title: Woman with a hand ulcer.
abstract: A 20-year-old woman presented to the emergency department for evaluation of a wound to left hand (Fig. 1). She admitted having a history of chronic severe headaches requiring daily use of analgesics. She first noted the ulcer approximately 10 months prior to presentation. Her examination was remarkable for a 10-cm by 8-cm ulceration to the dorsum of her left hand with exposed and necrotic metacarpals. Fibrous exudate was present in the wound-bed, and the ulcer was associated with a foul odor. She was afebrile on presentation with a peripheral white blood cell count of 6.4 x109/L, CRP 1.9 mg/dL, and ESR 15 mm/h.
authors.affiliation: Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA 23298-0522, USA. pstromberg@mcvh-vcu.edu
authors.forename: Paul E
authors.initials: PE
authors.lastname: Stromberg
authors.forename: Jennifer Y
authors.initials: JY
authors.lastname: Montgomery
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Evans
authors.forename: Brandon K
authors.initials: BK
authors.lastname: Wills
mesh_terms: D000671:Amputation, Surgical; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000506:poisoning*; D002908:Chronic Disease; D062787:Drug Overdose; D005260:Female; D006225:Hand / Q000473:pathology / Q000601:surgery; D006801:Humans; D007275:Injections, Intravenous; D009336:Necrosis / Q000139:chemically induced / Q000473:pathology; D010019:Osteomyelitis / Q000139:chemically induced / Q000473:pathology / Q000628:therapy; D010423:Pentazocine / Q000008:administration & dosage / Q000506:poisoning*; D012883:Skin Ulcer / Q000139:chemically induced* / Q000473:pathology / Q000628:therapy; D019966:Substance-Related Disorders; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D010423:Pentazocine