Cracking the case

Abstract

The approach to clinical conundrums by an expert clinician is revealed through presentation of an actual patient's case in an approach typical of morning report. Similar to patient care, sequential pieces of information are provided to the clinician who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. A 43-year-old woman presented to an outside hospital with painful plaques and patches on her bilateral lower extremities. Two weeks prior to presentation, she had noticed a single red lesion on her left ankle. Over the next two weeks, the lesion enlarged to involve the lower half of her posterior calf and subsequently turned purple and became exquisitely tender. Similar but smaller purple, tender lesions simultaneously appeared, first over her right shin and then on her bilateral thighs and hips. She also reported fatigue as well as diffuse joint pains in her hands and wrists bilaterally for the past month. She denied any swelling of these joints or functional impairment. She denied fevers, weight loss, headache, sinus symptoms, difficulty breathing, or abdominal pain.Although we do not yet have a physical exam, the tempo, pattern of spread, and accompanying features allow some early hypotheses to be considered. Distal lower extremity lesions which darkened and spread could be erythema nodosum or erythema induratum. Malignancies rarely have such prominent skin manifestations, although leukemia cutis or an aggressive cutaneous T cell lymphoma might present with disseminated and darkened plaques, and Kaposi's sarcoma is characteristically purple and multifocal. Autoimmune disorders such as sarcoidosis, cutaneous lupus, and psoriasis may similarly present with widespread plaques. Most disseminated infections that start with patches evolve to pustules, ulcers, bullae, or other forms that reflect the invasive nature of the infection; syphilis warrants consideration for any widespread eruption of unknown etiology. Antecedent arthralgias with fatigue suggest an autoimmune condition, although infections such as hepatitis or parvovirus can do the same. Systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) would be favored initially on account of her demographics and the hand and wrist involvement, and each can be associated with vasculitis. The significant pain as described is not compatible with most of the aforementioned diagnoses. Its presence, coupled with potential autoimmune symptoms, suggests a vasculitis such as polyarteritis nodosa (which can have prominent diffuse skin involvement), Henoch Schonlein purpura (with its predilection for the lower extremities, including extension to the hips and buttocks), cryoglobulinemia, or SLE-or RA-associated vasculitis. Calciphylaxis is another ischemic vascular disorder that can cause diffuse dark painful lesions, but this only warrants consideration if advanced renal disease is present.A skin biopsy of her right hip was taken at the outside hospital. She was discharged on a two-wee...

Acceptability and feasibility of recruitment and data collection in a field study of hospital nurses’ handoffs using mobile devices

“…The questionnaire used for the study incorporated three previously published instruments [ 5 , 15 , 16 ]. There were two versions of the questionnaire tailored to outgoing versus incoming nurses.…”

“…There were two versions of the questionnaire tailored to outgoing versus incoming nurses. In both cases, participants were asked to provide (1) their judgment of each patient’s risk of deterioration on a 7-point scale (patient acuity rating) [ 16 ], (2) their experience of the interaction with an instrument that was used in a previous study of nursing handoff (seven items for outgoing, nine items for incoming) [ 5 ], and (3) their perceived cognitive load (the effort or burden on their working memory) during the interaction on a 9-point scale [ 15 ]. Participants rated the risk of deterioration for every patient they handed off; they also rated their experience of the interaction and their cognitive load for each interaction (set of handoffs).…”