A 45-year-old woman with insulin-dependent diabetes mellitus presents with a sore on her right leg

She describes a long-standing history of asymptomatic lesions on her shins but had only recently injured her leg, causing the sore, which is slow to heal

Despite a 15-year history of diabetes, she has no systemic complications

She has large, well-circumscribed plaques on her anterior shins bilaterally, which are yellow-brown with telangiectasias and minimally violaceous borders.


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

A 60-year-old man presents with rapidly growing lesions on his face, trunk, axillae, flexural areas, and groin

The lesions appeared 3 months earlier in his perianal area and extended rapidly to other areas

Previously, he was treated with topical agents for atopic dermatitis and seborrheic dermatitis without improvement

Examination reveals disseminated violaceous papules and plaques on the face, trunk, axillae, and perianal area; some lesions were confluent and ulcerated

Yellowish-red to skin-colored papules are present on the scalp

He has no palpable lymphadenopathy or organomegaly.


A 13-year-old girl presents with a cystic lesion that has been on her forearm for several years

Concerned about the lesion, she reports that it may have grown slightly larger in the past year and it is intermittently painful

More recently, a second similar lesion has appeared in close proximity

She denies any other suspicious lesions elsewhere on her skin

Her family history is negative for skin cancer, and she reports no other medical conditions

Physical examination reveals two well-defined 6-mm nodules that are rubbery, slightly tender, and pink on the right proximal ventral forearm

The overlying skin is intact, and there is no associated adenopathy.


Adult-onset asthma with periocular xanthogranuloma

A 62-year-old man with well-controlled rosacea, a monoclonal gammopathy of undetermined significance, and chronic lymphocytic leukemia (CLL; stable on no current therapy) was seen in the clinic for a full-body skin check

Results of his examination were unremarkable except for the presence of periorbital, yellow-brown plaques with violaceous borders involving the upper and lower eyelids, bilaterally

There was induration, but no warmth or tenderness, of the periorbital plaques

He first noticed these lesions around the time he was diagnosed with CLL; initially they were more discrete yellow papules that developed into plaques over time


A healthy 16-year-old girl presents with six tan patches on her trunk and upper arms, freckles in her axillae, and a reddish discoloration under the tip of her thumbnail

The tan patches have been present since birth but have enlarged over the past 4 years

She reports paroxysmal pain and cold sensitivity involving the discolored portion of her thumb

Examination reveals six tan-brown macules with smooth borders ranging from 16 to 20 mm, axillary freckling, and a tender red-blue nodule under the thumbnail.


A healthy 15-year-old girl presents with a solitary, asymptomatic lesion on her back

The lesion has been present since birth but has enlarged over the past 2 years

She denies association with previous trauma and irritation

Examination reveals multiple, comedo-like openings filled with dark lamellate keratinocyte plugs grouped in a linear distribution over a slightly hypotrophic area of 3 cm by 7 cm

Dermoscopy revealed numerous circular and barrel-shaped homogenous areas in dark-brown shades with remarkable keratin plugs.


A 28-year-old healthy white woman with no significant past medical history presents with an enlarging papule on her right lateral neck

She describes a 1- to 2-mm pink papule that grew to approximately 10 mm within the past week

With minimal rubbing or trauma, the papule intermittently bleeds

It is otherwise nontender and nonpruritic

She has no history of skin cancer and is taking oral contraceptives

Physical examination shows a pink, friable papule on a stalk on the right lateral neck

There are no other similar lesions seen on examination.


A healthy 12-month-old infant girl presents with a yellowish-orange papule on the right upper extremity

Her mother first noticed this lesion approximately 6 months earlier

It has never bled, ulcerated, or formed blisters

The infant does not scratch the lesion nor appears otherwise bothered by it

However, when the lesion is rubbed, it appears to swell and turn bright red

On physical examination, there is a soft, oval-shaped, yellowish papule with a peripheral rim of erythema on the right extensor forearm.


An otherwise healthy 60-year-old dishwasher presents with asymptomatic green discoloration of his right middle fingernail over a period of 2 months

The discoloration began from the distal margin

He denies wearing gloves while working and reports a tendency to pick at his nails when nervous

On examination, distal onycholysis and green discoloration are present exclusively on the right middle nail plate starting from the distal edge without signs of paronychia

Dermoscopy reveals pigment localization under the nail plate.


Levamisole-induced antineutrophil cytoplasmic antibody vasculitis

A 43-year-old elementary school teacher presents with a rash that began on his left thigh approximately 4 months earlier; the rash has since spread

It is mildly itchy but has no associated pain or bleeding

His past medical history is significant for allergic rhinitis and atopic dermatitis

Suspecting eczema, he has been applying an over-the-counter hydrocortisone 1% cream as well as a moisturizer, which transiently alleviates the itch

He has not changed laundry or hygiene products

On physical examination, there are slightly erythematous, minimally scaly patches scattered over his left hip and buttock.


A 50-year-old woman presents with a 5-day history of progressive, painful rash involving her face, trunk, extremities, nasal tip, and ears, in addition to fever and arthralgia

She admits to a history of polysubstance use and states that her last use was a week prior to symptom onset

She denies a history of autoimmune disease or recent travel

Examination reveals retiform purpura with areas of necrosis and bullae formation

Urine toxicology screening is positive for cocaine, and laboratory findings include leukopenia and an elevated erythrocyte sedimentation rate (70 mm/h).


Acrodermatitis enteropathica-like eruption (AELE)

A 7-month-old male who had been born prematurely presents with a 2-month history of diarrhea, failure to thrive, alopecia, and rash involving the perioral, perianal, and acral areas

He had been treated unsuccessfully for presumed atopic dermatitis with topical corticosteroids

He was exclusively breastfed until 2 months ago, when he was transitioned to formula

Examination reveals an irritable, thin infant with sharply demarcated red, inflamed, scaly plaques and erosions around his mouth, anus, eyes, hands, and feet

Diffuse hair loss is noted on the scalp, eyebrows, and eyelashes

Paronychia and nail dystrophy are noted on his upper and lower extremities.


A 64-year-old woman presents with a 6-month history of a slowly enlarging bump near her left eyebrow

The patient says it appeared suddenly and became a nuisance, as well as cosmetically unacceptable as it enlarged

She denies any pain, tenderness, or oozing, and denies any other similar lesions elsewhere

Her pertinent dermatologic medical and family history are unremarkable

Physical examination reveals a 6-mm nontender subcutaneous mobile nodule on the left lateral eyebrow

There is no overlying ulceration or central punctum, and no discharge is noted

No other suspicious lesions are observed on examination of the scalp and face, aside from mild actinic damage.


A 30-year-old Hispanic woman presents with her 1-year-old son, concerned that he has only small amounts of thin, wispy hair on his head and has none anywhere else on his body

She notes that he does not yet have any teeth, but has a large forehead and ears

He has been irritable and crying for the past day

She reveals a personal history of very high body temperature at times during the summer and says she customarily stays indoors with the air conditioning on, especially in the summer

On physical examination, she has sparse hair on her scalp and eyebrows, as well as eczematous patches on her bilateral lower extremities.


Nipple inversion secondary to neglected malignancy

A 48-year-old premenopausal woman, who has had one pregnancy and has delivered once, presents with a 15-month history of left breast deformity

The patient began having pain in the region 2 months ago

A review of systems is negative for weight loss, fever, or nipple discharge

Her medical history is otherwise unremarkable, and her family history is noncontributory

Physical examination is notable for extensive left nipple inversion and retraction, a large underlying mass in the central breast, edema and ulceration of the overlying skin of the breast, and matted ipsilateral axillary nodes


A 25-year-old man with no remarkable past medical history presents with an itchy rash on the feet

Symptoms began 2 months ago, starting over the dorsal toes with redness, scaling, and itching

The eruption spread over the dorsum of the feet and progressed to weeping and crusting

He reports recently buying new shoes for work as a chef, which requires 15 hours daily of standing

Due to profuse sweating, his socks become soaked daily

Examination reveals symmetric erythematous plaques over the bilateral dorsum of both feet with fissures, scaling, and lichenification

No blisters or vesicles are present, but there are scattered crusted erosions.


A 55-year-old black man presents for evaluation of fine wrinkles that had developed over the past year

Physical examination reveals diffuse areas offine wrinkling that run parallel to lines of cleavage on his neck, chest, axilla, trunk, back, and upper arms bilaterally

The affected skin has normal pigmentation and lacks erythema, induration, and atrophy

Lateral tension obliterates the wrinkling

The patient never notes any inflammation, itching, or pain

There are no signs or symptoms of systemic involvement

He denies sunbathing and denies any history of skin disorders or other significant health problems.


A 26-year-old African American man with no significant past medical history presents with a growth on his left foot that had been increasing in size for 1 year

He initially thought it was a wart but had concerns when it continued to grow and became painful

Examination reveals an exophytic, brown, and mildly tender nodule, 3cm in diameter, on his left medial heel and instep

The overlying skin is crusted and friable

His nails and hair show no abnormalities

The remainder of the examination is unremarkable.


An African American woman, aged 50 years, presents with painless “bruises” on her leg

She first noticed bruises on both legs a year ago and reports that they have since become larger

Physical examination reveals blue-black macules and patches on both shins

The macules are asymptomatic, and the remainder of the physical examination is within normal limits

A venous stasis ulcer is seen on her right leg

She says she has a 10-year history of discoid and systemic lupus erythematosus treated with hydroxychloroquine and does not recall any history of trauma to her legs.


A man, aged 68 years, with no known history of atopy presents with a 4-month history of an itchy and burning rash on the legs that has been recurring every winter for the past 3 years

He notes that he had dry skin at baseline and did not use emollients, but he did try hydrocortisone 1% cream without improvement

Examination revealed ovoid, erythematous, well-marginated plaques on the lower legs and dorsal feet with variable scaling and focal weeping and crusting

There were no nail changes, and the rest of his skin examination was notable only for xerosis.


