Skin & Subcutaneous Tissue


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F1.jpg"}},{"insert":"\n\n"},{"insert":"\u0022It\u0027s good to be back\u0022, you think.\r\n\r\nAfter two weeks of vacation overseas, you are looking forward solving the everyday, yet tricky, medical riddles you encounter in the cardiology clinic.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F2.jpg"}},{"insert":"\n\n"},{"insert":"Your next patient is 46-year-old Mrs. Rodriguez, whom you are meeting for the first time.\r\n\r\nShe smiles and says \u0022hello\u0022, before presenting a referral letter from the rheumatology clinic. You open the letter and peruse its contents.\n"}]}


{"ops":[{"insert":"Mrs. Rodriguez initially presented to her general practitioner (GP) with worsening exertional dyspnea for several months. The GP noted numerous cutaneous stigmata suggestive of scleroderma and referred her to the rheumatology clinic, where she was diagnosed with systemic sclerosis.\r\n\r\nThe attending rheumatologist now requests that you evaluate her for cardiovascular complications.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F4.jpg"}},{"insert":"\n\n"},{"insert":"You proceed to take a history.\r\n\r\nMrs. Rodriguez\u0027s exertional dyspnea dates from around four months ago. This was mild at first, but slowly worsened over time. Currently, she is able to walk for around 100 meters before becoming breathless and developing a nonproductive cough.\n"}]}


{"ops":[{"insert":"There is no relationship between the dyspnea and any particular posture or environment. There is no history suggestive of orthopnea or paroxysmal nocturnal dyspnea.\r\n\r\nNo other cardiac or respiratory symptoms are present.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F6.jpg"}},{"insert":"\n\n"},{"insert":"Other than the recent diagnosis of systemic sclerosis, her medical history is unremarkable. Her surgical, gynecological and family histories are also unremarkable.\r\n\r\nMrs. Rodriguez has worked as an administrative assistant for the past two decades. She is unmarried and without children.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F7.jpg"}},{"insert":"\n\n"},{"insert":"You proceed to the physical examination.\r\n\r\nHer heart rate is 100 bpm, blood pressure is 124\/85 mmHg, respiratory rate is 25 per minute, and oxygen saturation is 95% on ambient air. Her jugular venous pressure is 4 cm.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F4.jpg"}},{"insert":"\n\n"},{"insert":"The general examination reveals multiple stigmata of systemic sclerosis. The skin of her face and arms is shiny, taut, and thickened. Multiple telangiectasia are seen on her face. There is swelling and reduced flexibility of both hands and wrists below the metacarpophalangeal joints.\r\n\r\nYou also note mild bilateral pitting edema.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M61_F9.jpg"}},{"insert":"\n\n"},{"insert":"The cardiorespiratory examination shows no chest deformities or scars. The trachea is undisplaced. \u00a0Chest expansion is normal and symmetric. A right parasternal heave is present. The second heart sound (S2) is loud and a fourth heart sound (S4) is present. The lungs are clear, with equal air entry.\n"}]}


{"ops":[{"insert":"What will you do next?\n"}]}
1. Elicit the abdominojugular reflux
2. Perform the pemberton test