen aureus; however, the condition usually fades on its own over time, typically leaving no blemish behind. As it happens, there are no systemic implications of any of the pigmented purpuras.
DISCUSSION
Punch biopsy confirmed the clinical impression of lichen aureus. This is one of several types of pigmented purpuric dermatoses, all of which involve extravasation of red blood cells and marked localized deposition of hemosiderin.
Some researchers consider all other forms to represent variants of the most common type, Schamberg’s disease, which typically begins with symmetrical involvement of the lower portions of both legs, slowly ascending to mid-thigh or (less often) to the waistline, then just as slowly descending—resolving, in most cases, in months to years. The hallmark of most types of pigmented purpuras is an orange-brown, speckled macular cayenne pepper–like discoloration.
Lichen aureus, one of the least common types, usually appears on the legs of adolescents and young adults. It presents as a solitary copper-colored macule or patch that is nonblanchable on digital pressure, confirming the presence of extravasated red blood cells.
Biopsy shows a T-cell infiltrate centered in the walls of small blood vessels, with endothelial cell swelling, narrowing of vessel lumens, extravasation of red blood cells, and marked hemosiderin deposition in macrophages.
The cause of the pigmented purpuric dermatoses is unknown. However, the predominately lower-leg involvement and hemosiderin deposition strongly suggest a role for venous stasis, gravitational dependence, increased activity while upright, or all three.
In addition to lichen aureus and Schamberg’s disease, several other forms of pigmented purpura have been noted. These include:
• Purpura annularis telangiectodes (Majocchi’s disease): Small annular plaques with prominent telangiectasias start, as does Schamberg’s, on bilateral distal extremities and spread proximally. The lesions tend to become targetoid (displaying concentric light and dark rings). This type is more common in young women and can occur in areas other than the legs.
• Eczematid-like purpura of Doucas and Kapetanakis: This condition involves pruritic eczematous papulosquamous annular lesions with sparse petechiae and hemosiderin staining. Histologically, it is characterized by the presence of spongiosis (intercellular edema of the epidermis). It must be distinguished from cutaneous T-cell lymphoma, which it can resemble both clinically and histologically.
• Gougerot-Blum syndrome: This condition, also known as pigmented purpuric lichenoid dermatitis, starts with lichenoid papules that fuse into reddish-blue to purple plaques. It is notable among the various pigmented purpuras for the presence of underlying induration, caused by a brisk lymphocytic infiltrate
The differential in this case also includes leukocytoclastic vasculitis, which was successfully ruled out with the biopsy, as were drug rash and contact dermatitis.
TREATMENT
Unfortunately, no good treatment exists for lichen aureus; however, the condition usually fades on its own over time, typically leaving no blemish behind. As it happens, there are no systemic implications of any of the pigmented purpuras.
DISCUSSION
Punch biopsy confirmed the clinical impression of lichen aureus. This is one of several types of pigmented purpuric dermatoses, all of which involve extravasation of red blood cells and marked localized deposition of hemosiderin.
Some researchers consider all other forms to represent variants of the most common type, Schamberg’s disease, which typically begins with symmetrical involvement of the lower portions of both legs, slowly ascending to mid-thigh or (less often) to the waistline, then just as slowly descending—resolving, in most cases, in months to years. The hallmark of most types of pigmented purpuras is an orange-brown, speckled macular cayenne pepper–like discoloration.
Lichen aureus, one of the least common types, usually appears on the legs of adolescents and young adults. It presents as a solitary copper-colored macule or patch that is nonblanchable on digital pressure, confirming the presence of extravasated red blood cells.
Biopsy shows a T-cell infiltrate centered in the walls of small blood vessels, with endothelial cell swelling, narrowing of vessel lumens, extravasation of red blood cells, and marked hemosiderin deposition in macrophages.
The cause of the pigmented purpuric dermatoses is unknown. However, the predominately lower-leg involvement and hemosiderin deposition strongly suggest a role for venous stasis, gravitational dependence, increased activity while upright, or all three.
In addition to lichen aureus and Schamberg’s disease, several other forms of pigmented purpura have been noted. These include:
• Purpura annularis telangiectodes (Majocchi’s disease): Small annular plaques with prominent telangiectasias start, as does Schamberg’s, on bilateral distal extremities and spread proximally. The lesions tend to become targetoid (displaying concentric light and dark rings). This type is more common in young women and can occur in areas other than the legs.
• Eczematid-like purpura of Doucas and Kapetanakis: This condition involves pruritic eczematous papulosquamous annular lesions with sparse petechiae and hemosiderin staining. Histologically, it is characterized by the presence of spongiosis (intercellular edema of the epidermis). It must be distinguished from cutaneous T-cell lymphoma, which it can resemble both clinically and histologically.
• Gougerot-Blum syndrome: This condition, also known as pigmented purpuric lichenoid dermatitis, starts with lichenoid papules that fuse into reddish-blue to purple plaques. It is notable among the various pigmented purpuras for the presence of underlying induration, caused by a brisk lymphocytic infiltrate
The differential in this case also includes leukocytoclastic vasculitis, which was successfully ruled out with the biopsy, as were drug rash and contact dermatitis.
TREATMENT
Unfortunately, no good treatment exists for lichen aureus; however, the condition usually fades on its own over time, typically leaving no blemish behind. As it happens, there are no systemic implications of any of the pigmented purpuras.
An 18-year-old man is referred to dermatology for evaluation of an asymptomatic lesion that has been present on his left inner thigh for several months. The lesion has persisted despite the use of a topical cream containing clotrimazole and betamethasone (applied twice daily for a week) and a subsequent 10-day course of oral terbinafine (250 mg/d). Neither treatment seems to have had any impact. There is no history of antecedent trauma. The patient and his family report that no other lesions have been noted and that the patient is quite healthy in other respects. However, there is a family history of melanoma, which has caused the parents more than a little concern. Examination reveals a 3-cm reddish brown polygonal macule with a darker center, located on the left inner thigh. The lesion is neither palpable nor blanchable with digital pressure. No such lesions are seen elsewhere on the patient’s body.
