Which of the following is the most appropriate underlying explanation for this patient's presentation?

A 9-year-old girl presents to the emergency department with a fever and a change in her behavior

She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection

She also was treated for a urinary tract infection 10 weeks ago

Her mother says that last night her daughter felt ill, and her condition has been worsening

Her daughter experienced a severe headache and had a stiff neck

This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine

The patient was born at 39 weeks and met all her developmental milestones

She is currently up to date on her vaccinations and did not have infections during early childhood

Her parents are divorced and her father has noted she does not seem to get sick when he takes care of her

Her temperature is 99.5°F (37.5°C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air

The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics


Which of the following is the most likely diagnosis?

A 55-year-old man presents to the emergency department with right knee pain

He woke last night with sudden-onset, sharp, 10/10 non-radiating pain in his right knee

He denies recent trauma and he has no known medical problems

He denies tobacco use and will often drink 6-8 beers or spirits on weekend nights

His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 140/90 mmHg, respirations are 16/min, and oxygen saturation is 97% on room air

Physical exam reveals an erythematous, edematous right knee

Passive extension of the knee is limited by pain

Synovial fluid aspiration is performed and sent for analysis, which reveals 20,000 leukocytes/mm^3, and no organisms visualized

Microscopic examination of synovial fluid is shown in Figure A


Which of the following is the most likely etiology of this patient’s symptoms?

A 44-year-old nurse presents to the emergency department with confusion

This has happened several times this past month with increasing frequency

Each time her symptoms improved with eating

She lives with her mother who has diabetes whose medications include metformin, insulin, lisinopril, amlodipine, and glyburide

Her temperature is 98.0°F (36.7°C), blood pressure is 132/81 mmHg, pulse is 85/min, respirations are 16/min, and oxygen saturation is 98% on room air

She is moving all her extremities but follows commands poorly

Laboratory studies are ordered as seen below

Leukocyte count: 7,500/mm^3 with normal differential

C-peptide level: 55 ng/mL (normal < 5 ng/mL)


Which of the following is the most likely diagnosis based on this patient’s ECG?

A 67-year-old man presents to the emergency department after fainting

He was outside tending to his lawn for several hours in the heat, when he stood up suddenly from pulling weeds and fainted

He denies any preceding symptoms and returned to baseline within 1 minute

The patient is not aware of any medical problems and just started seeing a primary care physician last week

He recently used a friend's prescription for ondansetron for nausea

His temperature is 99.3°F (37.4°C), blood pressure is 142/88 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air

Physical exam reveals intact cranial nerves, normal strength and sensation, and a stable gait


Which of the following is most strongly associated with this patient's condition?

A 1-year-old girl is brought to a neurologist due to increasing seizure frequency over the past 2 months

She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony

Her parents have noticed the patient occasionally stiffens and spreads her arms at home

She was born at 38-weeks gestational age without complications

Her medications consist of lamotrigine and valproic acid

Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min

Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back


Syndrome of inappropriate anti-diuretic hormone

A 55-year-old woman is brought to the emergency department by her husband with a 1 hour history of an unremitting headache

The headache started suddenly while she was eating dinner and she says it feels like the “worst headache of my life

” An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding

The patient undergoes surgical management of her condition

On hospital day 3, she is found to be disoriented to person, place, and time

Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission

Her temperature is 99.6°F (37.6°C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min

Physical examination shows poor skin turgor

Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L


Which of the following is the most likely underlying pathophysiology?

A 6-year-old boy presents to the emergency department after falling from his scooter

He has dull, aching pain along his left side where he hit the ground

He fell sideways off the scooter as he rounded a curve in the road

He has never had any serious injuries but that he always seems to bruise easily, especially after he started playing soccer this fall

His parents deny that he has an abnormal number of nosebleeds or bleeding from the gums

They have never seen blood in his stool or urine

His mother notes that her brother has had similar problems

His temperature is 98.6°F (37°C), blood pressure is 112/74 mmHg, pulse is 82/min, and respirations are 11/min

On physical exam, the patient has extensive bruising of the lateral left thigh and tenderness to palpation

Laboratory tests are performed and reveal the following:

Partial thromboplastin time (PTT): 56 seconds


Increased enterohepatic circulation of bilirubin

Obstruction of the extrahepatic biliary tree

Obstruction of the intrahepatic biliary tree

A 1-month-old girl presents to her pediatrician with her mother

The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence

The child had a runny nose and cough for a few days last week

The patient’s mother endorses decreased appetite during the aforementioned illness which has now returned to baseline

The patient’s family history is significant for an older brother with glucose-6-phosphate dehydrogenase (G6PD) deficiency and a maternal uncle with cirrhosis secondary to chronic hepatitis B

On physical exam, the patient has scleral icterus and dark urine staining her diaper

Laboratory testing reveals the following: Serum: Na+: 137 mEq/L Cl-: 102 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 12 mg/dL Glucose: 96 mg/dL Creatinine: 0.36 mg/dL Alkaline phosphatase: 146 U/L Aspartate aminotransferase (AST): 86 U/L Alanine aminotransferase (ALT): 76 U/L Total bilirubin: 4.6 mg/dL Direct bilirubin: 3.8 mg/dL


A 55-year-old male bodybuilder presents to the emergency department with weakness of his right arm

The patient states he has experienced these symptoms for a few weeks

however, today his hand felt so weak he dropped his cup of tea

The patient has a medical history of diabetes

He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25. The patient uses anabolic steroids

He has lost 17 pounds since he last came to the emergency department 1 month ago

His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air

Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm

The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam

Symptoms are not changed with changes in head and neck position


A 57-year-old immigrant from Nigeria presents to the emergency department for sudden, severe pain and swelling in her lower extremity

She was at a rehabilitation hospital when her symptoms started

The patient has a medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures

Her current medications include metformin, insulin, lisinopril, and valproic acid

The patient has IV drug and alcohol use disorder and has presented to the ED many times for intoxication

Her temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min

Physical exam reveals anasarca and asymmetric lower extremity swelling

Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started

The patient is then transferred to the general medicine floor for continued management


Which of the following is the most likely cause of this patient's symptoms?

Inflammation and infection of colonic outpouching

A 43-year-old man presents to the emergency department with bright red blood in his stool this morning

He noticed this yesterday as well, but it was much scanter

He was celebrating his birthday last night and admits having "too much to drink" and vomited profusely overnight

He currently feels well and is not nauseous

He has no other significant medical history and does not take any medications

His temperature is 99.2°F (37.3°C), blood pressure is 110/75 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air

Physical exam reveals a nontender abdomen with normal bowel sounds

Rectal exam reveals grossly bloody stool

Laboratory studies are ordered as shown below

Leukocyte count: 5,500/mm^3 with normal differential


A 14-year-old boy presents to his pediatrician with a 2-month history of intermittent arm and leg spasms

He says that the spasms usually occur after he wakes up as he is getting ready for school, and consist of disorganized jerking motions that stop after a few minutes

He has also noticed that they occur when he stays up late to cram last minute for exams

He has no medical history and takes no medications

He recently started experimenting with alcohol and marijuana that one of his friends has been stealing from their parents

His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min


A 37-year-old woman presents to the emergency department in cardiac arrest

She was found to have altered mental status at home, and during transport to the hospital, she became pulseless

Cardiopulmonary resuscitation is ongoing and 2 intravenous lines are placed

The patient is obese, and her only medication is an oral contraceptive pill

She recently underwent Achilles tendon repair

She otherwise is known to smoke cigarettes on occasion

Physical exam is notable for a critically ill patient with chest compressions ongoing

The monitor shows pulseless electrical activity

Her right lower extremity is in a post-operative splint

The patient regains her pulse after several rounds of CPR and epinephrine

A bedside echocardiograph is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle


Which of the following personality disorders is the most likely diagnosis?

A 23-year-old woman presents to the emergency room for a self-inflicted laceration of her distal volar forearm

The patient states she knew her boyfriend was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist

In the emergency department, the bleeding has stopped and the patient is currently medically stable

When interviewing the patient, she is teary and apologizes for her behavior

She is grateful to you for her care and regrets her actions

Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating

The patient states that she struggles with her romantic relationships though she deeply desires them

Her temperature is 98.6°F (37°C), blood pressure is 112/71 mmHg, pulse is 73/min, and respirations are 14/min

On physical exam, you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts

You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious


Which of the following describes this patient's most likely diagnosis?

A 39-year-old man presents to his doctor for a wellness checkup

He is concerned about a rash that does not seem to be improving

He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated

He has a family history of skin cancer, colon cancer, and ovarian cancer

The patient has a medical history of asthma and seasonal allergies

His temperature is 98.6°F (37.0°C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air

Physical exam reveals the finding in Figure A


A 19-year-old woman presents to her primary care physician with headaches, blurry vision, and tinnitus over the past month

She started treatment for a skin condition with a new oral medication 2 months prior

She has not noticed any changes in her complexion as of yet

Her temperature is 98.2°F (36.8°C), blood pressure 100/65 mmHg, pulse 87/min, and respiratory rate 14/min

She is oriented to person, place, and time

Neurological exam reveals papilledema upon examination of both eyes

Skin examination is notable for the findings in Figure A


This child is most likely to develop which of the following complications?