An elderly man presents with asymptomatic hyperpigmented, confluent, brown macules on his upper and lower lips, along with hyperpigmented macules on his hands

He also has diffuse blue-black bilateral melanonychia with nail dystrophy on his toenails, and his fingernails contain longitudinal melanonychia with hyperpigmentation of the proximal nail beds

He denies any family history of mucocutaneous pigmentation or gastrointestinal or systemic symptoms

In the last 5 years, results of a colonoscopy, upper gastrointestinal endoscopy, and blood work have all been within normal limits.


A man, aged 42 years, presents with a 6-month history of a painful, scaly skin rash

The eruption is symmetrically distributed over photosensitive areas, affecting his face, neck, upper back, forearms, and hands

The dorsal surfaces of his hands and forearms exhibit a dusky brown coloration over rough and cracked skin

He complains of itching and burning and reports intermittent vomiting and diarrhea

He admits to heavy alcohol intake for the last 2 decades and denies taking any medications

Neuropsychiatric evaluation reveals short-term memory loss, speech problems, and poor concentration.


A 68-year-old white man presents with 4 weeks of progressively worsening thickening of the skin and plaques on the bilateral nipple and areola

He has no personal or family history of warts or epidermal nevi and has not had hormonal therapy

On examination, he has hyperpigmented, verrucous plaques bilaterally, with no associated erythema or lymphadenopathy

Skin biopsy shows hyperkeratosis with papillomatosis

Corticosteroid treatment failed, but there was some minor improvement with calcipotriol after several weeks of use.


A 4-year-old white male presents with a 3-month history of an asymptomatic papular rash on his back, abdomen, chest, upper arms, and ankles

His medical and family histories are otherwise unremarkable

On examination, the grouped papules are shiny, monomorphic, skin-colored, and pinhead-sized

The papules exhibit koebnerization but no erythema or tenderness

His nails, hair, oral mucosa, and genitals are normal.


An African-American man, aged 35 years, presents with a 3-month history of pruritic penile lesions

Examination reveals an arcuate pattern of raised violaceous-to-flesh-colored papules with central clearing on the glans penis and a few scattered, raised violaceous-to-flesh-colored polygonal papules of the glans penis and distal penile shaft

Results of the remainder of the skin examination are normal, and there is no inguinal lymphadenopathy

His sexual history includes no previous sexually transmitted diseases and no new sexual partners within the past year.


A 50-year-old woman presents with darkening skin that started several weeks ago

She recently went to the beach and developed severe redness in sun-exposed areas within a few hours of being out in the sun

She did not wear sunscreen and says she usually does not burn in the sun

She started hydrochlorothiazide for hypertension 4 months ago

On physical examination, hyperpigmentation is noted on the dorsal hands, proximal forearms, dorsal feet with sparing of skin covered by her sandal straps, “V” of her neck, cheeks, and forehead.


A 61-year-old woman presents with a 7-month history of a bump on the front of her left knee

The lesion is slightly tender but otherwise is asymptomatic

She is concerned that the lesion may be cancerous

She has no other medical problems and takes vitamin D daily

On physical examination, a firm subcutaneous tumor is noted on the left knee measuring 8 cm without overlying skin changes

She has no other similar lesions elsewhere on her body.


A 65-year-old man presents with a recurring rash on his back

He has had the rash several times before, most often during the summer, and it was treated successfully with an antifungal shampoo prescribed by a prior dermatologist

He has a history of depression and hypertension

On physical examination, hyperpigmented macules coalescing into patches with very fine white scale are found

The lesions are scattered primarily on his upper chest and upper back.


GGXC-mediated coagulation factor deficiency

ENPP1-mediated premature arterial calcification

A 22-year-old woman presents for evaluation of progressive skin changes on her neck and arms beginning sometime around puberty

She tried various over-the-counter anti-itch, antiaging, and eczema creams that were ineffective

She has no personal or family history of skin conditions and is otherwise healthy

Review of systems is negative for skin laxity, joint hypermobility, or vision changes

Physical examination reveals numerous nontender, noninflammatory, yellow, 2- to 5-mm papules that coalesce into reticulated plaques on the nape of her neck and bilateral antecubital fossa

A punch biopsy demonstrates fragmentation and calcification of elastic fibers.


A 47-year-old otherwise healthy woman presents to the clinic with several concerns

Over the past several months, she has experienced thickening of her skin around her hands, forearms, and face

Her fingers turn blue and then pale when she is exposed to cold

Additional recent symptoms include fatigue and gastroesophageal reflux

She takes no medications and has no family history of autoimmune disease

On physical examination, the patient has skin thickening on the hands, forearms, and face

She also has hypopigmented macules on the hands and lower legs.


A 15-year-old Black man presents with a 1-year history of light spots on his back

The rash has grown slowly, with several new lesions appearing near the first one

He has not tried any treatments for this condition

He has no relevant medical history and none of his family members have similar skin findings

On examination, there are several well-demarcated depigmented macules and patches on his lateral back.


Pityriasis lichenoides et varioliformis acuta (PLEVA)

A 60-year-old Black woman presents with a 30-day history of a nonitchy rash

The rash is located on her face, trunk, and extremities

She reports that she has tried topical steroids on the rash, which did not help

The patient has no other medical conditions and takes no medications

She notes that she had unprotected sex with a new partner about 4 months prior to presentation

On physical examination, the patient has many scattered erythematous scaly papules on her face, abdomen, back, and upper and lower extremities including the palms and soles.


A 64-year-old man with a history of numerous nonmelanoma skin cancers presents with a lesion on the left side of his nose that was first noticed about 6 months ago and is slowly growing

The patient has not tried any medications on the lesion

The patient wears eyeglasses and the nose pad of his eyeglasses rubs on the lesion

On physical examination, an erythematous papule is found on the left superior nasal sidewall with a central depression.


A 54-year-old woman with a history of depression presents to the clinic with a 1-year history of an intermittent rash

She was hospitalized for COVID-19 approximately 1 year ago and soon after developed a rash all over her body

The lesions persist for several days and have a burning sensation

The patient has no associated joint pain or other systemic symptoms

She tried antihistamines for the rash with no symptomatic relief

On examination, erythematous wheals are evident on her arms and legs as well as her back and abdomen.


A 42-year-old Hispanic man with no prior medical history presents with a 2-month history of a rash on his face, chest, and arms

He reports that the rash gets worse after sun exposure and he has associated joint pain

He has taken over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) for the joint pain and topical steroids for the rash with no symptomatic relief

Physical examination reveals erythematous patches over the malar cheeks and dorsal nose sparing the nasolabial fold and erythematous macules on the forearms and chest.


A 6-year-old girl presents with a 1-year history of a waxing and waning rash on her limbs and face

The rash starts as red scaly bumps that fade over several weeks leaving smooth white spots

Every few months, the patient gets several new red bumps

Her parents have tried topical steroid creams that did not help clear the rash

Examination reveals scattered erythematous scaly papules on both legs and several hypopigmented macules on her legs, arms, and face.


A 15-year-old girl presents with patches of hair loss on her scalp that have been present for the last 6 months

She reports that her scalp is not itchy or painful and denies any recent illnesses, diet changes, or stressful life events

She does not have any other medical conditions and takes no medications

Her uncle had a similar condition that started when he was in his 20s, but no one else in the family has experienced hair loss

The patient says she has not tried any treatments for the condition

On examination, she has several well-demarcated patches of hair loss on her frontal and parietal scalp, with no perifollicular erythema or scale.


A 65-year-old man of Middle Eastern descent presents with a tender, weeping mass on his right palm

Since appearing 8 months ago, the lesion has enlarged into a 0.9-cm, pink pedunculated nodule with abundant serous crust

The patient has no significant history of trauma

His medical history is significant for atrial fibrillation, hypertension, coronary artery disease, congestive heart failure, and lung cancer, which was treated with right lobectomy

It is unclear what medications were used to treat his lung cancer

His current medications include metoprolol, lisinopril, allopurinol, aspirin, and digoxin

The patient also presents with additional pink, scaly plaques on his right ankle, consistent with nummular eczema.


A 33-year-old Black man presents to a dermatology clinic with a 5-month history of asymptomatic lesions on his arms and trunk

He is otherwise healthy with no personal or family history of skin disease

He has no history of fever, cough, shortness of breath, or joint pain

The patient has not tried any treatments for these lesions

On examination, there are several smooth, well-demarcated hypopigmented plaques on his upper arms and left flank

He has no similar lesions elsewhere on his body.


A 61-year-old man presents with a 7-month history of lesions on his hands and arms

His medical history includes depression, hypertension, and hyperlipidemia

He has no personal or family history of skin problems

His skin lesions are not painful or itchy, and he is not bothered by their appearance

He has not tried any treatments for the lesions

Physical examination reveals a number of pink, annular plaques with smooth raised borders on the patient’s dorsal forearms and hands

On close inspection, small discrete papules are seen within the plaques.


A 32-year-old woman presents with an itchy rash that began 3 months ago

She has a history of anxiety but otherwise no known medical conditions

She has tried over-the-counter hydrocortisone cream to treat the rash, finding some relief from the itchiness, but the rash continues to spread

She has no known allergies and has not changed her skin care products or medications

On examination, the patient has dark purple and gray flat-topped papules with fine gray-white streaks on her flexural wrists, dorsal hands, elbows, ankles, and dorsal feet.


A 35-year-old woman presents to the dermatology clinic with inflammation of her fingernails that first appeared 5 months ago and recently worsened

She reports wearing acrylic nails for the last year, removing them just before the clinic visit

On examination, the patient has erythema and swelling of the lateral nail folds and hyperpigmentation of the proximal nail folds of all fingers on her right hand

Examination also reveals nail dystrophy, onycholysis, and an absence of cuticles

She has not tried any treatments for this condition.


A 42-year-old woman was admitted to the hospital for complications related to type 2 diabetes

Her inpatient team noticed that her right fifth finger was swollen, red, and appeared to have a fissure

The patient stated that although the fissure was not present since birth, her finger has looked this way for “a while” and typically did not bother her

On examination, she had hyperkeratotic plaques on some of her fingers

She denied trauma to the site of injury and her family and travel history were unremarkable.