Elderly Man with Headaches and Weakness
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
A 71-year-old man presents with complaints of headaches and weakness that have been ongoing for almost a month. He denies any fever, nausea, or vomiting. He has noticed an occasional cough and denies any weight loss. The patient has an extensive history of coronary artery disease, hypertension, and hyperlipidemia. History is also significant for coronary artery bypass grafting. He denies any history of smoking. The man is afebrile, and the rest of his vital signs, including pulse oximetry, are within normal limits. Physical exam shows an elderly, ill-appearing man in no obvious distress. Breath sounds bilaterally are clear. You order a chest radiograph along with some bloodwork. The chest radiograph is shown. What is your impression?
Just a Case of The Flu?
ANSWER
This ECG reveals sinus tachycardia transitioning to a wide complex tachycardia. A fusion complex is present, suggesting this is ventricular tachycardia. T-wave abnormalities in the inferior leads are present and suggest inferior ischemia.
There are two items of note that one must be aware of in order to accurately interpret this ECG. Normally, the computer measurements of heart rate and intervals are correct and often more accurate than a clinician can manually measure. These are typically measured as an average of all beats taken during the 12-second analysis prior to printing. However, when the rate abruptly changes during the analysis of the heart rate and rhythm, these measurements become inaccurate.
In this ECG, the computer notes the rate to be 156 beats/min; however, careful analysis of the sinus tachycardia prior to onset of ventricular tachycardia shows the rate is 107 beats/min, and the ventricular tachycardia rate is 188 beats/min.
The second item of note is that the ECG instrument measures all leads simultaneously over a 12-second period and separates them into the appropriate leads for printing. Hence, the progression from leads I to aVR to V1 to V4 represents a continuous tracing, in a similar fashion to the rhythm strip in lead II at the bottom of the page. Knowing this can help determine the presence of fusion complexes, as well as atrioventricular dissociation between QRS complexes and P waves indicative of ventricular tachycardia.
This patient developed hemodynamically significant ventricular tachycardia during the 12-second interval required for a 12-lead ECG analysis, a rare occurrence. She was treated with DC cardioversion, which resulted in a return to normal sinus rhythm.
ANSWER
This ECG reveals sinus tachycardia transitioning to a wide complex tachycardia. A fusion complex is present, suggesting this is ventricular tachycardia. T-wave abnormalities in the inferior leads are present and suggest inferior ischemia.
There are two items of note that one must be aware of in order to accurately interpret this ECG. Normally, the computer measurements of heart rate and intervals are correct and often more accurate than a clinician can manually measure. These are typically measured as an average of all beats taken during the 12-second analysis prior to printing. However, when the rate abruptly changes during the analysis of the heart rate and rhythm, these measurements become inaccurate.
In this ECG, the computer notes the rate to be 156 beats/min; however, careful analysis of the sinus tachycardia prior to onset of ventricular tachycardia shows the rate is 107 beats/min, and the ventricular tachycardia rate is 188 beats/min.
The second item of note is that the ECG instrument measures all leads simultaneously over a 12-second period and separates them into the appropriate leads for printing. Hence, the progression from leads I to aVR to V1 to V4 represents a continuous tracing, in a similar fashion to the rhythm strip in lead II at the bottom of the page. Knowing this can help determine the presence of fusion complexes, as well as atrioventricular dissociation between QRS complexes and P waves indicative of ventricular tachycardia.
This patient developed hemodynamically significant ventricular tachycardia during the 12-second interval required for a 12-lead ECG analysis, a rare occurrence. She was treated with DC cardioversion, which resulted in a return to normal sinus rhythm.
ANSWER
This ECG reveals sinus tachycardia transitioning to a wide complex tachycardia. A fusion complex is present, suggesting this is ventricular tachycardia. T-wave abnormalities in the inferior leads are present and suggest inferior ischemia.
There are two items of note that one must be aware of in order to accurately interpret this ECG. Normally, the computer measurements of heart rate and intervals are correct and often more accurate than a clinician can manually measure. These are typically measured as an average of all beats taken during the 12-second analysis prior to printing. However, when the rate abruptly changes during the analysis of the heart rate and rhythm, these measurements become inaccurate.
In this ECG, the computer notes the rate to be 156 beats/min; however, careful analysis of the sinus tachycardia prior to onset of ventricular tachycardia shows the rate is 107 beats/min, and the ventricular tachycardia rate is 188 beats/min.
The second item of note is that the ECG instrument measures all leads simultaneously over a 12-second period and separates them into the appropriate leads for printing. Hence, the progression from leads I to aVR to V1 to V4 represents a continuous tracing, in a similar fashion to the rhythm strip in lead II at the bottom of the page. Knowing this can help determine the presence of fusion complexes, as well as atrioventricular dissociation between QRS complexes and P waves indicative of ventricular tachycardia.
This patient developed hemodynamically significant ventricular tachycardia during the 12-second interval required for a 12-lead ECG analysis, a rare occurrence. She was treated with DC cardioversion, which resulted in a return to normal sinus rhythm.