A 3-year-old boy presents with his parents to a pediatrician for a new patient visit

The child was recently adopted and little is known about his medical or family history

The child seems to be doing well, but the patient is much larger than any of the other 3-year-olds in his preschool class

He eats a varied diet at home and with limited juice and snack foods

His temperature is 98.6°F (37°C), blood pressure is 101/67 mmHg, pulse is 110/min, and respirations are 24/min

On physical exam, the patient is in the 73rd percentile for weight, 99th percentile for height, and 86th percentile for head circumference

He appears mildly developmentally delayed

He has a fair complexion and tall stature with a prominent sternum

The patient also has joint hypermobility and hyperelastic skin

He appears to have poor visual acuity and is referred to an ophthalmologist, who finds downward lens subluxation of the right eye


Which of the following is the most likely diagnosis in this patient?

An 84-year-old man presents to the physician with numbness and tingling in the right hand for the last 6 months

He reports these symptoms started intermittently in the middle finger after returning from a golfing trip but has progressed to being nearly constant

The thenar eminence, thumb, and other digits are spared

His medical problems include hypertension, hyperlipidemia, hypothyroidism, and chronic neck pain for which he takes amlodipine, hydrochlorothiazide, atorvastatin, levothyroxine, and duloxetine

Surgical history consists of posterior lumbar fusion and elective left total hip arthroplasty

He has a 90-pack-year smoking history and quit 10 years ago

The patient’s temperature is 99.6°F (37.6°C), blood pressure is 134/80 mmHg, pulse is 90/min, and respirations are 16/min

Physical exam reveals 4/5 strength in elbow extension and wrist flexion on the right

He has 5/5 strength in the remainder of the motor exam on the right upper extremity and on the left upper extremity

The triceps reflex is 1+ on the right compared to 2+ on the left

His neck pain, which radiates down his right arm, is reproduced with axial loading during neck extension with simultaneous rightward rotation and lateral bending


A 17-year-old boy presents to the emergency department after a car accident

He drove his car into a pole while speeding at night

He has no past medical history and takes no medications

The patient is unable to offer a history and repetitively asks the nurses what happened

He knows his name and address and is able to remember other information about himself

His temperature is 97.6°F (36.4°C), blood pressure is 122/74 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% of room air

Physical exam reveals a confused young man

Cranial nerves 2-12 are intact and the patient has normal strength and sensation

Throughout the exam, he continuously asks what happened to him


A 34-year-old nulliparous woman presents to the clinic with 2 weeks of copper-colored discharge from her right nipple

Her breast has not been tender, and she has not noticed any changes to the skin

She is otherwise healthy and does not take any medications

Her temperature is 36.5°C (97.7°F), blood pressure is 110/82 mmHg, pulse is 68/min, respirations are 12/min, and oxygen saturation is 99% on room air

Exam of the right breast reveals no mass on palpation

Bloody discharge is expressed from the right nipple


A 55-year-old woman is brought to the emergency department by her husband with a 1 hour history of an unremitting headache

The headache started suddenly while she was eating dinner and she says it feels like the “worst headache of my life

” An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding

The patient undergoes surgical management of her condition

On hospital day 3, she is found to be disoriented to person, place, and time

Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission

Her temperature is 99.6°F (37.6°C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min

Physical examination shows poor skin turgor

Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L


Arrhythmogenic right ventricular dysplasia

A 7-year-old adopted boy presents to the emergency department after fainting

He just switched from being home-schooled to public school and joined the basketball team

He has fainted several times during basketball practices

He did not sustain any injuries or have any prodromes prior to these episodes

He is usually unconscious for less than a minute

He is otherwise healthy and has met all developmental milestones

He does not currently take any medications

His temperature is 97.6°F (36.4°C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air

Physical exam reveals a well-appearing and playful boy

An echocardiogram is ordered and pending


A 48-year-old woman, gravida 3 para 3, presents to the clinic with a 5-month history of intermittent loss of urine

Her urinary leaking occurs throughout the day and night, and she often has to get up to use the bathroom while asleep

Exercising does not affect the loss of urine

She states that she often cannot make it to the bathroom in time once she senses a need to void

Her last menstrual period was 2 weeks ago

Her urinalysis is unremarkable, and her postvoid residual volume is 40 mL

On pelvic examination, there is no dribbling of urine when the patient coughs


A 26-year-old woman presents to the clinic with diarrhea, bloating, flatulence, and abdominal cramps

These symptoms have been going on for 2 months

She has lost 6 pounds (2.7 kg) over these 2 months

Her medical history is significant for mild intermittent asthma for which she uses an albuterol inhaler as needed

She is sexually active with 1 male partner

She recently returned from South India following a mission trip for 6 weeks

Her temperature is 98.6°F (37.0°C), blood pressure is 105/70 mmHg, pulse is 95/min, and respirations are 14/min

On examination, the patient’s skin is pale

Labs are obtained and show the following results:

A biopsy of the small bowel reveals blunting of villi and a mixed infiltration of lymphocytes, plasma cells, and eosinophils


Which of the following is the most likely underlying etiology for this patient’s chief concern?

A 33-year-old woman presents to the emergency department with muscle spasms

She has noticed "twitching" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon

She has felt more fatigued over the past month

She takes no medication other than whey protein supplements, a multivitamin, and fish oil

Her temperature is 98.5°F (36.9°C), blood pressure is 103/71 mmHg, pulse is 105/min, respirations are 11/min, and oxygen saturation is 100% on room air

Physical exam reveals a thin woman with thinning hair

She appears pale and her mucous membranes are dry

Her neurological and cardiac exams are unremarkable

Laboratory studies are ordered as seen below

Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 6,100/mm^3 with normal differential Platelet count: 187,500/mm^3 Serum: Na+: 130 mEq/L Cl-: 100 mEq/L K+: 2.3 mEq/L HCO3-: 28 mEq/L BUN: 40 mg/dL Glucose: 79 mg/dL Creatinine: 0.9 mg/dL Ca2+: 8.2 mg/dL Mg2+: 1.8 mg/dL Thyroid stimulating hormone (TSH): 4.0 mIU/L Free T4: 0.4 ng/dL (normal: 0.7-1.53 ng/dL) The patient is given 4 liters of lactated ringer solution and 40 mEq of potassium

Her repeat whole blood potassium 3 hours later is 2.4 mEq/L, and her repeat BUN is 20 mEq/L

Another 40 mEq of potassium is administered

Another repeat whole blood potassium is 2.5 mEq/L


Which of the following is most likely responsible for the patient’s symptoms?

A 69-year-old man presents to clinic due to shortness of breath, worsening pain in his right shoulder, and episodes of hemoptysis

He has a history of coronary artery disease and underwent an uncomplicated coronary angioplasty with stent placement 2 years ago

He routinely travels both domestically and internationally as a senior shipyard worker and has a 30-pack-year smoking history

He has not smoke or drank alcohol in over 7 years

His temperature is 99.5°F (37.7°C), blood pressure is 140/60 mmHg, pulse is 97/min, and respirations are 13/min

Physical exam is notable for right pupillary constriction as well as paresthesias in his right fourth and fifth digits

There is no pain with active shoulder rotation


A 39-year-old man presents to his doctor for a wellness checkup

He is concerned about a rash that does not seem to be improving

He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated

He has a family history of skin cancer, colon cancer, and ovarian cancer

The patient has a medical history of asthma and seasonal allergies

His temperature is 98.6°F (37.0°C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air

Physical exam reveals the finding in Figure A


Which of the following is the most likely etiology of this patient’s presentation?

A newborn boy is evaluated 30 minutes after birth

He was born at 39 weeks gestation to a 27-year-old primigravid mother via cesarean section for cervical insufficiency

The pregnancy was complicated by gestational diabetes and the amniotic fluid was clear

Upon delivery, the patient had strong respiratory effort and a strong cry

His Apgar scores at 1 and 5 minutes were 7 and 8, respectively

The patient now is exhibiting increased work of breathing and is progressively more tachypneic

His birth weight is 3,568 g (7 lb 14 oz)

His temperature is 99.0°F (37.2°C), blood pressure is 60/44 mmHg, pulse is 146/min, and respirations are 72/min

On physical exam, the patient is grunting with nasal flaring and subcostal retractions

Breath sounds are decreased at the bases bilaterally

His chest radiograph can be seen in Figure A


Which of the following conditions is most likely to occur in this patient based on his current history and ECG?