A 50-year-old woman presents with a crop of lesions that recently appeared on her buttocks and legs

On examination, the red macules and papules range in size from a few millimeters to a few centimeters; when pressed, the lesions do not blanch or partially blanch

The patient reports joint pain over her ankles and knees, along with malaise

When questioned, she acknowledges having had a “cold” a few weeks earlier, for which her primary care provider prescribed an antibiotic

Direct immunofluorescence of the lesions reveals immunoglobulin A (IgA) deposits around the small vessels in the papillary dermis.


A 70-year-old White man presents for evaluation of a recent foot injury

The patient states that he hit his foot at home and noticed blood on the floor; because of a previous injury, he was unable to view his sole

A large (several cm), irregularly shaped plaque is seen on the mid-anterior volar foot

The lesion is brown and black, with central red discoloration and overlying yellow-white scale.


A 35-year-old construction worker presents with a well-circumscribed, verrucous plaque on his left upper arm

The lesion has been present for a few months, but recently has increased in size and become painful

He reports that a cough preceded his skin lesion, but otherwise has no relevant medical history

A large verrucous and ulcerating lesion with pustules is seen

On palpation, a purulent discharge is expressed.


A 45-year-old woman presents with enlarging blood vessels on her tongue that recently have increased in size and number

Numerous 1- to 2-mm discrete red macules and papules are seen on her tongue, oral mucosa, nose, lower lip, and fingertips

She has had frequent nosebleeds since childhood as well as iron-deficiency anemia that has not responded to iron supplementation

Her father, who died at the age of 50, had similar symptoms.


A 12-year-old boy presents to the dermatology clinic with a 2-year history of a brown patch on his chest

The 8-cm patch had been asymptomatic, but over the past 6 months, it has become darker, with hair and acne vulgaris developing within the lesion

The patient is self-conscious about the lesion’s appearance and wishes to learn if it can be treated to lessen the hyperpigmentation.


A 28-year-old Black man presents with a 2-year history of dyspigmentation of his back and chest

The patient notes that the lesions initially had red borders but these have faded over the past several months

Physical examination reveals circular, ashy-gray macules distributed diffusely over his back and chest

The patient denies pain or pruritus and takes nomedication

He notes that he recently traveled to Mexico

He has been relatively unconcerned about the lesions and only sought medical care to rule out cancer.


A 45-year-old woman presents with oval-shaped lesions on her arms that she first noted a few months ago

The lesions began as an area of discrete erythema, progressed to induration, and then became dark, smooth, and shiny

She has a family history of rheumatoid arthritis

On examination, the patient has multiple hyperpigmented and hypopigmented indurated plaques with a shiny surface; her nails and fingertips are normal, and autoantibody tests were negative.


An 8-year-old boy presents with a 2-month history of an asymptomatic rash on the dorsum of his right hand

He and his family have recently moved from a coastal region in Mexico

Medical and family history are otherwise unremarkable

On examination, he has a 2-cm pigmented macular lesion with an irregular outline centrally located on the dorsal aspect of his right hand

The remainder of the physical examination is normal

Dermoscopy rules out a nevoid lesion, and septated filaments are observed on potassium hydroxide (KOH) test.


A 53-year-old man presents to the clinic with ulcerated, scarred, and hypertrophic plaques on both lower extremities

He is a refugee from Sudan who arrived in the United States a month earlier

He reports that the lesions started as red bumps that slowly expanded and developed a raised border

Several of his family members in Sudan have had similar lesions in the past, and he is concerned that he may have developed the same condition.


A 48-year-old white man presents to the dermatology clinic with papulosquamous cutaneous lesions that recently appeared on his chest, arms, and the dorsal aspects of his hands

The patient has a family history of autoimmune disorders, including systemic lupus erythematosus (SLE)

Physical examination reveals that the lesions lack induration and do not appear to be leaving scars

Biopsy of the lesion is performed, revealing mild inflammatory infiltrate

Direct immunofluorescence shows a granular deposition at the dermal-epidermal junction

Serology indicates that the patient is positive for anti-Ro/SSA (Sjögren-syndrome-related antigen A).


Confluent and reticulated papillomatosis

A 15-year-old white adolescent presents to the dermatology clinic with an asymptomatic rash on his upper back that has persisted for 4 months

Physical examination reveals hyperpigmented scaly papules coalescing into confluent plaques with peripheral reticulated papillomatosis

The boy is overweight but has no history of any other medical conditions.


An 8-year-old boy presents to the clinic for evaluation of a progressively worsening nail dystrophy that began a few months ago

The patient’s mother denies a family history of skin diseases and reports that her son has no history of medical problems

On physical examination, all of the boy’s fingernails and toenails show hyperkeratosis, longitudinal ridging, loss of luster, and roughness

His hair, skin, and oral mucosa are unremarkable

Nail biopsy reveals spongiotic changes and exocytosis of inflammatory cells into the nail epithelia

The results of a fungal culture are negative.


Central centrifugal cicatricial alopecia

A 54-year-old woman presents with 2 years of gradual hair thinning

She says that her mother also experienced hair thinning starting in her 50s

She denies clumps of hair coming out in the shower or on her pillow

She denies any preceding stressful life events

She denies wearing her hair in tight braids

She denies loss of eyebrows or eyelashes

Physical examination reveals frontotemporal hair thinning without scarring.


A 20-year-old man presents with 2 months of hair loss

He says that approximately 8 months ago, he was involved in a motor vehicle accident which resulted in several fractures and a difficult recovery

He has noticed clumps of hair coming out in the shower and on his pillow

He denies any recent infections or genital sores

Physical exmamination reveals diffuse hair thinning on the scalp without scarring.


Subcutaneous panniculitis-like T-cell lymphoma

A 45-year-old woman presents with 3 months of tender bumps on the shins

She says that 4 months ago, she was hospitalized for abdominal pain and was found to be positive for hepatitis B

She denies itching or scratching at the bumps

She denies any rash on the trunk or extremities

Physical examination reveals tender, subcutaneous nodules on the bilateral shins.


A 70-year-old man presents with 1 year of a non-healing growth on the right cheek

He says he first noticed it when he accidentally bumped into it and it bled easily

He denies any preceding trauma to the lesion

Physical examination reveals a pearly, eroded telangiectatic papule on the right cheek.


An 8-year-old male presents with 1 week of itchy blisters on the ears

He just recently returned from spring break with his family

He denies using any particular products on the ears before the rash

He says that this has occurred yearly for the last several years, always around the same time

Physical examination reveals tiny vesicles atop erythematous patches on the superior helices.


A 67-year-old male presents with unrelenting itch present over the last 6 months

He denies exacerbation of itch with water

A KOH scraping is performed which is negative for scabies

Physical examination is significant for numerous punctate and linear erosions consistent with excoriations as well as diffuse shoddy lymphadenopathy.


A 34-year-old woman presents with scaly lesions on the palms and soles

Lesions have been present for about a month

She denies recent genital sores or history of sexually transmitted diseases

She denies any family history of similar lesions on the palms or soles

She denies exposure to arsenic or well water

She is otherwise healthy aside from a recent bout of stomach flu which she thinks she got from a bad piece of chicken

Physical examination reveals discrete scaly papules on the palms and soles.


A 25-year-old male presents with 6 months of discoloration in the underarms

He denies any blisters or erosions in the areas

He denies any history of diabetes, insulin resistance, or weight gain

He denies discoloration only with sweating

Physical examination reveals reddish-brown patches in the underarms; Wood's lamp reveals coral red fluorescence.


Drug reaction with eosinophilia and systemic symptoms

A 72-year-old woman is seen by the Dermatology consult service for a rash which has developed during a prolonged 6-week hospitalization following a hemorrhagic stroke

She is currently intubated, so history is limited, but per chart review, nurses documented the rash starting 5 days ago

She has been experiencing high fevers as well as unexplained transaminitis over the last few days

She has taken atorvastatin and pantoprazole for years, including during the hospitalization

Following the stroke, she was started on carbamazepine for seizure prophylaxis

She contracted MRSA pneumonia 2 weeks ago and has been on vancomycin since then

She has also been on cefepime and micafungin for the last 5 days given the fevers and transaminitis

Physical examination is significant for diffuse erythematous patches extending over the face, chest, back, and extremities, as well as facial edema.


A 2-month-old male infant presents with a rash in the diaper area

He was seen by his pediatrician and was given topical triamcinolone as well as zinc oxide paste which did not help

His mom says that she was unable to make enough breastmilk and so has recently been feeding him from a new formula

Physical exam reveals erythematous erosions in the diaper area, as well as peri-oral scaling and a shiny tongue


A 25-year-old male presents with 2 years of pruriginous erythematous plaques with silver scales on elbows, knees and buttocks

He says that his father is known for hand and back arthritis

He denies personal and family history of dermatology conditions and atopy

Physical exam reveals pitting on all 10 fingernails.


A 60-year-old female presents with a non-healing painful ulcer on her right leg for 4 months

She says she first noticed it after she accidentally bumped into a chair

She is known for rheumatoid arthritis and hypertension, and has taken methotrexate and bisoprolol for years

According to the patient, oral antibiotics and wound debridement have only increase the size of the ulcer

Physical exam reveals a 5x5 cm fibrinous ulcer with violaceous undermined borders on her right shin.


A 10-year-old male presents with non-blanchable palpable purple papules on both legs for a week

His parents deny any other history of infectious diseases or new medications

The boy complains about abdominal pain and trouble walking

Physical exam reveals red and swollen ankles on top of palpable purpura on both legs.


Mycoplasma pneumoniae-induced rash and mucositis

A 12-year-old female presents with hemorrhagic crusts on the lips and erosions of the oral, genital, and conjunctival mucosa for 2 days

According to the parents, there was a pneumonia outbreak at school

The patient also had a high fever and cough a week before the onset of cutaneous lesions

The parents deny any new medication and a history of allergies

The physical exam reveals no other skin findings.


A 16-year-old male presents with an increased number of perinasal dome-shaped smooth flesh-colored papules

The physical exam reveals hypopigmented macules on his back, three café-au-lait patches, and flesh-colored papules emerging from nail folds

A biopsy of the facial lesions shows dermal proliferation of fibroblasts in a collagenous stroma associated with increased dilated blood vessels.


