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History: A 8-month girl was brought to Dermatology OPD by her mother with a diffuse reddish macular lesion on the right side of her face present since birth. Lesion was smaller, lighter in colour & gradually increased in size. What’s the diagnosis?

Intro: Port wine stain (nevus flammeus) is a discoloration caused by a capillary malformation in the skin. Named after fortified red wine from Portugal.

Cause: Mutation in GNAQ gene on chromosome 9q21 & RASA1 gene. Associated with Sturge-Weber syndrome or Klippel–Trénaunay-Weber syndrome.

Types: Nevus flammeus nuchae, Midline nevus flammeus.

CF: Flat & pink asymptomatic macular patch usually seen at birth or may be acquired. Color may deepen to a dark red or purplish color in adults. Common sites are face, head, neck, abdomen, legs, or arms.

Dx: History based, skin biopsy, MRI Brain (R/O Sturge–Weber syndrome).

Rx:  Pulse Dye or Nd: YAG or KTP Laser, surgery excision, radiation, tattooing, rapamycin LA. If left untreated, these vascular lesions may deepen in color or may undergo hypertrophy & nodular thickening.

Clinical Rounds by ClinicHours

History: A 8 yr old boy came to the ED with accidental ingestion of an Endodontic file while having a dental procedure. Pt. was asymptomatic at the time of presentation with no SOB, abdominal complaints & vomiting. What’s the next step you will do in ED?

Answer: CXR -AP view & abdominal x-ray – Erect & supine was done on arrival after initial assessment. Pt. was hemodynamically stable. Pt was admitted to the surgery ward for observation. There were no signs of peritonitis or perforation. In this case, FB passed spontaneously with the stool on its own & no surgical intervention was required.

Foreign body ingestion is a common clinical problem. Commonly seen in children, older people, people with intellectual disability, psychiatric pathologies & prisoners/inmates.

Most ingested foreign bodies will pass through GI tract without symptoms & cause only minor mucosal injury. However, 10% – 20% of cases will require non-operative intervention, 1% may develop complications (e.g. bowel obstruction, perforation, severe hemorrhage, abscess formation, or septicemia) & require surgical interventions.

Look for dysphagia, abdominal pain, signs of peritonitis, stridor, wheezing, gagging, nausea/vomiting, neck/throat pain, atypical chest pain or non-cardiac chest pain, choking & LGIB.

Endoscopy is the first-line intervention for the removal of FB. However, Button battery ingestion can be potentially fatal and thus requires immediate intervention. Check out the management algorithm for sharp FB ingestion.

Clinical Rounds by Clinic Hours

History: A 56 yr old k/c/o CKD-5 on MHD thrice weekly with HTN presented to ED with SOB, drowsy, anasarca. He has missed his hemodialysis this week. BP-170/102 mmhg, P-84 bpm, Spo2 – 82% on RA (99% on NRBM 14/L O2), B\L crepts +nt. Serum K+ – 8.4 mmol/L. What’s the finding in ECG?

Answer: ECG shows sine wave appearance in severe hyperkalemia. Hyperkalaemia is defined as a serum potassium level of > 5.2 mmol/L. ECG changes generally do not manifest until there is a moderate degree of hyperkalaemia (≥ 6.0 mmol/L). The earliest manifestation of hyperkalaemia is an increase in T wave amplitude.

The patient was treated with 10% 10ml of IV calcium gluconate, nebulised with Salbutamol, 10 units of regular insulin IV combined with  dextrose 50%, IV sodium bicarbonate 50 mEq and Inj. Furosemide 40mg IV. Emergent haemodialysis was initiated. Pt was shifted to ICU.

Clinical Rounds by Clinic Hours

History: A 56 year old female presented to ED with 1 episode of GTC seizure. Neurological examination was normal except for postictal confusion. NCCT brain showed multiple calcified granuloma, some showing perilesional oedema in the frontal, parietal & occipital lobes. Routine CXR showed typical rice-grain-shaped calcification in the chest wall muscles. Xray thigh and forearm were ordered which showed similar lesions. What’s the diagnosis?

Clinical Rounds by ClinicHours