A 55-year-old man presents to the emergency department after fainting while moving furniture

He states that he has been working in a hot, humid attic all day and forgot his water bottle

He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute

He awoke at his neurologic baseline afterwards

The patient has a history of hypertension being managed by his primary care doctor

His temperature is 98.7°F (37.1°C), blood pressure is 149/82 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 99% on room air

He demonstrates an unremarkable cardiopulmonary exam

The patient walks with a steady gait and his neurologic exam is non-focal

The patient is given 2 liters of oral fluids and feels back to his baseline


A 2-day-old boy has an episode of vomiting in the hospital nursery

The vomitus was described as “bright green” without any traces of blood

The patient has urinated several times since he was born but has not passed any stool

He was born at 37 weeks of gestation to a 38-year-old G3P3 woman

The pregnancy was uncomplicated and the patient’s mother refused all prenatal testing

The patient’s 2 older siblings are both healthy

His temperature is 98.6°F (37°C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min

On physical exam, the patient has upslanting palpebral fissures, epicanthal folds, and a single transverse palmar crease

His abdomen is non-tender, firm, and distended

Digital rectal exam evacuates a small amount of stool and flatulence

A nasogastric tube is placed to decompress the stomach

The patient’s abdominal radiograph can be seen in Figure A


A 55-year-old man presents to the emergency department with worsening dyspnea over the past 48 hours

He recently had a cold that kept him home from work for the past week

He has a past medical history of diabetes, obesity, and hypertension

He had his Achilles tendon repaired 4 weeks ago and he has been less mobile

His temperature is 99.2°F (37.3°C), blood pressure is 150/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air

Physical exam is notable for dyspnea provoked by walking short distances

Jugular venous distension is noted on exam

The patient’s blood pressure is 130/70 mmHg during inspiration

A bedside echocardiogram demonstrates impaired diastolic filling with normal ventricular contractility


Which of the following is the most likely underlying diagnosis?

Acute inflammatory demyelinating polyneuropathy

A 65-year-old man presents to the emergency department with low back pain

The pain started 6 hours ago when he was gardening and carrying a heavy bag

The pain is rated as 10/10 in severity and radiates down the posterior aspect of the right thigh

His only medical problem is hypertension for which he takes amlodipine

The patient is a non-smoker, uses alcohol infrequently, and has never used illicit drugs

His temperature is 99.6°F (37.6°C), blood pressure is 140/70 mmHg, pulse is 90/min, and respirations are 20/min

Physical examination reveals 3/5 strength to hip extension, knee flexion and extension, and plantar flexion bilaterally

Sensation to pinprick is diminished over the posterolateral legs and lateral aspects of both feet

Ankle and knee reflexes are absent bilaterally

The patient’s underwear is wet and a bladder scan reveals 800 mL of urine


A 69-year-old man presents to his primary care physician for trouble sleeping

He recently retired from working the day shift at a cemetery

When the patient retired, his goal was to finally be able to go out with his wife

however, he finds that he is unable to stay awake past 6 pm in the evening

His wife is disappointed that they cannot do any activities in the evening together

The patient has tried drinking caffeine but finds that it does not help

The patient’s wife claims that the patient seems to sleep peacefully, and the patient states he feels rested when he awakes

The patient has a medical history of irritable bowel syndrome which is managed with fiber supplements

His temperature is 98.6°F (37°C), blood pressure is 125/83 mmHg, pulse is 87/min, and respirations are 11/min

The patient’s neurological exam is within normal limits


A 66-year-old woman presents to the emergency room after experiencing a tonic-clonic seizure

She has been having worsening headaches and intermittent nausea over the past 5 months

The headaches are constant and dull, and they typically worsen when she sneezes or laughs

Recently, she has become increasingly nauseous and has vomited twice in the past 10 days

Her medical history is significant for type 2 diabetes mellitus and hypertension for which she takes metformin and losartan

Her temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min

She is noted to have papilledema on fundoscopy, but physical exam is otherwise normal

Her CT scan findings are presented in Figure A


A 55-year-old man presents to the emergency department after feeling lightheaded then fainting while he was carrying boxes upstairs

The patient works on a farm and does not see a doctor often

He has a history of hypertension but does not take medications routinely

He has not had any chest pain, dyspnea, or weakness during this time frame and currently feels at his baseline

His temperature is 98.1°F (36.7°C), blood pressure is 152/93 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 98% on room air

Physical exam is unremarkable and the patient walks with a stable gait and no focal weakness

Laboratory studies are ordered as seen below

Leukocyte count: 6,500/mm^3 with normal differential


A 27-year-old man presents to the emergency department after he developed pain in his right leg after landing off a ski jump

The patient is otherwise healthy and does not take any medications

He states his pain is 10/10. He is requesting medications and is crying out in pain

His temperature is 98.7°F (37.1°C), blood pressure is 149/85 mmHg, pulse is 103/min, respirations are 15/min, and oxygen saturation is 99% on room air

Physical exam reveals swelling over his right leg and knee

The patient cries out in pain with passive motion of the foot at the ankle

A radiograph is performed as seen in Figure A


Which of the following is the most likely etiology of this patient’s condition?

A 4-day-old girl presents with her parents to the pediatrician for a routine visit

She was feeding well until this morning when she had several episodes of vomiting

The parents describe the vomitus as “bright green” and the patient has shown little interest in feeding since then

She was born at 36 weeks gestation to a 37-year-old G2P2 mother

The pregnancy was complicated by gestational diabetes, and all prenatal testing was unremarkable

The patient has not yet regained her birth weight and is in the 46th percentile for height and the 36th percentile for weight

The patient’s temperature is 99.2°F (37.3°C), blood pressure is 68/46 mmHg, pulse is 132/min, and respirations are 32/min

On physical exam, the patient is in mild distress

Her abdomen is distended and firm without guarding

The patient’s abdominal radiograph can be seen in Figure A and the patient’s upper gastrointestinal series can be seen in Figure B


A 72-year-old man presents to his primary care physician for a general checkup

He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house

The patient is otherwise healthy and takes no medications

His temperature is 98.0°F (36.7°C), blood pressure is 141/90 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 98% on room air

Physical exam is notable only for minor pallor but is otherwise unremarkable

Basic laboratory studies are ordered as seen below


A 37-year-old machinist presents to his primary care physician with eye problems

He has felt a mass in his eye that has persisted for the past month

The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery

His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air

Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid


Second degree atrioventricular block, Mobitz type II

A 24-year-old woman presents to clinic for a routine annual exam

She has generally been feeling well, but notes feeling intermittent palpitations over the past few months

Her past medical history is unremarkable and she is not currently taking any medications

She denies drinking alcohol, smoking cigarettes, or using recreational drugs

She attributes her palpitations to recently drinking more caffeine, but would like to obtain an electrocardiogram since her symptoms are worrisome and affecting her ability to concentrate on her career as a fitness instructor

Her temperature is 36.9°C (98.4°F), blood pressure is 116/76 mmHg, pulse is 55/min, respirations are 12/min, and oxygen saturation is 98% on room air

Her electrocardiogram is shown in Figure A


A 66-year-old man presents to the clinic for evaluation of a skin lesion on his hand

The lesion has grown rapidly over the previous 2 weeks

He endorses trauma to the area when he accidentally scraped his hand against a window and notes that there was some bleeding

His medical history is significant for chronic renal failure for which he received a renal transplant 5 years prior, as well as multiple surgeries for skin cancer

His current medications include aspirin, atorvastatin, prednisone, tacrolimus, and mycophenolate mofetil

His temperature is 98.6°F (37°C), blood pressure is 136/91 mmHg, pulse is 82/min, and respirations are 11/min

Physical exam is notable for a 2 x 2.5 cm nodular lesion of the dorsal hand as seen in Figure A


A 72-year-old man with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia presents to his primary care provider for concerns about his cognitive decline

His wife has noticed that he has a worsening ability to organize, plan, and exhibit impulse control over the last month

The patient states that he is able to complete his activities of daily living without assistance, but has some weakness of his left upper and lower extremities that began 3 months prior

He needs reminders from his wife about daily tasks to complete

He enjoys spending time with his spouse, playing cards with his friends, and taking daily walks around his neighborhood

His temperature is 98.2°F (36.8°C), blood pressure is 149/87 mmHg, pulse is 87/min, and respirations are 12/min

Physical exam reveals an elderly man who is oriented to person, place, and time

He has 4/5 left-sided weakness of the upper and lower extremities and associated pronator drift of the left upper extremity

A mini-mental status exam reveals he is able to remember 2 out of 3 words after 4 minutes

He is able to appropriately draw a clock

A magnetic resonance imaging study of the brain is shown in Figure A


A 59-year-old man presents to his primary care physician for fatigue

however, he recently has experienced weight loss, abdominal pain, and general fatigue

He has a medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for 1 week

His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate

His temperature is 99.5°F (37.5°C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air

A mild systolic murmur is heard in the left upper sternal region

The rest of the physical exam is within normal limits

Laboratory values are ordered as seen below

Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 66,500/mm^3 with normal differential Platelet count: 177,000/mm^3 Leukocyte alkaline phosphatase: elevated Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.3 mEq/L BUN: 20 mg/dL Glucose: 120 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.9 mEq/L AST: 12 U/L ALT: 10 U/L


A 35-year-old man presents to his primary care physician with pain along the bottom of his foot

The patient is a long-time runner but states that the pain has been getting worse recently

When running and at rest he has a burning and aching pain along the bottom of his foot that sometimes turns to numbness

Taking time off from training does not improve his symptoms

The patient has a medical history of surgical repair of his Achilles tendon, ACL, and medial meniscus

He is currently not taking any medications

The patient lives with his wife and they both practice a vegan lifestyle

His temperature is 98.6°F (37°C), blood pressure is 114/72 mmHg, pulse is 81/min, and respirations are 12/min

On physical exam, the patient states that he is currently not experiencing any pain in his foot but rather is experiencing numbness/tingling along the plantar surface of his foot