A 40-year-old female complains about squamous papules on her ears for 10 years

These lesions responded to topical corticosteroids but recurs when the treatment is stopped

Physical exam reveals erythematous scaly papules with signs of atrophy and scarring, as well as cicatricial alopecia

Skin biopsy shows lichenoid interface dermatitis with hyperkeratosis and follicular plugging.


A 30-year-old female presents with itchy skin lesions on her arms and legs

She denies family history of atopy and psoriasis

She does not take any medication and has no risk factors for hepatitis

Physical exam reveals flat purple papules and plaques on her wrists and shins as well as white plaques with with lacy patterns in the oral mucosa.


A 40-year-old female presents with a recurrent skin eruption on her nose and cheeks for 2 years

These lesions appears usually in the summer following excessive sun exposure, and disappears without scarring

She has complains about arthritis and chronic fatigue

Physical exam reveals butterfly-shaped erythematous plaques over the malar area, non-scarring alopecia and oral ulcers.


A 22-year-old male presents with a follicular eruption that has been present for 2 weeks

He has a history of anorexia nervosa and alcoholism

There is no identifiable preceding incident related to the eruption

He denies a history of atopy, drug use, and new medications

A review of systems shows positive findings for joint pain and bleeding gums

Physical exam reveals ecchymosis and purpuric follicular papules with corkscrew-like hair on his legs and arms.


A 5-year-old female presents with a plaque on her left leg

The lesion appeared a few months after her birth

It has been increasing in size proportionally to her growth

The parents mentions that the skin lesion sometimes becomes irritated, erythematous and itchy when the patient plays with it or when she gets sick

Physical exam reveals a red-brown well delimited plaque on her left leg without any noticeable erythema or epidermal changes.


A 12 year old male presents to clinic with concerns for new red bumps developing on the chest, arms, and legs over the past few months

Patient states the lesions begin as small bumps that slowly grow in size and persist

He denies any pain, itch, or symptoms associated with the lesions

He has not tried any treatment and denies any recent travel

The patient's mother states the patient also has a few light brown patches on the body, and some of her other family members had similar spots

The patient is currently receiving extra classes for learning disability, and recently was evaluated by orthopaedics for spinal irregularities

On physical examination, multiple skin colored papules that are able to be pushed in with a finger are spread across the chest, arms, and bilateral lower extremities

Seven light tan-brown ovoid uniform patches are scattered throughout the trunk and legs

The bilateral axilla are noted to have few scattered ovoid tan brown macules.


A 6 month old male presents to dermatology clinic for evaluation of skin depressions on the arms and legs present for a few months

The patient's mother denies any trauma that may have incited the depressions

Lesions are not painful or itchy to the patient

Mother denies any recent travel or treatments

Past medical history is relevant for full term prenatal course

At birth, patient was noted to be red across the entire body with thin flaky yellow skin attached to the back and chest which slowly healed

Recently, patient was also evaluated by orthopaedics and completed a hand x-ray that showed epiphyseal stippling

Physical examination is remarkable for multiple follicular based depressions a curvilinear distribution on the hands, legs, and feet on the hands, legs, and feet


A 34 year old woman presents to clinic complaining of a painful, red spot on the left shoulder that developed about 4 years ago

She denies any trauma that may have incited it

It has been evaluated by multiple dermatologists and treated with intralesional corticosteroid injections, but it continues to enlargen and has become more raised

Physical examination reveals a multilobular violaceous, poorly demarcated firm plaque that is tender to palpation on the left shoulder

Histopathologic analysis of the lesion reveals lesional cells that stain positive for CD34 and negative for Factor 13a.


A 45-year-old-man with a past medical history of knee pain and hypertension complains of dark spot on the lower lip that develop whenever he takes certain oral medications

He states the rash has been ongoing for several years, and usually begins as a pink spot with a darker brown-black center

He denies any bleeding or ulceration at the site

Current medications includes naproxen, multivitamins, and metoprolol

Physical examination reveals a well demarcated red-purple patch with a darker red-violaceous center


A 67-year-old-male farmer presents complaining of a growing mole on the right side of his cheek

He states the mole was present for several years, but then started growing rapidly on one side a few weeks ago

Sometimes the mole will bleed on its own

Physical examination shows tan-brown ovoid irreuglarly shaped hyperpigmented macule with focal ulcearion

Dermoscopy demonstrates a blue-gray veil in the center of the lesion.


A 13-year-old girl presents to the dermatology clinic with a light patch over both knees that the mom noticed a few months ago

The patient denies any pain at the site, and thinks she may have bumped her knee that caused the light patch

Physical examination reveals well demarcated depigmented irregularly shaped patches on the bilateral anterior knees.


A 45-year-old man with a past medical history of hypertension presents with concerns of a rash on his left lower back that his wife noticed two days ago

The rash has been progressively enlargened

Patient denies any pain or any prior treatments

He thinks the surrounding skin is warm and may be infected, but he denies any drainage

He reports that they went hiking eight days ago in Rhode Island

Physical exam demonstrates a non-scaly large annular, pink-red patch on the left lower back with a bright pink center and clear central clearing.


Acute Generalized Exanthematous Pustulosis

A 54-year-old female is hospitalized for a left lower leg cellulitis and treated with ampicillin

On day 4 of hospitalization, she developed a rash on the neck, under the arms that start as small yellow bumps but rapidly spread

She denies any any personal or family history of psoriasis

Physical examination reveals multiple studded monomorphic yellow pustules on erythematous bright pink bases that coalesce into plaques across the flexural neck, bilateral axilla, and inframmary folds.


A 30 year old male is admitted to the hospital for a rash that developed on the chest and then spread across the back, face, and legs

He recently started lamotrigine two weeks ago for seizure prevention

He denies any other recent medication changes

He endorses significant pain at the site of the rash and also pain with urination

Physical examination reveals diffuse pink erythematous patches of the chest, back with few scattered dusky central patches

Applying pressure with a finger and moving laterally results in separation of the skin on many areas of the back

A thin erosion is appreciated on the glans penis.


A 66-year-old woman with a past medical history of hypertension and diabetes mellitus type 2 presents to clinic with a mildly painful, pruritic peeling skin on the chest and back that began 4 weeks ago

She denies any new medications, new topical creams or lotions, or laundry detergents

She has been applying vaseline to the spots

She also thinks she may have a similar spot on the scalp

She denies any similar spots in the mouth, and denies forming any blisters on the skin

Physical exam demonstrates multiple thinly eroded pink-red oval plaques on the chest, scalp, back with yellow brown corn-flake like scale


A 21-year-old African American woman presents to clinic with rough, firm spots on both earlobes that developed three months ago when she underwent ear piercings

She has tried over the counter hydrocortisone without any improvement

She notes that she has a history of multiple similar spots that developed after she injured herself, and multiple family members have similar spots

On physical exam, thick violcaeous firm plaques are noted at the sites of ear piercings that extend beyond margin of the scar.


A 35-year-old man with a past medical history of obesity and tobacco use presents to clinic with a seven month history of boils under the arms and in the groin

He reports that the boils come up twice a week under the arms, and once a week in the groin

The individual boils are painful and will often drain foul odorous yellow green material

Many of the boils have been drained in the emergency room

Physical examination reveals multiple painful, tender subcutaneous nodules draining yellow-white malodorous pus in the bilateral axilla and inguinal folds

Scattered double headed comedones are present with few sinus tracts noted.


A 45-year-old man presents to the primary care clinic with a red, itchy rash on the eyebrows and around the nose that has been ongoing for eight months

He has tried moisturizers to the areas, but the flakiness returns a few days later

He also reports he has dandruff in his scalp

He denies any new facial products or using any other creams or lotions

Physical examination reveals greasy yellow scale on poorly demarcated erythematous patches on the eyebrows and bilateral nasal alar creases

Mild white scale is appreciated diffusely across the scalp.


A 24-year-old obese woman presents to the dermatology clinic with darkening, rough skin around the neck for six months

She has tried to clean the area with over the counter shampoo and rubbing alcohol without improvement

She denies any rash elsewhere on the body

The rash always begins as dark patches, and she denies any blistering or redness before the dark spots develop

Physical examination reveals thick, velvety ropey hyperpigmented rough, poorly demarcated plaques circumferentially around the neck.


A 65-year-old African American man presents to dermatology clinic for multiple non-painful, non-itchy brown spots on the face

He notes they started developing when he was 42 years old, and they have increased in number and size

Sometimes he tries to remove them with a needle, but they will bleed

Physical exam reveals multiple dark, flat topped ovoid papules, and few pedunculated brown-black papules on the bilateral zygomatic cheeks.


A 5-year-old boy presents to the pediatrician office with complaints of multiple spots that began on the abdomen and spread to the arms and legs

The spots are not itchy or painful, unless he scratches them

Sometimes the skin surronding the lesion will become very red and painful, but then the lesion and redness fade

The parents report they have tried topical corticosteroids but the lesions do not go away

Mom endorses a history of atopic dermatitis in her sister and herself

Physical exam reveals multiple dome shaped skin colored to light pink papules with central umbilication and yellow core across the chest and back.


A 65-year-old female presents to the dermatology clinic for evaluation of eyelid redness and neck rash ongoing for four months that began after she started a new body lotion

She reports increasing fatigue when climbing stairs and lifting heavy items over her head

She has not tried any topical treatments

She denies any recent medication changes, fevers, chills, or recent travel

Physical examination reveals poorly demarcated patchy pink erythema affecting the periocular areas with a bright pink poorly demarcated patch diffusely across the upper back and shoulders in the shape of a V

The bilateral dorsal hands reveals thin pink rough plaques on the knuckle joints.


A 53-year-old man with a past medical history of multiple myeloma presents to dermatology clinic with multiple yellow, irritated spots under the eyes

He reports the lesions developed about four months ago, beginning as a red spot that will enlargen, bleed, and then scab over with yellow material

He denies any new facial creams, topical treatments, or new medications

Physical examination is remarkable for hepatosplenomegaly and on the lower eyelids bilaterally are yellow-pink thinly ulcerated plaques with yellow crust.