An 80-year-old woman presents to the emergency department (ED) with chest tightness and palpitations over the past three hours. She called her primary care provider to make an appointment, but was prompted to go directly to the ED. She was transported by her granddaughter, who remains with her. The patient tries to downplay her symptoms as “a case of the flu”; however, the granddaughter states that for the past two weeks, her grandmother has had increased shortness of breath, dyspnea on exertion, a six-pound weight gain, and bilateral lower extremity edema not previously present. The patient denies fevers, chills, productive cough, syncope, or near-syncope. Medical history is remarkable for a bioprosthetic aortic valve replacement (21-mm Carpentier-Edwards pericardial valve) in May 2008 for critical aortic stenosis, and paroxysmal atrial fibrillation requiring cardioversion on two separate occasions (the last, six months ago). Her most recent echocardiogram (one year ago) was remarkable for bioprosthetic aortic valve dysfunction with a peak gradient of 60 mm Hg across the valve, well preserved left ventricular systolic function without segmental contraction abnormalities, and mild diastolic dysfunction with a left ventricular ejection fraction estimated to be 55%. Associated findings included mild to moderate mitral regurgitation and left atrial enlargement. Her right heart and central venous pressures were normal. Medical history is also remarkable for a recent (four months ago) episode of shingles involving her left chest and flank. The patient is a retired librarian, is self-sufficient, and lives alone. Her granddaughter lives across the street from her and checks on her daily. The patient has never smoked and has an occasional glass of wine. Her current medications include furosemide, pravastatin, metoprolol XL, a multivitamin, and sublingual nitroglycerin as needed. Of note, she did not use the sublingual nitroglycerin prior to presenting to the ED, and upon inspection, the prescription is long past its expiration date. Physical examination reveals a blood pressure of 92/66 mm Hg; pulse, 100 beats/min; and respiratory rate, 18 breaths/min. The patient is afebrile. Pertinent physical findings include jugular venous distention to the level of the jaw, lungs that are clear to auscultation, a musical grade III/VI systolic murmur best heard at the apex with radiation to the carotid arteries bilaterally, a benign abdominal exam, and 3+ pitting edema to the level of the mid-thigh bilaterally. The neurologic exam is grossly intact. Suspecting another episode of paroxysmal atrial fibrillation, you order an ECG. The ECG technician arrives, connects the electrodes to the patient, and promptly calls for help as the patient’s chest tightness returns and she becomes lightheaded and dizzy. You arrive promptly and are handed the ECG, which shows: a ventricular rate of 156 beats/min; PR interval, 190 ms; QRS duration, 138 ms; QT/QTc, 362/583 ms; P axis, –5°; R axis, 114°; and T axis, 0°. What is your interpretation of this ECG?
Car Accident and a Language Barrier
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
You are asked to see a 41-year-old man complaining of right upper arm pain. He was brought in by EMS from a reported single-vehicle crash, in which he was one of approximately 15 people traveling in a van. The patient speaks little to no English, and details of the accident are sketchy. Best as can be ascertained, the vehicle either went out of control or was hit and ran off the road. There were known fatalities at the scene. Due to language barriers, history is limited. Physical exam shows a middle-aged Asian man who appears quite uncomfortable. He indicates he is hurting in his chest, back, and right arm. His vital signs are normal, and primary survey appears stable, with the patient having multiple abrasions on his face and whole body. Examination of his right arm shows multiple abrasions with some bruising and swelling, as well as a deformity just above the elbow. The patient is able to slowly move his wrist and fingers. Distal pulses and sensation appear intact. Radiograph of the right humerus is shown. What is your impression?
Exertional Dyspnea Forces Man to Leave Job and Gain Weight
ANSWER
The ECG reveals sinus rhythm with a marked sinus arrhythmia, biatrial enlargement, incomplete right bundle branch block, right ventricular hypertrophy, ST and T wave abnormalities in the anterolateral precordial leads, and a prolonged QT interval.
There is a P for every QRS and a QRS for every P, and each P wave is similar in its respective lead (sinus rhythm); however, the rate is irregular, hence the diagnosis of marked sinus arrhythmia. Biatrial enlargement is illustrated by the presence of notched P waves in leads I and V1 with peaked P waves in leads II, III, and aVF (right atrial enlargement) and a P wave ≥ 110 ms in lead I with a terminally negative P wave ≥ 1 mm2 in V1 (left atrial enlargement).
An incomplete right bundle branch block is illustrated by the presence of an RSR’ in lead V1 with a small R and a QRS duration which is borderline normal (< 100 ms). Right ventricular hypertrophy is demonstrated by the presence of a tall R wave in V1 (in this case, R’) that is ≥ S wave in V1, an inverted T wave in V1, borderline right-axis deviation (R axis, 90°), and right atrial enlargement.
ST and T wave changes in the lateral leads are suggestive of anterolateral ischemia; however, in this case they are indicative of repolarization changes from right ventricular enlargement and an incomplete right bundle branch block. Finally, QT prolongation is suggested by the presence of a QT interval > 400 ms in a man when corrected for rate.
The patient’s history, physical examination, and ECG are highly suspicious for right-sided heart failure with the presence of jugular venous distention, a murmur of tricuspid insufficiency, hepatic congestion, and peripheral edema, as well as ECG documentation of right atrial and ventricular enlargement (cor pulmonale). An echocardiogram subsequently confirmed the diagnosis and also revealed pulmonary hypertension, with pulmonary artery pressures of 70 mm Hg.
ANSWER
The ECG reveals sinus rhythm with a marked sinus arrhythmia, biatrial enlargement, incomplete right bundle branch block, right ventricular hypertrophy, ST and T wave abnormalities in the anterolateral precordial leads, and a prolonged QT interval.
There is a P for every QRS and a QRS for every P, and each P wave is similar in its respective lead (sinus rhythm); however, the rate is irregular, hence the diagnosis of marked sinus arrhythmia. Biatrial enlargement is illustrated by the presence of notched P waves in leads I and V1 with peaked P waves in leads II, III, and aVF (right atrial enlargement) and a P wave ≥ 110 ms in lead I with a terminally negative P wave ≥ 1 mm2 in V1 (left atrial enlargement).