Strength is 5/5 and reflexes are 2+ in the lower extremities


A 50-year-old man presents to the emergency department with chest pain

He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion

He also endorses some shortness of breath

He also believes the pain is worse when leaning back and improved when leaning forward

His wife noticed he fainted after the pain started but regained consciousness shortly after

He has a medical history of diabetes and hypertension for which he is on metformin and losartan

His temperature is 99.2°F (37.3°C), blood pressure is 130/87 mmHg, pulse is 99/min, respirations are 22/min, and oxygen saturation is 100% on room air

A normal S1 and S2 are auscultated with clear breath sounds


A 5-year-old boy presents to his primary care physician for recurrent colds, fatigue, and fussiness

Over the past several weeks, the child has been more fatigued and his parents state that “he always seems to be sick

” They state that sometimes he complains about his bones hurting and they note that he is less playful

His temperature is 102°F (38.9°C), blood pressure is 92/60 mmHg, pulse is 115/min, respirations are 23/min, and oxygen saturation is 99% on room air

Physical exam is notable for diffuse non-tender lymphadenopathy

Abdominal exam reveals hepatosplenomegaly

Laboratory studies are ordered as seen below

Leukocyte count: 27,500/mm^3 with 35% lymphoblasts


A 71-year-old woman arrives to clinic with sudden vision loss

She was in her usual state of health until waking up this morning unable to see out of her right eye

She denies pain, but reports her right eye “feels funny

” The patient’s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis

Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate

Her temperature is 98°F (36.7°C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air

The patient's pupils are symmetric in size and equally reactive to light with accommodation

A fundoscopic exam of the right eye is shown in Figure A


A 72-year-old man presents to the clinic for his annual exam

For the past few months, he has pain in his chest with physical activity

The pain goes away after he takes a break

He reports no chest pain while he is resting, and the pain is not worsening

His past medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia

His medications include amlodipine, atorvastatin, and metformin

His temperature is 36.5°C (97.7°F), blood pressure is 132/80 mmHg, pulse is 74/min, respirations are 14/min, and oxygen saturation is 98% on room air

He has a regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, or gallops

His anterior, lateral, and posterior chest are non-tender to palpation

His electrocardiogram is shown in Figure A


A 76-year-old woman is brought to a primary care physician by her daughter who is concerned about her mother's growing inability to take care of herself

Initially, she attributed her mother's forgetfulness and word-finding difficulties to normal aging, but over the past few years, her mother's memory has worsened, her mood has grown more irritable, and her mother has been found wandering the neighborhood unsure of how to get home

Her medical history includes type 2 diabetes mellitus which is well-controlled with metformin

On exam, her temperature is 98.2°F (36.8°C), blood pressure is 115/82 mmHg, pulse is 73/min, respirations are 12/min, and oxygen saturation is 99% on room air

Cardiopulmonary exam reveals normal S1 and S2, no murmurs, and clear lungs bilaterally

She scores 16/30 on the Montreal Cognitive Assessment (MoCA) test


A 17-year-old girl presents to the emergency department with a headache

The patient has had headaches in the past but this is the worst headache of her life

Her symptoms started yesterday and have been getting progressively worse

The patient states that the pain is mostly on the left side of her head

There has been a recent outbreak of measles at the patient’s school and the patient’s mother has been trying to give her daughter medicine to prevent her from getting sick

Her mother fears that her daughter may have caught measles

Her temperature is 98.6°F (37°C), blood pressure is 123/74 mmHg, pulse is 85/min, and respirations are 13/min

On exam, the patient is an obese girl who is clutching her head with the light in the room turned off

Her neurological exam is within normal limits

Fundoscopic exam reveals mild bilateral papilledema

An MRI of the head is obtained and reveals cerebral edema

A lumbar puncture reveals an increased opening pressure with a normal glucose level


Which of the following is the most likely etiology of this patient's symptoms?

A 77-year-old man presents to the emergency department with a complaint of sudden onset weakness in his right upper extremity

At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking

When his wife noted this she brought him into the hospital

On arrival to the emergency department, the patient is not responding to verbal stimuli and only withdraws his left upper extremity and lower extremity to pain

His past medical history is notable for hypertension and atrial fibrillation treated with metoprolol, apixaban, and lisinopril

His temperature is 99.0°F (37.2°C), blood pressure is 170/100 mmHg, pulse is 95/min, and respirations are 16/min

The patient has a seizure and subsequently demonstrates agonal breathing

He no longer responds to painful stimuli

A fingerstick blood glucose is 122 mg/dL


A 27-year-old man presents to the emergency department with altered mental status

He has become gradually more confused over the past several days

His wife also notes he has had diarrhea, nausea and vomiting, and abdominal pain for the past week

The patient has a history of depression and multiple suicide attempts

He takes fluoxetine as well as over-the-counter pain medications for a recent muscle strain

He works in a large industrial compound that manufactures semiconductors

He exercises regularly and recently has started making his own beer at home

His temperature is 98.3°F (36.8°C), blood pressure is 107/75 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 99% on room air

Physical exam reveals a confused man with a garlic odor on his breath and the finding in Figure A

Cardiopulmonary exam reveals a rapid heart rate with no murmurs and clear breath sounds


Which of the following is the most likely diagnosis?

A 54-year-old man presents to the clinic with 4 weeks of persistently worsening back pain

The pain is localized to 1 spot in his lower back and is worse with physical activity

His medical history is pertinent for intravenous drug use

His temperature is 36.8°C (98.2°F), blood pressure is 118/90 mmHg, pulse is 92/min, respirations are 13/min, and oxygen saturation is 99% on room air

On physical exam, he has midline back tenderness to palpation at L2-L3. Laboratory workup reveals an erythrocyte sedimentation rate of 112 mm/h and C-reactive protein of 10 mg/dL


A 67-year-old man presents to the emergency room reporting sudden-onset abdominal and back pain that began 3 hours ago

He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite

He denies any diarrhea or hematochezia and says the pain is not affected by movement

He has a history of hypertension, hyperlipidemia, and depression

He currently takes amlodipine and atorvastatin and is compliant with his medications

He has a 45-pack-year smoking history, but he does not drink alcohol or use any illicit drugs

His temperature is 98.6°F (37°C), his blood pressure is 110/64 mmHg, pulse is 97/min, and respirations are 15/min

Physical exam is notable for diffuse abdominal tenderness without rigidity or guarding

During evaluation, the patient becomes diaphoretic and pale and reports that he feels fatigued

Repeat blood pressure is 87/50 and pulse is 127. Intravenous fluid boluses are administered


Which of the following is most likely to confirm the diagnosis?

Rectal swab for selective anaerobic culture

A 68-year-old woman presents to the emergency room with several days of frequent, nonbloody, watery stools

She recently completed a course of clindamycin 2 weeks ago for a tooth infection

Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin

She traveled recently and has no sick contacts

Her temperature is 37.0°C (98.6°F), blood pressure is 118/82 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air

On exam, her abdomen is soft, non-distended, and non-tender to palpation

however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding


A 21-year-old woman presents to her primary care physician due to a history of abdominal pain

She states that she has had recurrent bouts of mood swings, bloating, and abdominal pain that occur together approximately every 4 weeks

She states that when these symptoms occur, she gets into frequent arguments at work, is unable to concentrate, and sleeps longer than usual

Furthermore, she has episodes of extreme anxiety during these periods, leading her to take off time from work

She notes that these symptoms are causing distress in her interpersonal relationships as well

She has no past medical history and takes no medications

She experienced menarche at age 12 and has regular periods

Her temperature is 98.2°F (36.8°C), blood pressure is 100/70 mmHg, pulse is 75/min, and respirations are 12/min

Physical exam reveals a nontender abdomen

Pelvic exam reveals a closed cervix with no cervical motion or adnexal tenderness

Her cardiopulmonary and neurological exams are unremarkable


A 6-year-old boy is brought to the emergency department by his father for elbow pain

He was riding his bicycle when he fell onto his outstretched right hand

He immediately clutched his right elbow in pain and began crying

He has no medical problems and takes no medications

His temperature is 98.4°F (36.9°C), blood pressure is 108/64 mmHg, pulse is 100/min, and respirations are 20/min

On exam, the boy is holding his right wrist with his left hand and cries upon palpation of a region that is 2 cm proximal to his elbow

The radial head is palpated just distal to the lateral epicondyle

He is unable to make a pincer with his right thumb and index finger

When asked to hold a pen between his right thumb and index fingers, he drops it

The radial pulse is diminished on the right


A 67-year-old man presents with a recurrent episode of syncope

He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly

He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting

When he wakes up, he is mildly confused but typically returns to baseline within a minute

The patient has a past medical history of diabetes, dyslipidemia, and hypertension

His temperature is 98.5°F (36.9°C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air

The patient's neurological exam is unremarkable

However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint


Figure A is the lateral radiograph of a 44-year-old male who sustained a fall on his outstretched hand while rollerblading

The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling


What is the most likely cause of this presentation?

