I'm a 4th yr. doing an away rotation SubI in medicine. I just have to put this out there to see if something so crazy has happen to others in IM. I'm taking care of a pt. with ESRD on HD and he came in with fever. So it looks like he has pneumonia, since everything else turned out neg. So he has these weird lesions on his legs, i guess they would be macules...it's hard to have to use all this derm wording since I can't show you a picture...but they look like scabbed over sores on his legs, not feet. Anyway, they don't bother him, they don't drain, they don't itch, they don't look infected. Well my attending today is like...I don't know what those are either. You might want to consult the dermatologists to find out what it is! Are you kidding me? I have never seriously heard of an INPATIENT derm consult before. I can see referring him when he leaves, but come on. I thought I would post it and continue my quest to 10+ posts. I'm a newbie!
I rotated through the derm service at Duke, and we did inpatient consults on a daily basis (usually more than one per day too!). Although what you're describing doesn't necessarily sound classic for it, I'd consider NFD (nephrogenic fibrosing dermopathy) in any renal patient with dermatologic findings. It's a condition that was first described only within the past 10 years or so, and as a result many attendings don't even know it exists. Patients generally develop stiffness/contractures though, which it doesn't sound like your patient has. Anyway, if you get derm involved they almost always end up getting a biopsy, which is nice when it gives a definitive answer. It's pretty difficult to speculate without a picture or a better description. http://www.emedicine.com/DERM/topic934.htm Let us know what happens though. I'm very intrigued!
Having just done a derm rotation, I can tell you that inpatient derm consults are common and can be very helpful. I feel like I know a lot more derm after that rotation but those guys/gals know a ton so just call the consult. You'll probably learn something interesting by talking to them if nothing else.
ditto. A derm rotation is a very valuable experience going into a medicine residency. I'd very highly recommend it.
check that out with your derm guy. I was recently studying for Step 2 and it was one of my questions. It was such a strange question, I remembered it. But it wasn't on the real thing!
Well guys, Thanks for the feedback. Who knew I would evoke such a quick response. I haven't done a derm rotation yet...I feel since I'm color-blind it's kinda pointless for me...(along with my lifelong dream of being a pathologist...blasted H&E stains). Well I looked at both of the ideas suggested. Given what I saw on my patient, it definitely looks more like the bullous dermatitis of dialysis given that he's been on HD for over 4 years. He also has HCV, so maybe it's porphyria cutanea tarda. At any rate, I at least have something interesting to bring up if he's still there when I get back from my interview on Monday. Ok, so they do have inpatient derm consults out there...I stand corrected...but Saturday morning derm consults?? I was thinking if you wanted a derm consult why didn't you bring this up the previous 3 days he was in the hospital, because it's not like there's a dermatologist on call on saturday mornin'. And if you happen to have one at the hospital you're at, THAT'S CRAZY!
in my experience, some of the most interesting medicine cases have been for dermatological reasons...I had an interesting vasculitis case with isolated derm findings...also a classic dermatitis herpetiformis in celiac sprue case...I always respect the derm guys...they are all smart enough to become the best internists...I can't honestly say derm is AS challenging, but they definitely use a great deal of their faculties to diagnose conditions...anyway let us know, and thanks for the info on bullous dermatitis of dialysis and NFD (apache and gun)
Well, in case anyone was really left wondering what happened with my patient. I got back today from interviewing yesterday and found out that my patient left AMA. He was supposed to go see the derm folks this am, but I don't think he made it. I'm gonna stick with bullous dermatitis 2ary to dialysis.
THere is a rather long DDx for skin lesions in HD patients. I think Habif is a good derm textbook it might help you, it has a lot of images.
porphyria cutanea tarda is usually on sun exposed areas especially the hands, I doubt it would be on the legs. calciphylaxis I think is typically painful, but I don't remember for sure. Did this patient have diabetes?
It's an accademic point, perhaps, but you're a medical student at an accademic institution (presumably). I think it's justified by that alone....just for curiosity sake. If nothing else, it will enhance your learning, the team's learning, the learning of the consulting resident..... Further, it could potentially affect management descisions. Is this a clue to the etiology of the patient's ESRD (i.e. does the patient have a chronic viral infection), to the patient's fever, to a med reaction, the list goes on to infinity? If derm thinks this can be managed outpt, the consultant will let you know. Go for it!