A 34-year-old woman presents with complaints of a severely itchy rash affecting both lower legs that developed three days ago after returning from camping six days ago

She reports during the camping trip they often hiked for several hours a day, and she wore shorts due to the humid, hot weather

When the rash began, it began as small red bumps that formed larger fluid filled bumps

She has tried over the counter cortisone that helps with the itch a little bit

She denies any new topical lotions, laundry detergents, or body washes

Physical exam reveals multiple streaks of yellow vesicles on bright pink erythematous bases in a linear distribution on the bilateral lower extremities.


A 22-year-old female presents with a brown rough spot on the left shin which she noted when shaving her leg

She thinks it may have been there for a few weeks

She denies any pain, pruritus, or spontaneous bleeding from the site

She cannot recall any trauma that may have caused the lesion

She denies any personal or family history of skin cancer

Physical exam reveals a thin, firm brown dome shaped papule on the left shin that invaginates upon pinching.


Which of the following is the most likely diagnosis?

A 5-year-old girl is brought to the emergency department by her mother because of multiple episodes of nausea and vomiting that last about 2 hours.

During this period, she has had 6–8 episodes of bilious vomiting and abdominal pain.

The girl feels well between these episodes.

She has missed several days of school and has been hospitalized 2 times during the past 6 months for dehydration due to similar episodes of vomiting and nausea.

The patient has lived with her mother since her parents divorced 8 months ago.

She is at the 60th percentile for height and 30th percentile for weight.

Her temperature is 36.8°C (98.8°F), pulse is 99/min, and blood pressure is 82/52 mm Hg.

Abdominal examination shows a soft abdomen with mild diffuse tenderness with no guarding or rebound.

The remainder of the physical examination shows no abnormalities.


A 67-year-old man presents to the emergency department with a fever and altered mental status.

The patient has a history of Alzheimer dementia and is typically bed bound.

His son found him confused with a warm and flushed complexion thus prompting his presentation.

The patient has a past medical history of dementia, diabetes, and hypertension and typically has a visiting home nurse come to administer medications.

Prior to examination, he is given haloperidol and diphenhydramine as he is combative and will not allow the nurses near him.

His temperature is 102.9°F (39.4°C), blood pressure is 104/64 mmHg, pulse is 170/min, respirations are 22/min, and oxygen saturation is 100% on room air.

Physical exam is notable for dry and flushed skin and a confused man.

There is no skin breakdown, and flexion of the patient’s neck elicits no discomfort.

Laboratory studies are drawn as seen below. |  | Hemoglobin: 15 g/dL | Hematocrit: 45% | Leukocyte count: 4,500/mm^3 with normal differential | Platelet count: 227,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 24 mEq/L | BUN: 30 mg/dL | Glucose: 97 mg/dL | Creatinine: 1.5 mg/dL | Ca2+: 10.2 mg/dL | AST: 12 U/L | ALT: 10 U/L |  | Urine: | Color: Yellow | Bacteria: Absent | Nitrites: Negative | Red blood cells: Negative |  | An initial chest radiograph is unremarkable.

The patient is given 3 liters of Ringer's lactate and an electric fan to cool off.

Two hours later, his temperature is 99°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 100% on room air.

The patient’s mental status is at the patient’s baseline according to the son.


Which of the following represents the most likely etiology of her anemia.

A 41-year-old woman presents to her primary care physician with complaints of fatigue and weakness.

She denies any personal history of blood clots or bleeding problems in her past, but she says that her mother has had to be treated for breast cancer recently and is starting to wear her down.

Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia.

She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and currently denies any illicit drug use.

Her vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 111/min; and respiratory, rate 23/min.

On physical examination, her pulses are bounding and irregular, complexion is pale, but breath sounds remain clear.

On examination, the physician finds diffuse skin pallor and orders a complete blood count.

Her laboratory data demonstrate a hematocrit of 27.1%, MCV of 79 fL, and a reticulocyte count of 2.0%.


What is the most likely cause of his condition?

A 56-year-old man with known coronary artery disease presents to the emergency department complaining of chest discomfort and palpitations for 2 hours.

On arrival, the vital signs include blood pressure 122/76 mm Hg, heart rate 180/min, respiratory rate 22/min, temperature 37.0℃ (98.6℉), and blood oxygen saturation (SpO2) 98% on room air.

A 12-lead electrocardiogram demonstrated ST-segment elevation in the anterolateral leads.

The troponin level was 0.8 ng/mL (normal 0–0.4 ng/mL).

The patient declined primary percutaneous intervention and was treated with antifibrinolytics in the coronary care unit.

After 1 hour of treatment, the patient loses consciousness and the blood pressure falls to 60/40 mm Hg.

Cardiac monitoring shows the electrocardiogram (ECG) pattern in lead 2 shown below.


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

A 16-year-old female high school student is brought to the physician by her parents for her repeated behavioral problems at home and school during the past 10 months.

Her teachers describe her behavior as uncooperative and disruptive as she persistently refuses to answer questions, insults her teachers, and annoys her classmates on a daily basis.

At home, her parents try to address her frequent violations of curfew, but attempts at discussing the issue often result in their daughter losing her temper and screaming at her parents.

Her grades have deteriorated over the past year.

She has no history of psychiatric illness.

On questioning, the patient refuses to answer and frequently disrupts the physician’s conversation with the parents.


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

Collection of fluid in the tunica vaginalis

A 4-year-old boy presents to the office with his mother.

She states that the patient has been complaining of pain in his scrotum with swelling, abdominal pain, and nausea for the last 2 or 3 days.

On exam, the abdomen is soft and nontender to palpation.

The right scrotal sac is mildly enlarged without erythema.

A tender mass is palpated in the right scrotal area.

The mass does not transilluminate when a penlight is applied.

The patient is afebrile and all vital signs are stable.


Adjustment disorder with depressive features

A 59-year-old man presents to his primary care physician, accompanied by his wife, who requests treatment for his “chronic pessimism.” The patient admits to feeling tired and “down” most of the time for the past several years but insists that it is “just part of getting old.” His wife believes that he has become more self-critical and less confident than he used to be.

Neither the patient nor his wife can identify any stressors or triggering events.

He has continued to work as a librarian at a nearby college during this time and spends time with friends on the weekends.

He sleeps 7 hours per night and eats 3 meals per day.

He denies suicidal ideation or periods of elevated mood, excessive irritability, or increased energy.

Physical exam reveals a well-dressed, well-groomed man without apparent abnormality.

Basic neurocognitive testing and labs (CBC, BMP, TSH, cortisol, testosterone, and urine toxicology) are within normal limits.


ِA 62-year-old man comes to the emergency department because of colicky pain in the lower abdomen and abdominal distension for the past 12 hours.

He has chronic constipation for which he takes lactulose and senna laxatives.

His temperature is 37.1°C (98.7°F), blood pressure is 110/60 mm Hg and pulse is 85/min.

On physical examination, there is diffuse abdominal distension and tenderness, and bowel sounds are faint.

His plain abdominal radiograph is shown.


What is the most likely explanation for the patient’s presentation?

A 17-month-old girl was brought to the emergency department by her mom following a fall.

The mom reports that the patient was playing in the playground when she tripped and fell onto the mulch.

She had an uncomplicated birth history and has been meeting developmental goals except for language delay, for which she is to receive a hearing test for further evaluation next week.

Physical exam reveals bruising along the left lateral thigh, knee, and elbow; all lab tests are within normal limits.

Radiograph shows a fracture of the olecranon.

Serum chemistry and liver panels were within normal limits.


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

A 3855-g (8-lb 8-oz) newborn is examined shortly after birth.

She was delivered at 40 weeks' gestation by cesarean delivery because of breech presentation.

Physical examination shows asymmetric thigh creases.

The left leg is shorter than the right leg and positioned in external rotation.


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

A 27-year-old G1P0 woman at 9 weeks estimated gestational age presents for a prenatal visit.

She has no current complaints and takes no medications.

She is vegetarian and emigrated from Nepal 7 years ago.

She does not use tobacco, alcohol or recreational drugs.

The patient’s vital signs include: blood pressure 111/95 mm Hg, temperature 36.7°C (98.6°F), pulse 88/min.

Laboratory results are significant for the following: | Hemoglobin 10.2 g/dL | Erythrocyte count 5.5 million/mm3 | Mean corpuscular volume 65 μm3 | Mean corpuscular hemoglobin 21 pg/cell | Red cell distribution width 13.5% (ref: 11.5–14.5%) | Serum ferritin 170 ng/mL | .


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

A 55-year-old man comes to the emergency department because of a dry cough and severe chest pain beginning that morning.

Two months ago, he was diagnosed with inferior wall myocardial infarction and was treated with stent implantation of the right coronary artery.

He has a history of hypertension and hypercholesterolemia.

His medications include aspirin, clopidogrel, atorvastatin, and enalapril.

His temperature is 38.5°C (101.3°F), pulse is 92/min, respirations are 22/min, and blood pressure is 130/80 mm Hg.

Cardiac examination shows a high-pitched scratching sound best heard while sitting upright and during expiration.

The remainder of the examination shows no abnormalities.

Serum studies show a troponin I of 0.2 ng/mL (N < 0.01).


Of the following organisms, infection with which one is most consistent with her symptoms?

A 22-year old active duty soldier presents to your clinic with complaints of intense fatigue, fevers, abdominal pain, and a nonproductive cough.

Her symptoms began a few days ago, but she returned from a tour of duty in Malawi and Mozambique four weeks ago.

She endorses sleeping outside, using minimal bug spray, and swimming in rivers during her tour.

On physical exam, her temperature is 101.5, and she appears exhausted.

She has a hive-like rash scattered over her body.

Her abdominal exam is notable for hepatosplenomegaly, and her lung exam is notable for scattered crackles.

Her CBC with diff is remarkable for marked eosinophilia, and she has an elevated IgE.


Which of the following is the primary cause of the patient’s lab results?