A 46-year-old woman presents to her primary care doctor to request a referral to ophthalmology

Her vision has been steadily declining over the past 2 years and she thinks she needs a prescription for glasses

She further complains that her lips and feet feel numb

Her medical history is notable for medullary thyroid cancer status post total thyroidectomy

She enjoys a diverse diet and takes levothyroxine

Her blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 12/min

Her pupils are equal, round, and reactive to light, but appear opacified

Extraocular movements are intact, albeit slow

Her visual acuity is decreased bilaterally

The remainder of her physical exam is unremarkable

Her basic metabolic panel is shown below: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.9 mEq/L HCO3-: 25 mEq/L BUN: 10 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Thyroid-stimulating hormone: 1.5 µU/mL Ca2+: 7.0 mEq/L Phosphorus: 6.5 mEq/L Albumin: 3.6 mg/dL The patient's ECG is shown in Figure A


Which of the following is the most likely disorder that this patient is suffering from?

A 27-year-old man presents to his primary care physician for exposure to toxic materials

The patient states that when he left for work this morning he was certain that he had closed the door to his pantry

Upon returning home, he saw that the door to his pantry was wide open

The patient is certain that his neighbors have been tampering with his food and potentially poisoned him

He further states that he knows they have been trying to break into his house and steal his things

He has tried multiple times to get them evicted from the building to no avail

It is for this reason that he is certain that they are trying to get their revenge upon him

His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min

The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms

The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies

He storms out of the office angrily, stating that he deserves the best in medical care


A 25-year-old man presents to his primary care physician with a chief complaint of "failing health

" He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather

He has begun taking an assortment of Peruvian herbs to little avail

Otherwise, he is not currently taking any medications

The patient lives alone and works in a health food store

He states that his symptoms have persisted for the past 8 months

When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity

On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble


A 55-year-old man presents to the emergency department with chest pain and shortness of breath

He has a medical history of hypertension, diabetes, and obesity

His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air

An ECG is performed and notable for ST elevation in leads II, III, and aVF

The patient is treated appropriately and transferred to the medical floor

On the 2nd day of his hospitalization, the patient has abdominal pain

His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL

A physical exam is notable for the finding in Figure A

He is requesting pain medication for his abdominal pain


Which of the following most appropriately describes the most likely diagnosis?

A 62-year-old man presents to the emergency department with skin lesions

He felt itchy recently, then noticed skin lesions that broke out prompting him to come to the emergency department

He recently went camping and hiking in the woods

The patient drinks 1-2 beers per day and smokes 1 pack of cigarettes per day

He is currently sexually active with multiple partners and does not use condoms

The patient was discharged 1 week ago for pneumonia which was treated with azithromycin

however, he feels that his symptoms may be returning

His temperature is 99.5°F (37.5°C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air

Physical exam reveals the findings in Figure A on the patient's arm

The skin lesions are thick and do not break when pressure is applied


A 45-year-old man presents to his primary care physician with a rash

He first noticed the rash 2 weeks prior and he endorses intermittent itchiness from the rash

His medical history is significant for chronic hepatitis C infection, hypertension, type 2 diabetes mellitus, and heart failure

The patient works as a butcher at a local meat processing shop and is sexually active with several partners

His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 155/95 mmHg, and respirations are 12/min

On physical exam, his skin has the finding shown in Figure A

Fine, lace-like white lines are also noted on the patient’s buccal mucosa


A 27-year-old woman presents to her primary care physician with new hair growth on her face and lower abdomen over the last month

She has started to develop pimples on her face and back over the last several months

Her last menstrual period was over 3 months ago and her periods have been irregular over the last year

The patient has a medical history of obesity and prediabetes with a hemoglobin A1c of 6.0% last year

Her temperature is 98.5°F (36.9°C), pulse is 80/min, blood pressure is 139/88 mmHg, and respirations are 13/min

Cardiopulmonary exam is unremarkable, and the patient’s abdomen appears slightly distended but exhibits no tenderness to palpation

The patient’s face has coarse stubble along the jawline and on the upper lip, and there is similar hair along the midline of her lower abdomen

A pelvic exam reveals mild clitoromegaly, a normal anteverted uterus, and a large left adnexal mass that is mildly tender

Her laboratory test results are shown below:

17-hydroxyprogesterone: 214 ng/dL (Normal: < 200 ng/dL)

Ultrasound findings are shown in Figure A


A 35-year-old man presents to the emergency department with altered mental status

He was found by his roommate to be disoriented this morning

He had complained of a right-sided headache for the past 5 days

He has a history of human immunodeficiency virus (HIV) infection being treated with bictegravir, emtricitabine, and tenofovir

His last CD4 cell count was 500/mm^3. He does not smoke tobacco and drinks alcohol socially

His temperature is 104.2°F (40.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min

Examination reveals 3/5 strength to right shoulder abduction and elbow flexion/extension and 4/5 strength to right hip flexion/extension

The remainder of the strength exam on the right and left sides is normal

Neck flexion does not elicit pain, and there are no tongue lacerations

During the exam, the patient’s eyes are seen to roll backward with repeated flexion/extension of his extremities and loss of urine


A 27-year-old woman presents for her first prenatal visit at an estimated gestational age of 16 weeks and 4 days by last menstrual period

She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving

She has had nausea and vomiting for about 2 months, tender and swollen breasts, and cravings for foods she typically does not eat

She took a pregnancy test about 10 weeks ago and was too nervous to read the result immediately

After 24 hours, she saw that it was positive

The patient has a past medical history of bulimia nervosa but has not been symptomatic in 2 years

She also had an appendectomy at age 15 for appendicitis

Her temperature is 98.5°F (36.9°C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min

The patient’s affect is normal and she is pleasant and excited about her pregnancy

A physical exam is notable for abdominal distension but is otherwise unremarkable

Ultrasound is shown in Figure A, and urine human chorionic gonadotropin is negative in the office


A 42-year-old man presents to the urgent care clinic with low back pain

He was working on a home improvement project the day prior to presentation when the pain started

" It is not positional and does not radiate

He denies fevers, chills, paresthesias, and bowel or bladder incontinence

He has a history of a distal radius fracture 2 years ago from falling off a ladder

He drinks 3 alcoholic beverages weekly and denies illicit drug use

The patient’s temperature is 98.4°F (36.9°C), blood pressure is 124/80 mmHg, pulse is 90/min, and respirations are 16/min

His body mass index (BMI) is 22.4 kg/m^2. There is tenderness to palpation of his paravertebral lumbar region bilaterally

Perineal and dermatomal sensation is symmetric and intact

Strength is 5/5 to knee flexion/extension and ankle dorsiflexion/plantarflexion

Patellar and Achilles reflexes are 2+ bilaterally

Raising either leg while the patient is in the supine position does not elicit any pain


A 57-year-old man presents to the emergency department with several days of malaise, weakness, and night sweats

Today, he experienced a headache with blurry vision, thus prompting his presentation

The patient has a history of diabetes and is followed closely by an endocrinologist

Otherwise, he has lost 10 pounds over the past month

His temperature is 100°F (37.8°C), blood pressure is 122/90 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 99% on room air

Physical exam is notable for a thin man but is otherwise unremarkable

His visual acuity is 20/100 in both eyes, though he says that he normally has 20/20 vision

His gait is mildly ataxic as well, but his neurological exam is otherwise nonfocal

Laboratory studies are ordered as seen below

Leukocyte count: 57,500/mm^3 with 35% blasts


A 65-year-old man presents to his primary care physician for stiffness in his arm

He has been having trouble combing his hair and reaching objects that are high on the shelf

The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension

His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide

The patient leads a sedentary life in which he tends to stay home and watch television

He does not engage in any physical or strenuous activity

His temperature is 98.6°F (37°C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min

On physical exam, the patient has decreased passive and active range of motion of his shoulder

The strength of the patient's upper extremity is 4/5 limited by pain


Which of the following is the most likely the diagnosis?

Obstruction of blood flow through the hepatic vein

Obstruction of the common bile duct by radio-opaque stones

A 23-year-old woman presents to the emergency department with severe abdominal pain

The pain has been dull and progressive, but became suddenly worse while she was exercising

Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated

She is sexually active and does not use condoms

She admits to drinking at least 5 standard alcoholic drinks a day

The patient also recently lost a large amount of weight for a fitness show she planned on entering

The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate

Her temperature is 99.5°F (37.5°C), blood pressure is 80/40 mmHg, pulse is 110/minute, and respirations are 15/minute with an oxygen saturation of 96% on room air

On physical exam, you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back

On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant

Intravenous fluids are started and labs are sent


Which of the following is the most likely cause of this patient's symptoms?

A 27-year-old woman presents to her primary care physician for an abnormal vaginal discharge

The patient has engaged in unprotected intercourse with 12 different partners

She has a medical history of asthma, IV drug abuse, and depression

She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex

The patient is given antibiotics and is advised on safe sex practices

The patient presents to the emergency department 3 days later with a complaint of a rash

She states that every time she has sex a rash has emerged on her skin

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air

A physical exam is notable for the finding in Figure A


Which of the following is the most likely cause of this patient’s symptoms?

A 16-year-old boy presents to an ophthalmologist with blurry vision

Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school

The patient is otherwise doing well in school and enjoys playing basketball

His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon

His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year

His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min

On physical exam, the patient is tall for his age and has long arms

He has 20 degrees of thoracic scoliosis, which is stable from previous exams

On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses


Which of the following is most strongly associated with this patient's condition?

