by M4, Medical Student
As a third-year medical student, my daily routine revolved around clinical duties, outside study with reference materials, and daily clinical image quizzes with VisualDx. The first two I certainly expected to improve my clinical acumen but I never anticipated the latter would intersect with patient care. The quizzes were simply meant to improve my pattern recognition skills, matching physical exam findings with specific disease processes.
That interpretation, however, was quickly dispelled during my surgery clerkship. On that clerkship, I had the opportunity to work one-on-one with my attending – the advantage of rotating at a branch campus. My attending gave me “first crack” at admitted patients and in clinic, testing my clinical skills and filling in my (admittedly large) blind spots.
No patient challenged me (and my attending) more than James*. This was his third admission to the hospital in the past few months or so. Our 24-year-old had a chronic wound on his leg that wouldn’t heal. Despite several rounds of IV antibiotics and debridement, his course continued to worsen. My attending, as always, let me see him first.
He told me how the wound had started: a few months ago, he had barely nicked his leg against a side-railing exiting the bus. One week later, a little wound appeared and it kept growing. The only item in his medical history was ulcerative colitis and it had been well controlled for the past few years on a biologic.
The 3-cm wound on his anterior leg seemed to have pretty clean margins; no pus was draining; and it didn’t have the horrible stench like so many previous diabetic ulcers. There was a little surrounding redness but nothing too impressive. This seemed nothing like the wounds I’d seen in wound clinic.
Something about his story seemed off. He didn’t have diabetes, and vascular disease seemed unlikely with his physical exam. If antibiotics and debridement hadn’t worked three times before, I suspected a fourth round wouldn’t fix the problem.
I decided to write down “the pertinents” to figure this out. 24-year-old male, history of UC with chronic leg wound with pathergy that had progressed despite several courses of IV antibiotics and debridement. The wound’s appearance reminded me of an image I had seen on a previous VisualDx quiz so I pulled out the application. I typed the most specific aspect of the wound I could think of: “pathergy”. The second result on the list popped out to me: pyoderma gangrenosum. Reading the description, I realized this may well be his diagnosis.
I told my attending about my hunch, and he was willing to pursue it. One dermatology consult and biopsy later, our answer was confirmed. Those daily quizzes diagnosed our patient, and with a course of steroids (and no more debridement!) his wound healed.
*Patient’s personal details have been changed for confidentiality.
Get a closer look at pyoderma gangrenosum from VisualDx.
Subscribe to VisualDx Today
Become a VisualDx subscriber today and gain access to clinical information and medical images of thousands of diagnoses. Your first 7 days are FREE.