A 46-year-old woman presents to the emergency department with progressive dyspnea and chest pain.

She reports that her symptoms started 1 week ago and have gotten progressively worse.

The chest pain is left-sided and is exacerbated by coughing or deep breaths.

She also endorses a 6-month history of joint pains involving her knees, elbows, and digits.

She does not have a significant medical or surgical history.

The patient’s temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 89/min, and respirations are 17/min with an oxygen saturation of 93% on room air.

On physical examination, a friction rub upon inspiration/expiration and crackles are appreciated at the base of the left lung.

She has an erythematous rash that spans the bilateral cheeks and nose.

There are also scattered ecchymoses on her arms and legs.

A chest radiograph shows a small left-sided pleural effusion.

A complete blood count is obtained, as shown below: |  | Hemoglobin: 9 g/dL | Hematocrit: 28% | Leukocyte count: 1,500/mm^3 with normal differential | Platelet count: 80,000/mm^3 |  | A urinalysis shows elevated protein levels.


A 31-year-old male presents with a 2-day history of watery diarrhea that began 8 days after his arrival from Africa.

None of the other members of his family became ill.

He reports symptoms of malaise, anorexia, and abdominal cramps followed by watery diarrhea.

He denies tenesmus, urgency, and bloody diarrhea.

His temperature is 98.6°F (37°C), respiratory rate is 15/min, pulse is 107/min, and blood pressure is 90/68 mm Hg.

A physical examination is performed and is within normal limits.

Intravenous fluids are started, and a stool sample is sent to the lab, which comes out to be negative for any ova/parasites, blood cells, or pus cells.


What is the most logical diagnostic test for this patient?

A 25-year-old woman complains of dyspnea and mild chest pain on exertion, which increases gradually with continued exertion.

She had similar symptoms last year and her medical record included the following arterial blood gas findings: | pH 7.51 | pO2 77 mm Hg | pCO2  32 mm Hg | An ECG last year demonstrated a right axis deviation.

The current chest X-ray showed enlarged pulmonary arteries but no parenchymal inﬁltrates.

A lung perfusion scan revealed a low probability for pulmonary thromboembolism.

The current ECG showed right heart strain but no evidence of primary cardiac disease.


A 4-year-old boy is brought to the physician because of a progressive rash for 2 days.

The rash started behind the ears and now involves the trunk and extremities.

Over the past 4 days, he has had mild sore throat, red, itchy eyes, and headache.

He was born at term and has been healthy except for recurrent episodes of tonsillitis and occasional asthma attacks.

Two weeks ago, he was treated for tonsillitis that resolved with penicillin therapy.

He immigrated with his family from Brazil 3 weeks ago.

His temperature is 38°C (100.4°F), pulse is 100/min, and blood pressure is 100/60 mm Hg.

Examination shows postauricular and suboccipital lymphadenopathy.

There is a non-confluent, pink maculopapular rash over the torso and extremities.

His palms and soles show no abnormalities.


Severe combined immunodeficiency syndrome

A 3-year-old Cuban-American male has a history of recurrent Pseudomonas and Candida infections.

Laboratory analysis reveals no electrolyte abnormalities.

Examination of his serum shows decreased levels of IgG and CT scan reveals the absence of a thymus.


A 38-year-old woman comes to the emergency department because of progressive headache, blurry vision, and nausea for 1 day.

Four days ago, she was diagnosed with a right middle ear infection.

Her temperature is 39.1°C (102.3°F), and blood pressure is 148/95 mm Hg.

Ophthalmologic examination shows bilateral swelling of the optic disc.

The corneal reflex in the right eye is absent.

Sensation to touch is reduced on the upper right side of the face.

Serum studies show increased concentrations of fibrin degradation products.


Which of the following is the most likely underlying cause of the patient's condition?"

A 7-year-old girl is brought to the physician for evaluation of recurrent epistaxis.

Her mother reports that she bruises easily while playing.

Her pulse is 89/min and blood pressure is 117/92 mm Hg.

Examination shows multiple bruises in the upper and lower extremities.

Laboratory studies show: | Platelet count 100,000/mm3 | Prothrombin time 12 seconds | Partial thromboplastin time 33 seconds | Bleeding time 13 minutes | A peripheral blood smear shows enlarged platelets.

Ristocetin assay shows no platelet aggregation.


Which of the following disorders does this patient potentially suffer from?

Obsessive compulsive personality disorder

A 30-year-old male biology graduate student was dismissed from his PhD program after 8 years because he was not able to produce a thesis, claiming that his data was never exactly how he wanted it.

He would spend weeks planning out a simple experiment, since everything had to be just right.

For many experiments, he would start over because he felt he went out of order in adding the reagents to his media for his cells.

He has had similar problems in his undergraduate courses, often failing to complete his assignments on time because he had to revise them until they were perfect.


Arterial blood gas analysis on room air shows: | pH 7.56 | PCO2 40 mm Hg | PO2 94 mm Hg | HCO3- 30 mEq/L | Measurement of which of the following is the most appropriate next step in diagnosis?"

A 24-year-old primigravid woman at 8 weeks' gestation is brought to the emergency department because of a 5-day history of nausea and vomiting.

She has not been able to tolerate much food or drink.

She has tried multiple oral antiemetics with limited relief.

She has not had fevers, chills, abdominal pain, urinary symptoms, or diarrhea.

Her temperature is 37°C (98.6°F), pulse is 105/min, and blood pressure is 108/60 mm Hg.

Examination shows dry mucous membranes and cool extremities, with delayed capillary refill time.


Which of the following is the most likely cause of these findings?"

A 64-year-old man comes to the physician because of a 2-week history of intermittent epigastric discomfort.

He reports that his urine has been very dark, and his stools have been pale for the past week.

His appetite has decreased, and he has had a 4.5-kg (10-lb) weight loss during this period.

He has smoked 1 pack of cigarettes daily for 30 years.

He has chronic left knee pain, for which he takes acetaminophen.

Examination shows jaundice of the skin and scleral icterus.

There are scratch marks on the extremities.

Abdominal examination shows a nontender, palpable mass in the right upper quadrant.

The remainder of the examination is normal.

Laboratory studies show: | Hemoglobin 11.6 g/dL | Leukocyte count 8,700/mm3 | Platelet count 172,000/mm3 | Serum | Urea nitrogen 17 mg/dL | Creatinine 1.1 mg/dL | Bilirubin | Total 6 mg/dL | Direct 5.2 mg/dL | Alkaline phosphatase 220 IU/L | Ultrasonography shows dilated extrahepatic and pancreatic ducts and a distended gall bladder.


A 55-year-old African American man presents to the emergency department with central chest pressure.

The pain was initially intermittent in nature but has become constant and radiates to his jaw and left shoulder.

He also complains of some difficulty breathing.

The patient was diagnosed with essential hypertension 1 year ago, but he is not taking any medications for it.

The patient denies smoking, alcohol, or drug use.

His blood pressure is 230/130 mm Hg in both arms, the temperature is 36.9°C (98.4°F), and the pulse is 90/min.

ECG shows diffuse T wave inversion and ST depression in lateral leads.

Laboratory testing is significant for elevated troponin.


A 19-year-old female college student comes to the physician for a sudden loss of visual acuity of her right eye.

She noticed that she was unable to read the time on the alarm clock when she woke up in the morning.

When she closes her right eye, she is able to see sharply.

When she closes her left eye, she has blurry double vision.

She does not recall trauma to her eye but has been working long nights on her honors thesis.

She has a history of occasional shoulder luxation.

She is 180 cm (5 ft 11 in) tall, and weighs 62 kg (136 lbs); her BMI is 19.1 kg/m2.

Her vital signs are within normal limits.

On physical examination, slender and long fingers are noted.

She has several flat, demarcated brownish nevi on her left cheek.

Ocular examination shows upward temporal subluxation of her right lens.


Which of the following is the most likely underlying cause of these findings?"

A 14-year-old boy is brought to the emergency department because of a 2-day history of fatigue.

He reports that during this time he has had occasional palpitations and shortness of breath.

Current medications include hydroxyurea and folic acid.

His temperature is 38.3°C (100.9°F), pulse is 120/min, respirations are 24/min, and blood pressure is 112/74 mm Hg.

Cardiac examination shows a midsystolic ejection murmur.

Laboratory studies show: | Hemoglobin 6.4 g/dl | Leukocyte count 6,000/mm3 | Platelet count 168,000/mm3 | Mean corpuscular volume 84 μm3 | Reticulocyte count 0.1% | .


Which of the following is the most likely diagnosis?

A 64-year-old woman comes to the physician because of several episodes of dizziness during the last month.

The episodes last between 30–40 seconds and during the episodes she feels as though she is spinning.

Episodes usually occur immediately after lying down or suddenly sitting up from a reclined position.

They also sometimes happen when she suddenly turns her head to look at something.

Last month, she had an upper respiratory tract infection that resolved spontaneously.

She has hypertension treated with hydrochlorothiazide.

Otoscopic examination shows no abnormalities.

There is no lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead.


A 45-year-old man presents to the clinic for the third time in the past 3 weeks asking for an MRI of his lower back.

He had initially gone to the gym as advised by his wife and had started doing some back exercises.

The next day, he developed soreness in his lower back and spent the whole day online trying to figure out what was wrong with him.

He has been to the emergency department a few times and subsequently has been redirected to the clinic where each time he was thoroughly examined and investigated for all the possible causes.

The patient still exhibits worry and would like to get an MRI to make sure everything is ‘okay.’ .


Shortly after undergoing a bipolar prosthesis for a displaced femoral neck fracture of the left hip acquired after a fall the day before, an 80-year-old woman suddenly develops dyspnea.

The surgery under general anesthesia with sevoflurane was uneventful, lasting 98 minutes, during which the patient maintained oxygen saturation readings of 96–100% on 8 L of oxygen.

She has a history of hypertension, osteoporosis, and osteoarthritis of her right knee.

Her medications include ramipril, naproxen, ranitidine, and a multivitamin.

She appears cyanotic, drowsy, and is oriented only to person.