A 1-year-old girl is brought to a neurologist due to increasing seizure frequency over the past 2 months

She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony

Her parents have noticed the patient occasionally stiffens and spreads her arms at home

She was born at 38-weeks gestational age without complications

Her medications consist of lamotrigine and valproic acid

Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min

Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back


A 60-year-old woman presents to the emergency department with back pain after gardening

Her pain is 7/10 in severity, non-radiating, and not relieved by rest

She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence

She has hypertension for which she takes hydrochlorothiazide and had a recent asthma flare requiring a prednisone taper

Her temperature is 98.6°F (37.0°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min

Physical exam reveals an uncomfortable middle-aged woman in no acute distress

There is no tenderness to palpation of the spinous processes

Flexion of the hip with the knee extended while the patient is supine does not elicit any pain, nor does forced dorsiflexion of the foot at terminal hip extension

She has 5/5 strength to hip flexion, extension, abduction, and adduction

and ankle dorsiflexion and plantarflexion bilaterally

Bilateral patellar and Achilles reflexes are 2+

Serum laboratory results are as follows: Hemoglobin: 12.0 g/dL Creatinine: 1.1 mg/dL Ca2+: 10.6 mg/dL


A 62-year-old man arrives at the emergency room complaining of chest pain and difficulty breathing

He reports that the dyspnea started 2 months ago after he had the flu

At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then

This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table

The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and rheumatoid arthritis

His medications include aspirin, lisinopril, metformin, and sulfasalazine

His temperature is 97°F (36.1°C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air

On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted

A chest radiograph is obtained and the result is shown in Figure A


Which of the following is the most likely explanation for this patient's presentation?

A 57-year-old woman presents to her primary care physician with weakness for the past 6 months with symptoms that have worsened recently

She feels fatigued, depressed, and has gained 10 pounds which she attributes to feeling too weak to go to the gym

She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment

The patient has a medical history of diabetes mellitus that is well-controlled with insulin and metformin

She has been admitted multiple times for hypoglycemia secondary to missing meals

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air

Physical exam is notable for 2/5 strength in the patient's upper and lower extremities, sparse fine hair on her body, and a rash on her face and arms

Laboratory values are ordered as seen below

Serum: Na+: 139 mEq/L K+: 3.3 mEq/L Cl-: 100 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 70 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L A muscle biopsy is obtained as seen in Figure A


A 24-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting

The symptoms began towards the end of running a marathon and persisted after finishing the race

The patient is otherwise healthy and has no other medical problems

His temperature is 98.0°F (36.7°C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air

Physical exam reveals a distended and tender abdomen

A radiograph is performed as seen in Figure A


Poor wound healing secondary to diabetes

A 69-year-old man presents to his primary care physician for a general checkup

The patient works as a farmer and gardens in his spare time

He has a medical history of poorly managed type 2 diabetes mellitus and irritable bowel syndrome

His current medications include lisinopril, metformin, insulin, fiber supplements, and a multivitamin

On physical exam, there is a calm, obese gentleman

Inspection of the patient's scalp reveals the finding shown in Figure A

The patient is sent home and instructed to keep a blood glucose journal

Three months later, the patient returns with his glucose journal

In addition, he complains of a cut on his scalp that is not seeming to heal

The patient's glucose journal reveals an average blood glucose of 175 mg/dL

His temperature is 98.8°F (37.1°C), blood pressure is 134/86 mmHg, pulse is 80/min, and respirations are 13/min

On inspection of the patient's scalp, the finding in Figure B is noted


A 57-year-old man is brought to a neurologist by his wife for abnormal behavior

He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house

One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker

The patient expresses frustration that he is no longer able to concentrate enough to enjoy his hobby of solving puzzles

His medical history is significant for gastroesophageal reflux disease for which he takes omeprazole

He has no family history of neurologic disease

His temperature is 98.6°F (37.0°C), blood pressure is 120/75 mmHg, pulse is 70/min, and respirations are 16/min

During the examination, the patient’s cell phone rings unexpectedly causing the patient to suddenly jerk his arms and legs

Further diagnostic investigation is performed which reveals an elevated 14-3-3 protein on cerebrospinal fluid analysis


Passage of gastric contents into esophagus

A 6-week-old girl presents with her parents to the pediatrician for blood-streaked diapers

The patient is breastfed every 2-3 hours and voids 10-12 times daily

The patient previously had several soft stools per day that ranged in color from mustard yellow to dark green

Over the past 2 days, the patient’s stools have become looser and streaked with blood

The patient has also regurgitated several of her feedings in the last few days

Neither the vomit nor bloody stools have seemed to bother the patient

The patient’s weight continues to trend along the 50th percentile

The patient’s temperature is 98.4°F (36.9°C), blood pressure is 66/51 mmHg, pulse is 127/min, and respirations are 26/min

On physical exam, the patient appears well nourished and is cooing

Physical exam reveals the finding seen in Figure A


A 68-year-old man presents for evaluation by a neurologist for an involuntary hand tremor that started approximately 3 months ago

The shaking improves when he reaches for objects but returns when he is not using his hand

His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min

His left hand exhibits a 4-6 Hz tremor when resting on his lap

The tremor extinguishes with voluntary movement

In addition, his left upper extremity has increased tone with passive range of motion


A newborn boy is assessed in the newborn nursery due to central cyanosis that does not respond to oxygen therapy

The patient was born to a G1P1 mother at 39 weeks gestation

The mother had diabetes that was managed with exercise and insulin during the pregnancy

The mother has never been vaccinated and did not follow routine prenatal care

The newborn's temperature is 99.5°F (37.5°C), blood pressure is 70/30 mmHg, pulse is 160/min, respirations are 27/min, and oxygen saturation is 80% on room air

The initial workup of the patient includes a chest radiograph seen in Figure A as well as lab values as seen below

Hemoglobin: 14 g/dL Hematocrit: 42% Leukocyte count: 6,500/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 101 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 12 mg/dL Glucose: 99 mg/dL Creatinine: 0.5 mg/dL Ca2+: 10.0 mg/dL AST: 12 U/L ALT: 10 U/L An electrocardiogram is obtained as seen in Figure B


Which of the following is the most likely underlying etiology of this patient's symptoms?

A 55-year-old man presents to the emergency department with nausea and vomiting for the past week

He decided to come in when his symptoms worsened

He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol

His wife recently returned from a cruise with symptoms of vomiting and diarrhea

The patient has a medical history of poorly managed diabetes, constipation, anxiety, dyslipidemia, and hypertension

His temperature is 99.5°F (37.5°C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 95% on room air

Physical exam reveals a systolic murmur heard loudest along the left upper sternal border

Abdominal exam reveals an obese, tympanitic and distended abdomen with a 3 cm scar in the right lower quadrant

Vascular exam reveals weak pulses in the lower extremities


A 52-year-old G3P3 woman presents to clinic with a 2-year history of urinary incontinence

She has had frequent, involuntary loss of urine over the last 2 years but presented today because of 10 days of dysuria

She has been treated for 2 urinary tract infections over the past 6 months

She does not endorse any loss of urine with coughing or laughter

She has no chronic medical illnesses and no surgical history

Her temperature is 99.5°F (37.5°C), blood pressure is 120/80 mmHg, pulse is 92/min, and respirations are 15/min

Her BMI is 30 kg/m^2. On pelvic examination, the vagina is dry and atrophic with a 2-cm tender, palpable anterior vaginal mass

The mass does not change with Valsava maneuver


Bleeding and infected vessel of Kiesselbach plexus

A 7-year-old boy is brought to the emergency department by his parents for worsening symptoms of previously diagnosed acute sinusitis

Initially, the pediatrician prescribed decongestants and sent the patient home

Since then, the patient has developed a nasal discharge with worsening pain

The patient has a medical history of asthma which is well-controlled with albuterol

His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 124/min, respirations are 17/min, and oxygen saturation is 98% on room air

The cardiopulmonary exam is within normal limits

Inspection of the patient's nose reveals a unilateral purulent discharge mixed with blood

The rest of the patient's exam is within normal limits


A 37-year-old machinist presents to his primary care physician with eye problems

He has felt a mass in his eye that has persisted for the past month

The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery

His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air

Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid


Which of the following is the most likely etiology of this patient's current symptoms?

A 55-year-old man with a history of polysubstance abuse is found down in his home acutely obtunded

Emergency medical services administered naloxone which immediately woke the patient up and improved his oxygen saturation from 40% to 90%

However, they noted subsequently that the patient demonstrated increased work of breathing and had crackles and wheezing on pulmonary exam

The patient arrives alert and oriented claiming he feels short of breath

He denies any chest pain or other symptoms aside from shortness of breath

He has a history of cocaine-induced cardiomyopathy and myocardial infarction from cocaine use 2 years ago

The patient has a 40 pack-year smoking history

His temperature is 96.0°F (35.6°C), blood pressure is 120/68 mmHg, pulse is 102/min, respirations are 26/min, and oxygen saturation is 88% on room air

Physical exam reveals increased work of breathing, pulmonary crackles, and wheezing

A chest radiograph is performed as seen in Figure A


Which of the following is the most likely diagnosis for the patient?