An incomplete right bundle branch block is illustrated by the presence of an RSR’ in lead V1 with a small R and a QRS duration which is borderline normal (< 100 ms). Right ventricular hypertrophy is demonstrated by the presence of a tall R wave in V1 (in this case, R’) that is ≥ S wave in V1, an inverted T wave in V1, borderline right-axis deviation (R axis, 90°), and right atrial enlargement.
ST and T wave changes in the lateral leads are suggestive of anterolateral ischemia; however, in this case they are indicative of repolarization changes from right ventricular enlargement and an incomplete right bundle branch block. Finally, QT prolongation is suggested by the presence of a QT interval > 400 ms in a man when corrected for rate.
The patient’s history, physical examination, and ECG are highly suspicious for right-sided heart failure with the presence of jugular venous distention, a murmur of tricuspid insufficiency, hepatic congestion, and peripheral edema, as well as ECG documentation of right atrial and ventricular enlargement (cor pulmonale). An echocardiogram subsequently confirmed the diagnosis and also revealed pulmonary hypertension, with pulmonary artery pressures of 70 mm Hg.
ANSWER
The ECG reveals sinus rhythm with a marked sinus arrhythmia, biatrial enlargement, incomplete right bundle branch block, right ventricular hypertrophy, ST and T wave abnormalities in the anterolateral precordial leads, and a prolonged QT interval.
There is a P for every QRS and a QRS for every P, and each P wave is similar in its respective lead (sinus rhythm); however, the rate is irregular, hence the diagnosis of marked sinus arrhythmia. Biatrial enlargement is illustrated by the presence of notched P waves in leads I and V1 with peaked P waves in leads II, III, and aVF (right atrial enlargement) and a P wave ≥ 110 ms in lead I with a terminally negative P wave ≥ 1 mm2 in V1 (left atrial enlargement).
An incomplete right bundle branch block is illustrated by the presence of an RSR’ in lead V1 with a small R and a QRS duration which is borderline normal (< 100 ms). Right ventricular hypertrophy is demonstrated by the presence of a tall R wave in V1 (in this case, R’) that is ≥ S wave in V1, an inverted T wave in V1, borderline right-axis deviation (R axis, 90°), and right atrial enlargement.
ST and T wave changes in the lateral leads are suggestive of anterolateral ischemia; however, in this case they are indicative of repolarization changes from right ventricular enlargement and an incomplete right bundle branch block. Finally, QT prolongation is suggested by the presence of a QT interval > 400 ms in a man when corrected for rate.
The patient’s history, physical examination, and ECG are highly suspicious for right-sided heart failure with the presence of jugular venous distention, a murmur of tricuspid insufficiency, hepatic congestion, and peripheral edema, as well as ECG documentation of right atrial and ventricular enlargement (cor pulmonale). An echocardiogram subsequently confirmed the diagnosis and also revealed pulmonary hypertension, with pulmonary artery pressures of 70 mm Hg.
A 42-year-old man has a two-year history of exertional dyspnea. In the past six months, his condition has become significant enough to force him to leave his job as a general contractor. He presents today with dizziness while standing, but not while walking. He denies syncope or near-syncope, angina, or palpitations. He says he has gained weight over the past month, to the extent that his clothes no longer fit. He attributes this to not working or exercising, and he believes this may be the cause of his increased exertional dyspnea. Medical history is remarkable for pneumonia 10 years ago. Surgical history is remarkable for repair of a right femoral fracture sustained in an automobile accident at age 17. The patient has worked in construction and as a general contractor, but had to stop two months ago secondary to dyspnea and chronic fatigue. He is unmarried, is active in his church, does not smoke or drink, and denies recreational drug use. His father died at 66 of lung cancer related to smoking. His mother and three siblings are alive and in good health. He is not allergic to any known medications, and his current medications include ibuprofen as needed for muscular aches and pains and an aspirin a day “because my dad’s doctor recommended it.” The review of systems is remarkable for fatigue despite the fact that the patient has been getting plenty of sleep. His girlfriend says he has been snoring loudly for the past two weeks and has never snored in the past. The man also states that he has had vague abdominal discomfort, without change in his bowel or bladder habits, and has noticed swelling in his lower extremities. He is alarmed to find out he has gained 24 lb in the past month. The physical exam reveals an anxious, obese, white man with a weight of 298 lb. Vital signs include a blood pressure of 114/80 mm Hg; pulse, 94 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 90% on room air. He is afebrile. Pertinent physical findings include jugular venous distention to the angle of the jaw and lungs that are clear to auscultation with a few late expiratory wheezes. The cardiac exam reveals distant heart sounds with a grade III/VI holosystolic low-frequency murmur best heard at the left lower sternal border. The abdominal exam is remarkable for mild hepatomegaly, which is tender to deep palpation. The lower extremities demonstrate 2+ pitting edema to the level of the knees bilaterally. The neurologic exam is intact. Laboratory blood work, an echocardiogram, and an ECG are ordered. The ECG is performed first and reveals the following: a ventricular rate of 94 beats/min; PR interval, 186 ms; QRS duration, 98 ms; QT/QTc interval, 384/480 ms; P axis, 62°; R axis, 90°; and T axis, 48°. What is your interpretation of this ECG, and how does it correlate with the history and physical exam?
Soap and Water Will Not Clean Dirty Skin
ANSWER
The correct answer is terra firma-forme dermatosis (TFFD; choice “d”), also known as “Duncan’s dirty dermatosis.” This relatively common condition usually affects adolescents and is one of the very few causes of hyperpigmentation that can be removed specifically with alcohol.
Dirty skin (choice “a”) is certainly seen, especially in this age-group, but the dirt is easily removed with soap and water.