Her temperature is 38.6°C (101.5°F), pulse is 135/minute, respirations are 36/min, and blood pressure is 155/95 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 81%.

There are several scattered petechiae on the anterior chest wall.

Laboratory studies show a hemoglobin concentration of 10.5 g/dL, a leukocyte count of 9,000/mm3, a platelet count of 145,000/mm3, and a creatine kinase of 190 U/L.


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

A 4-day-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her son's skin appears yellow.

She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted.

She has been breastfeeding exclusively and feels that he has been feeding well.

He has been having a bowel movement on average once every 3 days.


A 60-year-old man presents to the physician for a follow-up examination.

During the previous visit, splenomegaly was detected on the abdominal exam, which has been confirmed by abdominal ultrasound.

He has no complaints other than fatigue for several months.

His only medication is acetaminophen for knee pain.

The temperature is 36.7℃ (98.1℉), pulse is 68, respirations are 12/min, and blood pressure is 125/70 mm Hg.

On physical examination, the spleen size on percussion is 16 cm (6.2 in).

Otherwise, the physical examination shows no abnormalities.

The laboratory test results are as follows: | Hemoglobin 10 g/dL | Mean corpuscular volume 90 μm3 | Leukocyte count 80,000/mm3 | Platelet count 450,000/mm3 | The peripheral blood smear shows a predominance of neutrophils and the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).


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

A 75-year-old woman is brought to the emergency department because of vomiting, abdominal pain, and constipation for the past 2 days.

She has urinated frequently over the past week and has become excessively thirsty during this time.

She has no significant past medical history.

Her blood pressure is 95/70 mm Hg, pulse is 110/min, respirations are 25/min, and temperature is 37.1°C (98.8°F).

Lung auscultation shows rhonchi and wheezing localized to the right middle lobe area.

An electrocardiogram (ECG) shows a shortened QT interval.


A 30-year-old previously healthy male presents to your office with complaints of facial pressure and rhinorrhea for the past 3 weeks.

The patient reports that several weeks prior, he had a “common cold” which resolved.

However, he has since developed worsening facial pressure, especially over his cheeks and forehead.

He reports over 1 week of green tinged rhinorrhea.

His temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min.

Nasal exam reveals edematous turbinates and purulent discharge.


A 48-year-old man comes to the physician because of a 4-month history of persistent cough productive of white phlegm.

He coughs consistently throughout the day, and he has not noticed any particular triggers that make it worse.

He has also recently experienced some shortness of breath with exertion.

He has not had any weight loss, fever, or chills.

He had similar symptoms last year, which lasted about 6 months.

He has hypertension, for which he takes amlodipine.

He has worked in construction for the past 10 years.

He has smoked a pack of cigarettes per day for 30 years.

Examination shows an end-expiratory wheeze throughout all lung zones.


A 2-year-old girl is brought to the physician because of abdominal distention and twitching of her feet, which her mother noticed a week ago.

The patient has also had a low-grade fever for 5 days.

She has not had a bowel movement in 3 days.

She was born at term and has been healthy since.

She is at the 40th percentile for height and 20th percentile for weight.

Her temperature is 38.1°C (100.6°F), pulse is 128/min, and blood pressure is 135/82 mm Hg.

Examination shows an irregular palpable mass that crosses the midline of the abdomen.

The liver is palpated 3 cm below the right costal margin.

There are erratic movements of the eyes.

A 24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid levels.


Which of the following is the most probable cause of the newborn’s condition?

A 29-year-old G3P2 undergoes a cesarean section at 38 weeks gestation and delivers a boy weighing 4570 g with Apgar scores of 5 and 8 at 1 and 5 minutes, respectively.

The current pregnancy was complicated by gestational diabetes with poor glycemic control.

The newborn’s heart rate is 122/min, the respiratory rate is 31/min, and the temperature 36.4℃ (97.5℉).

On examination, the newborn is pale, lethargic, diaphoretic, and has poor muscular tone.

The liver is 2 cm below the right costal margin.


Of the following options, which underlying condition could cause this reaction?

A 4-year-old boy is referred to the transfusion clinic with malaise, fever, bilateral conjunctivitis, erythema of the oral mucosa, macular rash of the trunk, and inguinal lymphadenopathy following several days of loose stool.

The boy was born at 39 weeks gestation via spontaneous vaginal delivery.

He is up to date on all vaccines and is meeting all developmental milestones.

Kawasaki’s disease is suspected and therapy with intravenous immunoglobulin and aspirin is initiated.

Later that day, the patient develops trouble breathing, facial flushing, and rapidly evolving pruritic abdominal rash.

He is rushed to the emergency department where his blood pressure is 85/48 mm Hg, heart rate is 120/min, respiratory rate is 26/min, and temperature is 37.0°C (98.6°F).

On physical examination, the patient has severe facial edema and severe stridor, which can be heard without a stethoscope.


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

Abdominal aortic aneurysm repair complication

A 59-year-old man presents to the emergency department with abdominal pain.

He states that it seemed to come on abruptly, though he does endorse feeling pain the past several days.

He has been experiencing bloody diarrhea as well as a subjective fever.

His past medical history is notable for an ST elevation myocardial infarction (STEMI) treated 1 year ago, an abdominal aortic aneurysm (AAA) treated 1 week ago, chronic obstructive pulmonary disease (COPD), asthma, obesity, hypertension, stroke treated 5 years ago, an atrial arrhythmia, diabetes, constipation, and post-traumatic stress disorder (PTSD).

His temperature is 102.0°F (39°C), blood pressure is 197/128 mmHg, pulse is 135/min, respirations are 22/min, and oxygen saturation is 92% on room air.

On physical exam, you note an obese man in distress.

Cardiopulmonary exam is notable for bilateral wheezes and a systolic murmur.

There is bilateral lower extremity pitting edema and venous stasis ulcers.

Abdominal exam reveals diffuse tenderness which the patient describes as 10/10 in severity.

Laboratory values are ordered as seen below. |  | Hemoglobin: 14 g/dL | Hematocrit: 42% | Leukocyte count: 15,500/mm^3 with normal differential | Platelet count: 199,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.4 mEq/L | HCO3-: 22 mEq/L | BUN: 32 mg/dL | Glucose: 189 mg/dL | Creatinine: 1.9 mg/dL | Ca2+: 10.2 mg/dL | Lactate: 4.5 mg/dL | AST: 12 U/L | ALT: 10 U/L |  | .


A 44-year-old man presents to the emergency department due to sudden chest pain and difficulty breathing for the past 3 hours.

The pain is felt in the retrosternal area and radiates up to his left shoulder and arm; it worsens on inspiration, and is relieved when he is leaning forward.

His heart rate is 61/min, respiratory rate is 16/min, temperature is 36.5°C (97.7°F), and blood pressure is 115/78 mm Hg.

Physical examination shows no abnormalities.

Pericardial friction rub is heard on auscultation.

Laboratory results show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels.


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

Infiltrating ductal carcinoma of the breast

A 65-year-old woman presents to the emergency department with a new-onset seizure.

The patient was at home watching television when she suddenly began jerking her limbs and not responding according to her partner.

The patient works as a gardener is often dehydrated but drinks large volumes of water to compensate for her work.

She does not wear protective gear or sunscreen while working.

She has smoked 1.5 packs of cigarettes per day for the past 40 years.

She drinks liquor before bed every night.

The patient has a past medical history of hypertension and diabetes and recently lost 9 pounds.


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

A 45-year-old woman comes to the physician because of fatigue and irregular menstrual cycles for the past year.

She also complains of recurrent sinus infections.

During the past 6 months, she has had increased urinary frequency and swelling of her feet.

She has also had difficulty lifting her 3-year-old niece for the past 3 weeks.

She was recently diagnosed with depression.

The patient has smoked one half-pack of cigarettes daily for 25 years and drinks four beers on the weekends.

She is 160 cm (5 ft 3 in) tall and weighs 79 kg (175 lb); BMI is 31 kg/m2.

Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/82 mm Hg.

Physical examinations shows neck obesity and an enlarged abdomen.

Examination of the skin shows multiple bruises on her arms and legs.

There is generalized weakness and atrophy of the proximal muscles.

Laboratory studies show: | Serum | Na+ 150 mEq/L | K+ 3.0 mEq/L | Cl- 103 mEq/L | HCO3- 30 mEq/L | Urea nitrogen 19 mg/dL | Creatinine 0.9 mg/dL | Glucose 136 mg/dL | A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50) and a 24-hour urinary cortisol is 425 μg (N < 300 μg).

Subsequently, a high-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50).


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

A 43-year-old woman presents with left calf pain.

She denies any previous episodes of such pain.

Past medical history is significant for cervical carcinoma treated with cryosurgery with no evidence of recurrence.

Current medications are an estrogen-containing oral contraceptive and a multivitamin.

The patient reports a 40-pack-year smoking history, but no alcohol or recreational drug use.

The patient is afebrile and her vital signs are within normal limits.

On physical examination, her left calf is swollen, erythematous, and tender to palpation.


Normal post-operative visual adaptations

A 47-year-old man presents to his ophthalmologist for abnormal vision.

The patient was discharged from the hospital 2 weeks ago after a motor vehicle accident where he was given 1L of blood.

He also underwent several surgical procedures including enucleation of the right globe and exploratory abdominal laparotomy to stop internal bleeding.

Currently, he states that he has noticed decreased vision in his left eye.

The patient has a past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.

His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 97% on room air.

Physical exam is notable for 20/200 vision in the patient's left eye, which is worse than usual.

The patient's left eye appears red and irritated.


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

A 29-year-old woman presents to her primary care physician with worsening fatigue and lightheadedness over the past several months.

She states that she has felt easily fatigued and has experienced several falls during this time frame as well.

She drinks 5 to 8 drinks per day and works as a waitress.

Her temperature is 98.2°F (36.8°C), blood pressure is 114/64 mmHg, pulse is 98/min, respirations are 12/min, and oxygen saturation is 98% on room air.

Laboratory studies are ordered as seen below. |  | Hemoglobin: 9.0 g/dL | Hematocrit: 29% | Leukocyte count: 6,700/mm^3 with normal differential | Platelet count: 199,400/mm^3 | Methylymalonic acid: 1.0 umol/L (normal < 0.40 umol/L) |  | .


What is the most likely cause of her symptoms?

A 63-year-old woman with a history of adult polycystic kidney disease and COPD presents to her optometrist after having difficulty watching a movie.

She is accompanied by her daughter, who notes that her mother hasn’t been able to look at her since the previous day.

On exam, her right eye has full range of motion, but her left eye is fixed in a down and outward position.


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

A 23-year-old African American G1P0 woman at 18 weeks estimated gestational age presents with fatigue and lethargy.

She says the symptoms onset gradually about 1 week ago and have progressively worsened.

She denies smoking, drug or alcohol use.

The patient is afebrile and vital signs are within normal limits.

Her physical examination is unremarkable.

Her blood count shows the following: | Hemoglobin 10.8 g/dL | Red blood cell count 5.7 million/mm3 | Mean corpuscular volume (MCV) 76 μm3 | Red cell distribution width 12.4% (ref: 11.5–14.5%) | She is empirically started on ferrous gluconate tablets.

Five weeks later, she shows no improvement in her hemoglobin level.


A 49-year-old woman otherwise healthy presents to the outpatient department with swelling of the neck.

Family history is negative for any thyroid disorders.

Physical examination shows a nontender thyroid gland with a nodule on the right side.

The thyroid gland is mobile on deglutition.

Fine needle aspiration and cytology show empty appearing nuclei with central clearing, nuclear grooves and branching structures interspersed with calcific bodies.


A 43-year-old woman presents to a new primary care physician complaining of anxiety.

She has been worrying non-stop recently about the possibility that her husband will lose his job as a teacher.

Her husband, who is present, assures the physician that his job is entirely secure and states that she has "fretted" for their entire marriage, though the exact topic causing her anxiety varies over time.

She also worries excessively about everyday tasks, such as whether she will catch the train on time and whether their house in Southern California is sufficiently earthquake-proof.

She has no way to overcome these worries.

She endorses other symptoms including poor sleep (associated with racing thoughts about her various worries), fatigue, and impaired concentration at work, all of which have been present for at least the past year.

Her vital signs are within normal limits and there are no abnormalities on physical exam.


Which of the following is the most probable cause of his complaints?

A 13-year-old boy presents to the clinic for evaluation of pain, swelling, and redness in the left knee.

This began a month ago and has been progressively worsening.

He thinks his pain is due to playing soccer.

He is frustrated that the pain does not respond to Tylenol.

On examination, there is tenderness and warmth present over the knee with limitation of movement.

The laboratory values show a normal white blood cell (WBC) count and elevated alkaline phosphatase.

A radiograph of the knee shows mixed lytic and blastic lesions.


A 68-year-old male presents to your office for his annual physical exam.

He has no complaints at this time and his chronic hypertension is well controlled.

You notice a .5cm papule on the patient's eyelid that has a pink pearly appearance, rolled borders, and overlying telangiectasias.

On further questioning, you find out the patient was a door-to-door salesman and spent a lot of time outdoors, and he did not wear sunscreen.

The patient states that he first noticed the lesion about 6 months prior, and it has grown slightly since then.


What is the most likely diagnosis for this patient?

An obese 50-year-old woman presents to the emergency department of a rural hospital due to chest pain for the last 12 hours.

The pain is substernal, crushing in nature, radiating into her neck, and accompanied by profuse sweating.

Her history is significant for hypertension, and she admits poor compliance with her medications.

An ECG done at the clinic confirmed the presence of STEMI, and the patient was given aspirin.

The ambulance was in an accident on the way to the hospital and by the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation.

The patient is admitted and is stable for 3 nights with no dyspnea or edema.

Her blood pressure is kept under control while in the hospital.

On the fourth night, the patient becomes quite agitated and soon thereafter she is unresponsive.

She has an elevated JVP and upon auscultation, heart sounds are distant.


Which of the following best explains the findings in this patient?

Atrophy and fibrosis of the esophageal smooth muscle

Metaplastic transformation of esophageal mucosa

Neoplastic proliferation of squamous epithelium

Eosinophilic infiltration of the esophageal walls
"

A 68-year-old man comes to the physician because of a 4-month history of bad breath and progressive difficulty swallowing solid food.

Physical examination shows no abnormalities.

An upper endoscopy is performed and a photomicrograph of a biopsy specimen obtained from the mid-esophagus is shown.


Which of the following is the most appropriate next step in diagnosis?

A 43-year-old woman comes to the physician because of a 2-month history of progressive muscle pain and stiffness that worsens with exercise.

She also has difficulty climbing stairs, getting out of chairs, and putting things on shelves or in cupboards.

She has had constipation, occasional headaches, and a 9-kg (20-lb) weight gain during the past year.

She has hypertension controlled with atenolol and amlodipine.

She has used calamine lotion for the past 6 months for dry skin.

Her pulse is 80/min and her blood pressure is 138/76 mm Hg.

Physical examination shows weakness of the proximal muscle groups.

She has delayed tendon reflex relaxation, with a mounding of the muscle surface occurring just before relaxation.


A 40-year-old woman presents to the clinic for hair loss.

She was in her usual state of health until earlier this month when she started noticing more and more hair on her pillow in the morning.

The problem has only been getting worse since then; she's even started pulling out clumps of hair when she shampoos in the morning.

She has no other symptoms, and her past medical history is unremarkable.

The physical exam is notable for smooth, circular, non-scarring, hairless patches across her scalp.

A firm tug on a bundle of hair causes almost all of the hair to be removed.


A previously healthy 75-year-old man comes to the physician with a 6-month history of fatigue, weight loss, and abdominal pain.

He drinks 2 oz of alcohol on the weekends and does not smoke.

He is retired but previously worked in a factory that produces plastic pipes.

Abdominal examination shows right upper quadrant tenderness; the liver edge is palpable 2 cm below the ribs.

A liver biopsy specimen shows pleomorphic spindle cells that express PECAM-1 on their surface.


A 5-year-old boy is brought to the physician because of high-grade fever and generalized fatigue for 5 days.

Two days ago, he developed a rash on his trunk.

He returned from a family hiking trip to Montana 1 week ago.

His immunization records are unavailable.

His temperature is 39.8°C (103.6°F), pulse is 111/min, and blood pressure is 96/60 mm Hg.

Examination shows injection of the conjunctivae bilaterally.

The tongue and pharynx are erythematous.

Tender cervical lymphadenopathy is present on the left.

There is a macular rash over the trunk and extremities.

Bilateral knee joints are swollen and tender; range of motion is limited by pain.

Cardiopulmonary examination shows no abnormalities.


Which of the following is the most likely predisposing factor for this patient’s current condition?

A 59-year-old man is brought to the emergency department by his wife because of fever, chills, night sweats, and generalized fatigue for 2 weeks.

Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border, and crackles at both lung bases.

A transesophageal echocardiography shows a 12 mm vegetation on the aortic valve.

Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains that are unable to grow in a 6.5% NaCl medium.


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

A 52-year-old woman comes to the physician because of mild fatigue and dizziness for the past 2 days.

She has not been to work since yesterday due to her symptoms.

She says she has ""very high blood sugar” and has had similar episodes often in the past 2 years, for which she has visited multiple doctors around the city.

She has also purchased a home glucose monitoring device, which she uses daily.

Since the symptoms began, she has become socially withdrawn and spends much of her time at home researching diabetes on the internet.

One week ago, she took a day off work because of her symptoms.

She has had 3 laboratory test reports that all show normal fasting and post-meal blood glucose levels.

Her father and brother have diabetes mellitus type 2.

Physical examination shows no abnormalities.


Which of the following is the most likely diagnosis?

A 78-year-old man comes to the physician for evaluation of progressive hearing loss in both ears over the past year.

He has difficulties understanding conversations in crowded places and when more than one person talks at the same time.

He has no dizziness, ear discharge, ringing noise, or ear pain.

He has a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus.

Medications include enalapril, metformin, and atorvastatin.

Otoscopic examination shows pearly gray, translucent tympanic membranes with a normal light reflex.

A vibrating 512 Hz tuning fork is placed on the left mastoid process.

Once the patient no longer hears a tone, the fork is held over the ipsilateral ear and the patient reports to hear the tone again.

The same test is repeated on the right side with similar results.

There is no lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead.


A 65-year-old Asian woman comes to the physician for a routine health maintenance examination.

On questioning, she has had occasional night sweats during the past 2 months.

Seven months ago, she had an acute myocardial infarction and was treated with percutaneous coronary intervention.

She has hypertension, hyperlipidemia, and gastroesophageal reflux disease.

She has smoked one pack of cigarettes daily for 37 years.

Current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.

She is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.

Her temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.

There is a nontender skin lesion near the right large toenail.

The remainder of the examination shows no abnormalities.


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

A 22-year-old female software analyst presents to a medical clinic for evaluation of tingling and numbness in both hands for the past 2 months.

Her symptoms are usually aggravated by the end of the work day and absent on most off days.

She has been a type I diabetic for 2 years and is currently on insulin.

She admits to being sexually active but has had irregular periods for the past 3 months.


A 27-year-old woman presents to the emergency department for pain in multiple joints.

She states that she has had symmetric joint pain that started yesterday and has been worsening.

It is affecting her wrists, elbows, and shoulders.

She also endorses a subjective fever and some fatigue but denies any other symptoms.

The patient works as a schoolteacher and is generally healthy.

She is currently sexually active with 2 male partners and uses condoms occasionally.

Her temperature is 100°F (37.8°C), blood pressure is 122/85 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.

Her laboratory values are within normal limits.

Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.

The patient is discharged with ibuprofen.

Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control.


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

A 57-year-old man with HIV and GERD comes to the emergency department because of productive cough with malodorous phlegm and night sweats for the past week.

He has smoked 1 pack of cigarettes daily for 30 years and he drinks 8–10 beers daily.

Physical examination shows coarse crackles and dullness to percussion at the right lung base.

Scattered expiratory wheezing is heard throughout both lung fields.

The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).