Harbor Hospital Resident's POW

Skin rash and Weight Loss

2009-10-16T21:16:00.004-04:00

65 year old cab driver with history of chronic hepatitis C and eczema comes in to the office with a non-pruritic rash that has been progressing over the past few months. It involves his arms, back and chest. He denies any associated systemic symptoms. He denies any exposure to new chemicals, topical or systemic. His last travel to his home country, Ghana, was about a year ago. He drinks liquor on a daily basis. He is in a monogamous relationship with his girlfriend. His medications include Sildenafil and mometasone ointment prn. Review of systems is significant for an unintentional 30 lb wt loss since his last office visit a year ago. He has diffuse, hyperpigmented coalescing macules on his arms, trunk and back with fine superficial scales. He also has tenderness involving the LLQ.

Which of the following is the most likely diagnosis?

A. Pityriasis Versicolor
B. Pityriasis Rotunda
C. Tinea corporis
D. Eczema
E. Psoriasis

On follow up next week, the patient reports some improvement with the treatment prescribed for the skin rash. Blood work reveals a platelet count of 77, AST: 95, ALT: 70, ALP: 150. Abdominal CT shows multiple hepatic masses. EGD and colonoscopy were normal. PET scan showed multiple hepatic masses, the largest one being about 5 cm, which had abnormal uptake of FDG (SUV: 7.4). Alpha feto protein was 2024 (Nml <6).

Which of the following dermatological pathology is most common in primary HCC?

A. Pityriasis Versicolor
B. Pityriasis Rotunda
C. Tinea corporis
D. Eczema
E. Psoriasis

Rash after a Football Game

2009-09-26T09:46:00.004-04:00

A young woman with no PMH comes to office with a pruritic rash on her neck, forearms and upper back that she noticed after returning from a football game past evening. One of her friends who was at the game also developed similar rash on her legs. She denies exposure to new chemicals, topical or systemic. She denies travel or sick contacts. She is otherwise asymptomatic. She does not take any medications on a regular basis. On exam, she has extensive papular eruptions with minimal surrounding erythema and a few excoriations on neck, forearms and upper back.

Which of the following is the best initial empiric treatment options?

A. Prednisone, with a quick taper over a week
B. Topical mid-potency steroids
C. Doxycycline 100mg bid for 7-10 days
D. Topical and systemic Antihistaminics
E. Combination of H1 and H2 Antagonists- ANSWER

Old man with diffuse itchy rash

2009-03-08T18:53:00.003-04:00

90 y.o white gentleman with h/o HTN, HLD, COPD and GERD is admitted to the hospital for progressive epigastric discomfort and a sensation of food sticking in his lower esophagus. In addition, he has also noticed a red itchy rash for the past few days that has been spreading from neck to toes. He denies fever, malaise, weight loss or arthralgias. He denies any change in laundry detergent or soaps. He meds are also unchanged, which include Atenolol, Diovan, Ambien, