6/29/09: Dimples aren’t always good

“Did Mr. “high risk” tell you it started out as a dimple 2-3 years ago??” my preceptor was reading over the note I had written for the patient encounter.

“Yes,” I say thinking it was a minor detail left out of the initial patient presentation.

“Well that pretty much confirms the diagnosis.”

I had verbally presented the case to my preceptor about 20 minutes earlier but had left out that little detail to highlight more of a description of the current lesion on his lower left leg. It was 4 cm by 3 cm, a non-healing, scaly wound that bled with scratching; and it was getting larger in the past 6 months. My provisional diagnosis was atypical psoriasis.

We looked at the lesion together and in consult away from the patient my preceptor provided the argument that we might be looking at squamous cell carcinoma (SCC). After reeling back from what would have been a missed diagnosis for me from a benign (though painful) condition to a pre-cancerous or cancerous lesion, I go and look up SCC again.

Not that it makes me feel any differently about possibly missing an possibly harmful lesion, Fitzpatrick (my guide and bible for the next 6 weeks) tells me I fell into a common trap: “SCCIS (squamous cell carcinoma in situ) may be mistaken for a patch of eczema or PSORIASIS and go undiagnosed for years, resulting in large lesions with annular or polycyclic borders.” From Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. This quote was about 2” above a picture of SCC that might as well have been taken of the gentleman who I had just seen.

In reading over my note in the chart, my preceptor commented that, “if you see a dimple that wasn’t there at birth, start looking for the cancer because it is there!” I vaguely recall this as being one of the 2 million and 52 “DON’T MISS” nuggets of information crammed down our throats in the past year, but this time it has stuck (and it didn’t require a lawsuit either).