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A Piece of My Mind
April 8, 1998

The Teaching Case

Author Affiliations

Edited by Roxanne K. Young, Associate Editor.

JAMA. 1998;279(14):1053. doi:10.1001/jama.279.14.1053

You may have heard about J.D. on morning rounds: "Multiple medical problems: diabetes with extensive peripheral vascular disease, chronic renal failure, status post renal transplant, diffuse necrosis of distal extremities; acutely presenting with poorly healing diabetic foot ulcer and cellulitis."

He was a challenge to care for, and his nephrologist—who had over many years become his de facto primary care physician—had given up on what to do about his vascular insufficiency and extremity necrosis, which had already cost J.D. one leg. Having recalled the patient describe an episode of frostbite some 30 years ago that maybe, just maybe, could have been Raynaud's and a sentinel sign of some rare but treatable rheumatologic process, he turned to his colleague—the medical student—to pursue this remote but intriguing diagnostic question. He then disappeared.