Acanthosis nigricans (choice “b”) is often mistaken for dirty skin, but it cannot be removed by any nondestructive modality. Moreover, the most common form of acanthosis nigricans presents with a velvety, faintly raised brownish discoloration that usually affects the circumferential neck, axillae, and often, other intertriginous areas.
Reticulated and confluent papillomatosis (choice “c”) is a rare condition seen on the chest, back, and occasionally the face. It involves a slightly papular reticular (a netlike effect) patch, often in a triangular shape. Alcohol has no effect on it.
DISCUSSION
TFFD is surprisingly common, once its existence is recognized. Its etiology is, as one might expect, unknown, but it has been described in the literature (see “Suggested Reading” for examples) and is also defined by predictable histologic features seen on biopsy.
Besides the obvious implications, TFFD is probably most important as an imitator of acanthosis nigricans, which is often seen in overweight adolescents on their way to becoming diabetic. Unlike TFFD, acanthosis nigricans (type III, the most common form) has a multitude of potentially serious implications, although it is most often benign. Besides its well-known potential connection with diabetes, acanthosis nigricans can be seen in a myriad of insulin-resistant states and a bewildering variety of endocrinopathies.
SUMMARY
Unnecessary treatments and/or workups can be avoided by being aware of the existence of this common condition, which is easily diagnosed (and treated!) by wiping with alcohol—effectively ruling out the other items in the differential.
SUGGESTED READING
Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol. 1987; 123(5):567-569.
Pavlovic MD, Dragos V, Potocnik M, Adamic M. Terra firma-forme dermatosis in a child. Acta Dermatovenerol Alp Panonica Adriat. 2008;17(1):41-42.
ANSWER
The correct answer is terra firma-forme dermatosis (TFFD; choice “d”), also known as “Duncan’s dirty dermatosis.” This relatively common condition usually affects adolescents and is one of the very few causes of hyperpigmentation that can be removed specifically with alcohol.
Dirty skin (choice “a”) is certainly seen, especially in this age-group, but the dirt is easily removed with soap and water.
Acanthosis nigricans (choice “b”) is often mistaken for dirty skin, but it cannot be removed by any nondestructive modality. Moreover, the most common form of acanthosis nigricans presents with a velvety, faintly raised brownish discoloration that usually affects the circumferential neck, axillae, and often, other intertriginous areas.
Reticulated and confluent papillomatosis (choice “c”) is a rare condition seen on the chest, back, and occasionally the face. It involves a slightly papular reticular (a netlike effect) patch, often in a triangular shape. Alcohol has no effect on it.
DISCUSSION
TFFD is surprisingly common, once its existence is recognized. Its etiology is, as one might expect, unknown, but it has been described in the literature (see “Suggested Reading” for examples) and is also defined by predictable histologic features seen on biopsy.
Besides the obvious implications, TFFD is probably most important as an imitator of acanthosis nigricans, which is often seen in overweight adolescents on their way to becoming diabetic. Unlike TFFD, acanthosis nigricans (type III, the most common form) has a multitude of potentially serious implications, although it is most often benign. Besides its well-known potential connection with diabetes, acanthosis nigricans can be seen in a myriad of insulin-resistant states and a bewildering variety of endocrinopathies.
SUMMARY
Unnecessary treatments and/or workups can be avoided by being aware of the existence of this common condition, which is easily diagnosed (and treated!) by wiping with alcohol—effectively ruling out the other items in the differential.
SUGGESTED READING
Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol. 1987; 123(5):567-569.
Pavlovic MD, Dragos V, Potocnik M, Adamic M. Terra firma-forme dermatosis in a child. Acta Dermatovenerol Alp Panonica Adriat. 2008;17(1):41-42.
ANSWER
The correct answer is terra firma-forme dermatosis (TFFD; choice “d”), also known as “Duncan’s dirty dermatosis.” This relatively common condition usually affects adolescents and is one of the very few causes of hyperpigmentation that can be removed specifically with alcohol.
Dirty skin (choice “a”) is certainly seen, especially in this age-group, but the dirt is easily removed with soap and water.
Acanthosis nigricans (choice “b”) is often mistaken for dirty skin, but it cannot be removed by any nondestructive modality. Moreover, the most common form of acanthosis nigricans presents with a velvety, faintly raised brownish discoloration that usually affects the circumferential neck, axillae, and often, other intertriginous areas.
Reticulated and confluent papillomatosis (choice “c”) is a rare condition seen on the chest, back, and occasionally the face. It involves a slightly papular reticular (a netlike effect) patch, often in a triangular shape. Alcohol has no effect on it.
DISCUSSION
TFFD is surprisingly common, once its existence is recognized. Its etiology is, as one might expect, unknown, but it has been described in the literature (see “Suggested Reading” for examples) and is also defined by predictable histologic features seen on biopsy.
Besides the obvious implications, TFFD is probably most important as an imitator of acanthosis nigricans, which is often seen in overweight adolescents on their way to becoming diabetic. Unlike TFFD, acanthosis nigricans (type III, the most common form) has a multitude of potentially serious implications, although it is most often benign. Besides its well-known potential connection with diabetes, acanthosis nigricans can be seen in a myriad of insulin-resistant states and a bewildering variety of endocrinopathies.
SUMMARY
Unnecessary treatments and/or workups can be avoided by being aware of the existence of this common condition, which is easily diagnosed (and treated!) by wiping with alcohol—effectively ruling out the other items in the differential.
SUGGESTED READING
Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol. 1987; 123(5):567-569.
Pavlovic MD, Dragos V, Potocnik M, Adamic M. Terra firma-forme dermatosis in a child. Acta Dermatovenerol Alp Panonica Adriat. 2008;17(1):41-42.