A 22-year-old man presented with complaints of painful lesions on his penis and swelling in the left groin that started 10 days ago

He denied fever, chills, night sweats, rashes, dysuria, discharge, testicular pain, or proctitis

His female partner had been diagnosed with chlamydia one year earlier but he has not undergone evaluation

Multiple small, nontender scabbed lesions are identified in the bilateral scrotal area and on the shaft of penis

The right inguinal lymph node was tender and swollen.


A 51-year-old white man presents to the clinic with a 2-year history of a painful, recurrent rash on his fingers

He initially noticed redness, irritation, and pustules around his nails that he thought were caused by an infection

However, the rash progressed to affect the nail bed, eventually destroying his nails

On examination, well-demarcated, scaly plaques with associated pustules and nail atrophy are present on the right second and third distal digits


Pityriasis lichenoides et varioliformis acuta

An 8-year-old male child is brought to the clinic for the third time in 4 months presenting with red-brown papules with an overlying mica-like scale on the ventral side of his arms and legs

His medical and family histories are otherwise unremarkable

His mother states that when the macules and papules go away, the skin where the lesions were previously located is typically lighter than before.


A 24-year-old white female graduate student presents with erythematous, papulopustular patches of skin in a muzzle-like distribution surrounding the mouth, chin, and glabellar region

The lesions are tender to palpation, associated with a stinging and burning sensation, and are aggravated by exfoliating facial washes

Two-year treatment history includes a variety of topical antibiotics, azelaic acid cream, retinoid agents, benzoyl peroxide preparations, topical corticosteroids, and oral tetracycline for cyclic recurrences of outbreaks

These treatment methods were previously successful with complete resolution of each outbreak; however, at present the lesions are persisting despite treatment.


A 20-year-old woman presents to the clinic with a circular hypopigmented lesion on her right cheek

The patient stated that she used to have a mole in the same location

Over time she noticed a white area around the mole that enlarged to the current size of the lesion

After a few months she noticed the mole in the center of the lesion had disappeared

On further questioning, she denies any personal or family history of skin cancer.


A 29-year-old woman with a history of acne presents to the clinic with 3 discrete, atrophic, blue-tinged plaques on her face

The plaques were located on her forehead and cheeks bilaterally

The patient states the lesions had been present for several months and had slowly worsened until they stabilized at their current appearance

The patient reported that the lesions occurred after she went to a physician for “acne treatment.” The patient has no other medical conditions or relevant social history.


A 22-year-old woman complains of an itchy rash on her leg for 4 weeks

She is a collegiate swimmer and had a prior ringworm infection during her freshman year

She has been using over-the-counter antifungal cream for the past 3 weeks with no relief

Multiple round, erythematous, scaling lesions are present on her right leg, some of which are vesicular and weeping

Potassium hydroxide (KOH) test is negative for a dermatophytic infection.


A 62-year-old African American man presents to establish care and to undergo skin examination, which he reports receiving regularly since his sister was diagnosed with melanoma

Examination reveals 3-mm hyperpigmented horizontal bands across the nailbeds of all fingernails, which he reports have been present since his 20s

He denies experiencing any other nail changes or pain

He takes no medications, and he has no history of skin cancer or suspicious moles


A 60-year-old man presents to the clinic with a 1-cm long horn-like projection coming from the skin on the superior aspect of the skull just lateral to midline

The structure is yellowish-white in color and feels very firm to the touch

He states that he noticed a small, hard lesion a few months ago and that it has grown progressively larger from the time of initial presentation to now

The patient denies any pain at rest but states that he experiences pain when the lesion is struck accidentally.


A 43-year-old African American woman presents to the clinic with irritative lesions in the folds of her abdomen and in her genital region as well as painful ulcers in her oral mucosa

The patient reports noticing some flaccid blisters in addition to the lesions she presents with

On examination, erythematous, vegetative lesions are found

She states that the affected areas are painful but not pruritic

She has a previous history of herpes simplex virus (HSV).


A 20-year-old male with a medical history of diabetes mellitus type 1 presents with ecchymosis and bullous lesions on his back, posterior legs, and buttocks

He was playing football when he ran into another player and became unconscious

He was immobile in the hospital for 3 days before he regained consciousness

He has about 7 tense blisters with areas of surrounding erythema on the back, buttocks, and posterior thighs.


A 6-year-old Caucasian boy is brought to the clinic by his parents for dry, scaly skin that has persisted for the past 2 years despite the use of commercial moisturizers

His scaly skin is especially notable over his lower extremities, back, and elbows

The patient denies any pain over the affected areas and reports only a mild itch that is soothed with cold water or lotions

The parents report that he had a similar condition as an infant throughout his entire body and that he has siblings who also have persistently dry skin

His parents have tried exfoliating the scales with moderate success, but the scales recur shortly thereafter.


A 7-year-old healthy boy is brought to the dermatology clinic by his parents after having had a 3-week history of a rash

The patient’s rash was slightly pruritic, and it involved predominantly the trunk, starting as one larger pink patch with fine scale and subsequently spreading with smaller similar macules and patches

The boy’s palms and soles were spared of the rash.


A 24-year-old Caucasian woman presented with intermittent, inflammatory papulopustules and nodules on the face, neck, chest, and back

The lesions would appear 1 week premenstrually and resolve 1 week postmenstrually with normal menstrual cycles

She has a history of adolescent acne that is only responsive to isotretinoin 6 years ago

Examination revealed scarring and postinflammatory hyperpigmentation diffusely on her face.


A 15-month-old boy presents with a history of skin blistering since birth, primarily on his hands, feet, and the perioral face

Blisters and erosions also involve the trunk, some in an annular configuration

There is no family history of neonatal blistering or skin fragility

Over time, the patient has had a decreased number of new vesicles and bullae associated with trauma and friction but has developed thicker skin on the soles of the feet and dystrophic nails.


A 71-year-old Caucasian man with myelodysplastic syndrome and on chemotherapy with azacitidine presented to the hospital with 2 days of high fever and 4 days of worsening skin lesions

The lesions appeared on the elbows as “blood blisters,” which grew larger and more painful

He was placed on broad spectrum antibiotics by infectious disease physicians out of concern for ecthyma gangrenosum, and dermatology was consulted

On examination, violaceous, edematous plaques with a central pseudovesicle were seen on the bilateral elbows

Punch biopsies were performed for tissue culture and histology.


A 37-year-old man without a significant past medical history presents to the dermatology clinic with an itchy rash on his right hand that he has had for about 4 months

He had tried numerous over-the-counter hand creams and hydrocortisone cream with no improvement

Additional questioning revealed a 1-year-history of dry, itchy feet

As a construction worker, he wears occlusive, steel-toed work boots and often wears gloves

Examination of his hands reveals a normal left hand and a scaly right palm

Diffuse, fine, dry white scale was present on the plantar aspect of both feet.


The patient is a 46-year-old woman who presents at your primary care office for an examination with a single lesion that appears on her left arm

During the examination, it is revealed that the patient has a large sclerotic, indurated, hyperpigmented, anhidrotic, and hairless plaque on the right dorsal forearm

The patient states that these lesions had previously been slightly pink for several months before they had turned brown in color and had become “hard.” The patient has type 2 diabetes, but she has no other medical problems

In addition, she has no relevant social or family history.


A 38-year-old African American woman was referred to dermatology because of spots on her torso and arms

The lesions were asymptomatic, but their development, cause, and cosmesis were of concern

No benefit was seen with the use of OTC remedies such as hydroxycortisone 1% cream or vitamin E oil

Her medical history was significant for systemic lupus erythematosus, well controlled on hydroxychloroquine

Physical examination revealed numerous, well-circumscribed, 0.5- to 2-cm, hypopigmented, round-to-oval macules of wrinkled skin on her anterior chest wall, back, abdomen, and bilateral upper arms

Invagination of the lesions was noted with palpation


The patient is a 21-year-old male who presents for continued acne therapy

He has had severe acne on his face, chest, and back for years

He is happy with his current acne regimen of topical tretinoin, topical clindamycin, and oral minocycline

On examination, you notice significant blue-black discoloration confined to sites of previous acne scars

The patient has no other medical problems and no relevant social or family history.


A 53-year-old woman presents with a rash on her left lower extremity that has been present for several weeks

The patient is a native of Brazil and immigrated to the United States in the past month

She states that the rash is painless and does not itch

On examination, the patient has multiple, raised, hyperpigmented papules on the left lower extremity

There is a large, atrophic, hypopigmented patch on her lower shin, at the site of a previous large ulcer

The superior lesion is the newest, and is beginning to ulcerate


A 6-month-old infant presents with 2 weeks duration of erythematous papules on the soles of both feet and in the toe web spaces

On examination, a single burrow is visible on the left sole

Multiple family members also complain of a pruritic rash that has been bothering them for several months

The family members have tried multiple over-the-counter creams and remedies without success

The patient has no other medical problems or relevant family history.


A 42-year-old man presents with a four-day history of experiencing headache, malaise, and stabbing right-sided headache

Two days after his initial symptoms appeared, he developed a rash over the area of pain

He reports that he went hiking through the Texas hill country prior to becoming ill

The patient is otherwise in good health and has an unremarkable medical history

Physical examination reveals unilateral erythematous, thin, raised plaques over the right forehead

In addition, he has no relevant social or family history.


The patient is a 12-year-old Hispanic girl who presents with a 6-month history of nail dystrophy involving all of her fingernails

On examination, all 10 of her fingernails exhibit longitudinal ridging, pitting, fragility, thinning, and distal notching

The patient’s mother is very concerned about the cosmesis of her daughter’s nails

On review of systems, the patient’s mother noted that her daughter has started to develop circular patches of hair loss that appear to resolve on their own

The patient has no relevant social or family history and does not take any medications.


A 1-year-old boy presents with a single, L-shaped, yellow-orange hairless patch over the left preauricular skin

The patient’s mother notes that he has never grown hair in that location

The mother is concerned because the area used to be smooth, but seems to be changing

The patient has a history of prematurity and low birthweight but is otherwise healthy

The patient has no relevant social or family history.


An 8-year-old African-American boy presents with a 3-day history of fever, pain, and a rash on his trunk

On examination, the patient has several fragile, bullous lesions on his trunk, many of which have eroded, exposing erythematous, annular lesions

The patient is febrile and shaking in the office, and he appears to be in pain

He has no other relevant social or family history and does not take any medications

His mother is very concerned about her son.


A 13-year-old boy presents to the dermatology clinic concerned about the development of red, itchy, and sometimes painful bumps on his fingers

He first noted seeing the lesions 2 months prior, in early December

Although the initial lesions have since resolved, new lesions appeared after a skiing trip the previous weekend

The patient is otherwise healthy, with no significant past medical history, and he does not take any medications

Physical examination reveals erythematous, tender papules on the lateral and dorsal aspects of the distal fingers.


A 52-year-old Hispanic woman presents with a 3-year history of a very pruritic rash over her shins bilaterally

On examination, both shins are covered in hyperpigmented papules that have coalesced to form thin, rippled plaques

The patient is very concerned about the appearance of her legs and the intense pruritus in the areas of the rash

The patient has no other medical problems and has no systemic symptoms

She has no relevant social or family history and does not take any medications.


The patient is a 13-year-old adolescent girl who presents with a 1-month history of a dark lesion on her finger

She states that the lesion does not bother her, but she came to the clinician because her mother was very concerned about the enlarging area of hyperpigmentation

The patient has no past medical history, no relevant family or social history, and is otherwise in good health

On examination, the rash appears to be a 1 x 1 cm circular patch of hyperpigmentation with overlying scale on the middle finger

During the past month, the rash has grown in size but remains asymptomatic.


A 72-year-old man presents to the clinic with an intensely itchy rash on his abdomen and chest that appeared 2 months prior

He denies starting any new medications prior to the onset of the eruption and any systemic symptoms

Although he traveled and stayed in hotels recently, he reports that his wife does not exhibit any similar symptoms

Physical examination reveals numerous discrete papules, crusted papules, and papulovesicles on the chest, abdomen, and mid-back

His upper and lower extremities, face, and groin are unaffected.


The patient is a 38-year-old Hispanic woman who presents with a 1-year history of a very pruritic rash over her interscapular area

On examination, she has a circular area of slightly hyperpigmented macules in the interscapular region

The patient complains of pruritus but no pain in the area of the rash


The patient is a 19-year-old woman who presents with several years of a worsening rash

The rash appears as erythematous, hyperkeratotic thin plaques in a seborrheic distribution

The patient states that the rash is very irritating and sometimes pruritic

The patient’s main complaint is that the rash exudes a malodor

The patient states that her father has a similar rash that he chooses not to treat.


A 35-year-old woman is referred for evaluation and management of a rash involving both axillae

She reports recurring episodes of the same rash beginning in her early 20s

Lesions develop and involute spontaneously

Areas affected included the axillae, neck, and groin

Historically, outbreaks are more common and worse during the summer, and after vigorous exercise

Both her father and brother have the same problem; her brother saw a specialist, but forgot what he was told

Otherwise, she is healthy and taking no medications

Examination reveals moist, red, crusted, and malodorous plaques with fissures in both axillae.


On day-of-life 2, a 3-day-old boy who was born with no visible skin problems begins to develop erosions and bullae over both the palmar and plantar surfaces

These bullae are localized to areas of friction or trauma (eg, where electrocardiogram leads were placed)

The mother’s pregnancy was normal, and the infant had been born without complications

Aside from the development of bullae, the infant has no evidence of any other medical problems

The infant’s parents are healthy and have no medical problems

No one in the infant’s family has had similar dermatologic findings.


A 44-year-old woman presents for her annual full skin examination

She has a specific concern regarding a lesion on her left lower leg

She recalls having a mosquito bite in that area a few years earlier, but it never went away

The lesion is bothersome only when she shaves her legs and nicks it; otherwise, there is no associated pain or tenderness

Physical examination reveals a firm, flat, pink and brown nodule located on the left anterior proximal shin

The lesion dimples inward when pressure is applied.


A 79-year-old white man with an extensive history of nonmelanoma skin cancer presents for a routine skin examination

During his visit, he asks to have a groin rash checked

For 1 to 2 years, he has been using over-the-counter and prescription antifungal and antibiotic creams for a presumed “jock itch.” Recently, he has developed more discomfort and reports episodic, profuse bleeding from the area

Examination reveals a large erythematous, eroded plaque on the posterior right scrotum extending anteriorly to the right upper thigh

The left scrotum is minimally involved, and there is no adenopathy.


A 61-year-old woman presents concerned about a white discoloration on her left breast that she first noticed 6 months earlier

It itches at times, and she is worried it might be cancerous

She showed it to her gynecologist at her annual visit, and he referred her to the dermatology clinic

Physical examination of the left breast reveals a 10-cm white, smooth, porcelain-like plaque

There is no associated erythema and no noticeable scale.


A 56-year-old man presents with diffuse pruritic papules involving the upper body, with nose and forehead thickening

Over the past 2 years, he has been evaluated by multiple specialists for dysphagia, reflux, chronic kidney disease, hypertension, and dyspnea on exertion

Examination results are significant for generalized firm, fleshy, dome-shaped papules of several millimeters in diameter, on his forehead, ears, neck, trunk, back, proximal upper extremities, and dorsal hands, with forehead, glabella, and nose induration

Relevant laboratory findings include monoclonal gammopathy on serum immunofixation, consisting of immunoglobulin (Ig) G_ and IgA_, and unremarkable thyroid panel findings


A 34-year-old man presents with an itchy rash, primarily on his arms, but also, to a lesser extent, on his face

He denies any fever or malaise, and his medical history is unremarkable

He does not take any medications and notes that he spent the previous weekend doing yardwork on his property, and the rash appeared 4 days later

Physical examination reveals several linear arrangements of papulovesicles on the dorsal and ventral aspects of his forearms with surrounding erythema.


A 62-year-old white man with a past medical history of latent tuberculosis, vitiligo, and psoriasis presents for follow-up for treatment of psoriasis

The patient’s psoriasis has proven refractory to numerous treatments over the years, so he began treatment with secukinumab, a monoclonal antibody against interleukin-17A

After 2 months of therapy, the patient reports new-onset tongue pain

Physical examination demonstrates an erythematous, edematous, diamond-shaped plaque on the posterior dorsum of the patient’s tongue.


A 13-month-old toddler with spreading eczema on his trunk and arms is brought in by his mother

She is applying moisturizer and a cortisone cream

However, 2 days earlier, a wound appeared on his left hand that appears to be infected

Since then, more areas of raw, oozing skin have developed

Examination reveals lichenified scaling plaques scattered on the trunk and posterior knees and arms, and his left arm has monomorphic crusted vesicles and ulcerations on an erythematous base.


A 30-year-old healthy Hispanic woman presents with a slowly progressive facial deformity present since early childhood

She denies any new lesions during this time, any history of trauma to the area, and any family history of similar skin lesions

Examination reveals a bulging, deformed dermal mass with a “bag-of-worms” appearance involving the upper right quadrant of her face, with hypertrophy of the overlying skin and soft tissues

Neurofibromas and café-au-lait macules are not observed.


A healthy 45-year-old woman presents with a several-month history of a small papule at the corner of her right eye

The lesion is asymptomatic and is not enlarging, but she has cosmetic concerns

She denies diplopia, vision loss, or any other lesions on her face and body

Examination reveals a dome-shaped, smooth, translucent papule filled with watery fluid located below the lateral canthus of her right eye.


A 32-year-old white woman who has never smoked presents with pruritic, tender, erythematous, violaceous patches with eczema-like blisters on her upper, lateral thighs

In 2012, she began traveling annually from Pennsylvania to South Carolina, from January through April, where she works with and rides horses daily from morning to evening

Her symptoms began in her first year in South Carolina and appear consistently from January through March

Her lesions appear initially in mid-January as a red dot and progress by mid-February


A healthy 30-year-old man presents with a 3-year history of an asymptomatic, fleshy papule at the base of his great toe

He denies any new lesions during this time, a history of trauma to the area, or a family history of similar skin lesions

He was treated previously by another dermatologist with cryotherapy; however, he returns to the clinic with recurrence of the lesion

Examination reveals a pedunculated, flesh-colored, well-demarcated tumor on the plantar surface of the base of his great toe.