A 39-year-old female. History of hypertension and diabetes | Figure 1

ReginaldoCastro

Internal Medicine

Case Summary

A 39-year-old female.

History of: hypertension and diabetes mellitus, active smoker and alcohol use disorder, on anxiolytics and antidepressants.

Presentation: linear ulcerated lesion on the volar aspect of the wrist.

Characteristics: The lesion shows a necrotic crust with surrounding erythema and delayed healing.

Infection: No signs of acute infection at presentation.

Context: The lesion developed in the context of significant psychosocial stress.

Clinical Question

When managing skin lesions associated with psychosocial distress, how should dermatology and psychiatry collaborate to optimize patient outcomes?

Update 1

Dermatology and psychiatry should act in an integrated way, simultaneously treating the skin lesion and the underlying psychosocial factors, with an empathic approach, investigation of possible self-injury, optimization of local wound care and management of mental disorders, in order to improve healing and prevent recurrences.

Diagnosis Added: Suicide Attempt

Review Summary

Aim of the Review

The aim of this Cochrane Review is to find out if psychosocial interventions aimed at reducing substance abuse in people with a serious mental illness improve patient outcomes compared to standard care. Researchers in the Cochrane collected and analysed all relevant studies that randomly allocated people with severe mental illness and substance misuse to a psychosocial treatment or standard care to answer this question and found 41 relevant studies.

Key Message

From these 41 studies we did not find any high‐quality evidence to support any one psychosocial intervention over standard care. However, the differences in study designs made comparisons between studies problematic.

Study Overview

“Dual” diagnosis is the term used to describe people who have a mental health problem and also have problems with drugs or alcohol. In some areas, over 50% of all those with a serious mental illness (these include schizophrenia, bipolar disorders, and major depression) will have problems with drugs or alcohol that have negative and damaging effects on the illness symptoms and the way their medication works.

Interventions Studied

People who have substance misuse problems can be treated via a variety of psychosocial interventions. These include:

Other interventions include provider-oriented long-term interventions unifying services to provide integrated treatment so patients do not have to negotiate separate mental health and substance abuse treatment programmes.

Main Results

The review found 41 relevant studies with a total of 4024 people. These studies looked at a variety of different psychosocial interventions and compared them to standard care. Main results showed there was:

  1. no real difference in terms of numbers lost to treatment (low‐quality evidence);
  2. no real difference in terms of death (low‐quality evidence);
  3. no real difference in alcohol or substance used (low‐quality evidence);
  4. no real difference in global functioning or general life satisfaction (low‐ to moderate‐quality evidence).

In addition, studies had high numbers of people leaving early, differences in outcomes measured, and differing ways in which psychosocial interventions were delivered. More large-scale, high-quality and better reported studies are required to address these shortcomings.

Update Date

The review authors searched for studies that had been published up to October 2018.

Case Example

58 year old newly diagnosed DM presented with lesions in the palms and soles of a months duration. There’s no pruritus but he complains of pain at the site of the lesions.

Presentation: itchy, raised and firm blister-like lesions, presenting on patients palms and fingers. Similar lesions on heels and soles of feet. Possible DDx?

Presentation: Lesion present for 3 weeks, had surrounding swelling and erythema, received antibiotics. Lesion persisted despite antibiotics. Thoughts?

Case Summary: A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. History of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

Case Summary: A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. Cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

Case Summary: A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Clinical Notes: Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family. Are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?