An 84-Year-Old With a Blistering Rash That Is Spreading

Tuyyab Hassan, MD

Disclosures

April 03, 2019

Physical Examination and Workup

Upon physical examination, the patient appears frail but in no distress. Her temperature is 98.4°F (36.89°C). Her heart has a regular rhythm, with a rate of 88 beats/min. Her blood pressure is 146/88 mm Hg, and her respiratory rate is timed at 16 breaths/min. She has clear, equal bilateral breath sounds. No heart murmurs are noted, but a loud S2 heart sound is heard. Her apical impulse is not displaced.

The patient's abdomen is soft and nontender, and no appreciable organomegaly is detected. She has a deep, fixed, 3-cm mass underlying the nipple of her right breast, with overlying skin puckering. She does not have any axillary lymphadenopathy. Her current breast examination is unchanged from her last documented examination.

Examination of the skin reveals several tense bullae, excoriated papules, and vesicles ranging in size from a few millimeters to 3 cm over her hand, right arm, anterior chest, and abdomen (Figures 1 and 2).

Figure 1.

Figure 2.

These bullae and vesicles rest on an erythematous base, and they contain clear fluid. No involvement of the mucous membranes is noted, and the Nikolsky sign (blistering of healthy-appearing skin when it is rubbed) is not elicited.

Laboratory tests demonstrate a normal erythrocyte sedimentation rate, antinuclear antibody titer, and C-reactive protein level. The patient has a hemoglobin level of 12.7 g/dL, with mild eosinophilia measured at 0.48 × 109 cells/L. Her blood urea nitrogen level is 28 mg/dL, and her creatinine level is 2.1 mg/dL. Her liver function test results are unremarkable.

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