The mother of a 14-year-old girl brings the child into your clinic, essentially to gain support in her effort to convince the child to wash better. It seems that several times a year, areas of the girl’s arms and neck appear to be dirty, despite protestations of adequate washing by the patient, who will not let her mother (or anyone else, to date) scrub the areas. The patient denies having any symptoms in the affected areas and further denies applying any medication to them. She wears no jewelry that might have touched the areas. According to the mother and the patient, the latter is otherwise healthy. She almost never takes any medication, and she had normal blood work (including blood sugar) as part of a recent physical exam. There is no family history of serious health problems, such as diabetes or skin diseases. The child seldom exerts to the point of perspiration, although she does swim once or twice a week for exercise. You note that the child is moderately overweight and quite reluctant to allow anyone to see or touch the areas in question. But with considerable time and much persuasion, she allows you to examine and palpate her skin, which has a slight olive tone (type IV). The ill-defined, light brown macular discoloration stands out and indeed looks like dirt. However, it is confined to the patient’s anterior neck and lateral arms. Although there is no palpable component to the discoloration, it has a faintly reticular look to it in places. It spares all other locations, such as the axillae, posterior neck, and back. A brief scrub with soap and water fails to have any effect on the discoloration, but a few swipes with an alcohol swab completely restore the skin to its normal, light color, effectively removing the pigmented surface.
Woman with Chest Pain While in Mexico
Answer
This ECG demonstrates normal sinus rhythm with left-axis deviation and left ventricular hypertrophy with QRS widening and repolarization abnormality, with no evidence of ischemia. Left-axis deviation is defined by an R-wave axis of less than –30° and is determined by examining leads III, aVF, and II. If leads III, aVF, and II are all negative, left-axis deviation is present. In this example, leads III and aVF are negative, while lead II is isoelectric or slightly negative.
Left ventricular hypertrophy is defined by high voltages in the limb leads (R wave in lead I plus S wave in lead III ≥ 25 mm) or in the precordial leads (S wave in V1 plus R wave in V5 or V6 ≥ 35 mm). The QRS duration, measured from the first deflection of the QRS from baseline to its return to baseline, is normal if ≤ 100 ms (0.10 sec). In this example, the QRS is widened (130 ms) in the absence of a bundle branch block. The delayed depolarization of both ventricles in the presence of left ventricular hypertrophy results in delayed repolarization—hence the repolarization abnormality.
This patient underwent cardiac catheterization, which revealed extensive three-vessel coronary artery disease with 99% stenosis of the proximal left anterior descending coronary artery. This case illustrates that severe coronary artery disease can present without ECG evidence of ischemia, particularly in women and in patients with diabetes.
Answer
This ECG demonstrates normal sinus rhythm with left-axis deviation and left ventricular hypertrophy with QRS widening and repolarization abnormality, with no evidence of ischemia. Left-axis deviation is defined by an R-wave axis of less than –30° and is determined by examining leads III, aVF, and II. If leads III, aVF, and II are all negative, left-axis deviation is present. In this example, leads III and aVF are negative, while lead II is isoelectric or slightly negative.
Left ventricular hypertrophy is defined by high voltages in the limb leads (R wave in lead I plus S wave in lead III ≥ 25 mm) or in the precordial leads (S wave in V1 plus R wave in V5 or V6 ≥ 35 mm). The QRS duration, measured from the first deflection of the QRS from baseline to its return to baseline, is normal if ≤ 100 ms (0.10 sec). In this example, the QRS is widened (130 ms) in the absence of a bundle branch block. The delayed depolarization of both ventricles in the presence of left ventricular hypertrophy results in delayed repolarization—hence the repolarization abnormality.
This patient underwent cardiac catheterization, which revealed extensive three-vessel coronary artery disease with 99% stenosis of the proximal left anterior descending coronary artery. This case illustrates that severe coronary artery disease can present without ECG evidence of ischemia, particularly in women and in patients with diabetes.
Answer
This ECG demonstrates normal sinus rhythm with left-axis deviation and left ventricular hypertrophy with QRS widening and repolarization abnormality, with no evidence of ischemia. Left-axis deviation is defined by an R-wave axis of less than –30° and is determined by examining leads III, aVF, and II. If leads III, aVF, and II are all negative, left-axis deviation is present. In this example, leads III and aVF are negative, while lead II is isoelectric or slightly negative.
Left ventricular hypertrophy is defined by high voltages in the limb leads (R wave in lead I plus S wave in lead III ≥ 25 mm) or in the precordial leads (S wave in V1 plus R wave in V5 or V6 ≥ 35 mm). The QRS duration, measured from the first deflection of the QRS from baseline to its return to baseline, is normal if ≤ 100 ms (0.10 sec). In this example, the QRS is widened (130 ms) in the absence of a bundle branch block. The delayed depolarization of both ventricles in the presence of left ventricular hypertrophy results in delayed repolarization—hence the repolarization abnormality.
This patient underwent cardiac catheterization, which revealed extensive three-vessel coronary artery disease with 99% stenosis of the proximal left anterior descending coronary artery. This case illustrates that severe coronary artery disease can present without ECG evidence of ischemia, particularly in women and in patients with diabetes.
For two weeks, a Spanish-speaking woman, 60, has experienced substernal chest pain and shortness of breath. The pain began while she was visiting family in Mexico. She was seen by a local physician, who prescribed a medication that helped but did not relieve the pain completely. She exhausted her supply of this medication shortly after returning from vacation, and her chest pain worsened. The patient’s daughter transported her to your clinic, concerned that her mother may be having a heart attack. According to the daughter, who is interpreting, the pain is described as grade IV/X, intermittent, radiating to the back, and lasting for approximately 10 minutes before subsiding. It is exacerbated with activity, particularly climbing stairs, and resolves when the woman is at rest. She has been awakened by this pain on two occasions. The patient denies fever, chills, nausea, vomiting, dizziness, or syncope. Medical history is remarkable for hypertension, diabetes, and asthma. She has worked most of her life as a farm worker and as a cook. She does not use alcohol and has a 20–pack-year history of tobacco use. The patient’s medications include aspirin, metformin, pravastatin, telmisartan, verapamil, and a salmeterol inhaler. She is allergic to penicillin. Review of symptoms is remarkable for diarrhea that is resolving and headaches. Physical examination reveals a well-developed, obese woman who is comfortable, alert, and oriented. Her height is 5’3”; weight, 211 lb; blood pressure, 106/40 mm Hg; pulse, 80 beats/min; respiratory rate, 14 breaths/min; and temperature, 99.2°F. The cardiovascular exam reveals a normal rate and rhythm with no murmurs, rubs, or extra heart sounds. There are no carotid bruits or peripheral edema. The lungs are remarkable for scattered expiratory wheezes in both bases, with the right greater than the left. The abdomen is large but soft with good bowel tones in all quadrants. There are no palpable bruits or organomegaly. The neurologic exam shows no gross neural deficits. The serum glucose level is 148 mg/dL; hemoglobin, 10.6 g/dL; and troponin, 0.02 ng/mL. All other lab values are within normal limits. An ECG shows the following: a ventricular rate of 80 beats/min; PR interval, 168 ms; QRS duration, 130 ms; QT/QTc, 384/442 ms; P axis, 29°; R axis, –34°; and T axis, 96°. What is your interpretation of this ECG, and is there any evidence of ongoing ischemia?
Is This Man's Eczema Spreading?
Answer
The correct answer is neurodermatitis with associated “id” reaction (choice “c”). The patient probably did have eczema (choice “d”) on his legs, but it became secondarily infected, leading to the later appearance of the arm rash. There was nothing to suggest that this condition was fungal in nature (choice “a”), nor were there any signs of psoriasis (choice “b”).
Discussion Cutaneous reactions to bacterial, fungal, viral, and other antigens have long been recognized as diagnostic entities in dermatology and are usually termed “id” reactions (though an older term, autoeczematization, is also used). “Id” reactions are quite common, particularly in association with inciting conditions such as stasis dermatitis and neurodermatitis. The diagnosis is facilitated by the finding of two different rashes in distant locations that appear sequentially.
This case typifies one of the more common presentations: a bacterid reaction that stems from secondary bacterial infection of neurodermatitis, which is itself secondary to eczema, which, in this particular case, was a manifestation of atopic dermatitis. Recognition of the latter point is significant, since patients with atopic dermatitis are known to have dry, sensitive skin, a lowered threshold for pruritus, and increased numbers of Staphylococcus epidermidis that colonize and invade chronically excoriated skin. This is followed, within days to weeks, by the appearance of a papulovesicular rash at a distant site—often on the volar forearms.
The most common presentation of the bacterid phenomenon starts with stasis dermatitis (venous stasis disease), which becomes, in turn, pruritic and excoriated, then secondarily infected. Inflammatory tinea pedis can trigger a fungal id (“fungid”) reaction at distant sites, especially on the hands and fingers. Acute herpes simplex virus outbreaks are another known culprit, resulting in a more generalized, erythema multiforme–like eruption.
Whatever the trigger, the secondary “id” rash is, by definition, distant to the original, usually symmetrical in distribution, and most often composed of morphologically different lesions. In addition to the arms, it can also involve the neck, trunk, hands, and feet.
Treatment Treatment is twofold, as it must address both the precipitating infection (in this case, with cephalexin 500 mg qid for 10 days) and the underlying skin condition (in this case, with topical fluocinolone 0.05% ointment applied bid to the legs and daily use of emollients). In severe cases, we often prescribe a 10- to 14-day tapering course of prednisone as well. Direct treatment of the arm rash is not necessary, since it will clear with treatment of the triggering condition.
Answer
The correct answer is neurodermatitis with associated “id” reaction (choice “c”). The patient probably did have eczema (choice “d”) on his legs, but it became secondarily infected, leading to the later appearance of the arm rash. There was nothing to suggest that this condition was fungal in nature (choice “a”), nor were there any signs of psoriasis (choice “b”).
Discussion Cutaneous reactions to bacterial, fungal, viral, and other antigens have long been recognized as diagnostic entities in dermatology and are usually termed “id” reactions (though an older term, autoeczematization, is also used). “Id” reactions are quite common, particularly in association with inciting conditions such as stasis dermatitis and neurodermatitis. The diagnosis is facilitated by the finding of two different rashes in distant locations that appear sequentially.
This case typifies one of the more common presentations: a bacterid reaction that stems from secondary bacterial infection of neurodermatitis, which is itself secondary to eczema, which, in this particular case, was a manifestation of atopic dermatitis. Recognition of the latter point is significant, since patients with atopic dermatitis are known to have dry, sensitive skin, a lowered threshold for pruritus, and increased numbers of Staphylococcus epidermidis that colonize and invade chronically excoriated skin. This is followed, within days to weeks, by the appearance of a papulovesicular rash at a distant site—often on the volar forearms.
The most common presentation of the bacterid phenomenon starts with stasis dermatitis (venous stasis disease), which becomes, in turn, pruritic and excoriated, then secondarily infected. Inflammatory tinea pedis can trigger a fungal id (“fungid”) reaction at distant sites, especially on the hands and fingers. Acute herpes simplex virus outbreaks are another known culprit, resulting in a more generalized, erythema multiforme–like eruption.
Whatever the trigger, the secondary “id” rash is, by definition, distant to the original, usually symmetrical in distribution, and most often composed of morphologically different lesions. In addition to the arms, it can also involve the neck, trunk, hands, and feet.
Treatment Treatment is twofold, as it must address both the precipitating infection (in this case, with cephalexin 500 mg qid for 10 days) and the underlying skin condition (in this case, with topical fluocinolone 0.05% ointment applied bid to the legs and daily use of emollients). In severe cases, we often prescribe a 10- to 14-day tapering course of prednisone as well. Direct treatment of the arm rash is not necessary, since it will clear with treatment of the triggering condition.
Answer
The correct answer is neurodermatitis with associated “id” reaction (choice “c”). The patient probably did have eczema (choice “d”) on his legs, but it became secondarily infected, leading to the later appearance of the arm rash. There was nothing to suggest that this condition was fungal in nature (choice “a”), nor were there any signs of psoriasis (choice “b”).
Discussion Cutaneous reactions to bacterial, fungal, viral, and other antigens have long been recognized as diagnostic entities in dermatology and are usually termed “id” reactions (though an older term, autoeczematization, is also used). “Id” reactions are quite common, particularly in association with inciting conditions such as stasis dermatitis and neurodermatitis. The diagnosis is facilitated by the finding of two different rashes in distant locations that appear sequentially.
This case typifies one of the more common presentations: a bacterid reaction that stems from secondary bacterial infection of neurodermatitis, which is itself secondary to eczema, which, in this particular case, was a manifestation of atopic dermatitis. Recognition of the latter point is significant, since patients with atopic dermatitis are known to have dry, sensitive skin, a lowered threshold for pruritus, and increased numbers of Staphylococcus epidermidis that colonize and invade chronically excoriated skin. This is followed, within days to weeks, by the appearance of a papulovesicular rash at a distant site—often on the volar forearms.
The most common presentation of the bacterid phenomenon starts with stasis dermatitis (venous stasis disease), which becomes, in turn, pruritic and excoriated, then secondarily infected. Inflammatory tinea pedis can trigger a fungal id (“fungid”) reaction at distant sites, especially on the hands and fingers. Acute herpes simplex virus outbreaks are another known culprit, resulting in a more generalized, erythema multiforme–like eruption.
Whatever the trigger, the secondary “id” rash is, by definition, distant to the original, usually symmetrical in distribution, and most often composed of morphologically different lesions. In addition to the arms, it can also involve the neck, trunk, hands, and feet.
Treatment Treatment is twofold, as it must address both the precipitating infection (in this case, with cephalexin 500 mg qid for 10 days) and the underlying skin condition (in this case, with topical fluocinolone 0.05% ointment applied bid to the legs and daily use of emollients). In severe cases, we often prescribe a 10- to 14-day tapering course of prednisone as well. Direct treatment of the arm rash is not necessary, since it will clear with treatment of the triggering condition.
A 30-year-old man presents with a pruritic rash that first affected both legs and was followed two weeks later by the appearance of a different but equally pruritic rash on his volar forearms. These rashes have persisted despite the use of OTC topical steroid and antifungal creams, triple-antibiotic ointment, and frequent application of rubbing alcohol. Eczema has been a problem throughout the patient’s life, but since his 20s, it has mostly affected his lower legs. As a result, he has gotten into the habit of scratching, even fantasizing about being able to do so at home. Despite being remarkably atopic, with seasonal allergies and generally sensitive skin, he claims to be otherwise healthy. Examination of the patient’s legs shows heavily lichenified papulosquamous involvement of both legs. There are numerous focal areas of scabbing, redness, and edema, which sharply spare the skin under his socks, thin out, then disappear well below the knees. The patient is even observed scratching these areas as the history is taken, and readily admits doing so several times a day. A fairly dense, symmetrical papulovesicular rash is noted on both volar forearms, with only a few lesions remaining intact because of scratching. Elsewhere, his elbows, knees, scalp, and nail plates are free of significant changes.
Disoriented, Intoxicated, and Hurting All Over
Answer
The radiograph demonstrates a mildly displaced fracture of the right iliac wing. In addition, there is moderate diastasis of the pubic symphysis, with the right pubic symphysis being in superior position to the left. Also, a right sacral fracture is present.
The patient was admitted by the trauma service and initially evaluated by the orthopedic trauma team, who planned to take the patient to surgery for subsequent open reduction and internal fixation of these injuries.
Answer
The radiograph demonstrates a mildly displaced fracture of the right iliac wing. In addition, there is moderate diastasis of the pubic symphysis, with the right pubic symphysis being in superior position to the left. Also, a right sacral fracture is present.
The patient was admitted by the trauma service and initially evaluated by the orthopedic trauma team, who planned to take the patient to surgery for subsequent open reduction and internal fixation of these injuries.
Answer
The radiograph demonstrates a mildly displaced fracture of the right iliac wing. In addition, there is moderate diastasis of the pubic symphysis, with the right pubic symphysis being in superior position to the left. Also, a right sacral fracture is present.
The patient was admitted by the trauma service and initially evaluated by the orthopedic trauma team, who planned to take the patient to surgery for subsequent open reduction and internal fixation of these injuries.
A woman, approximately 30 years old, is airlifted to your facility after being “found in a ditch,” presumably as a result of a motor vehicle collision. Details are sketchy. Upon arrival at your facility, she is awake, crying, and complaining of “hurting all over.” She appears to be intoxicated. She is able to give you her name, but not much else in the way of history. Primary survey shows her vital signs to be: blood pressure, 105/75 mm Hg; heart rate, 102 beats/min; and respiratory rate, 20 breaths/min. She is afebrile. She has a superficial scalp laceration but no other obvious injuries. You obtain preliminary portable radiographs of the pelvis. What is your impression?
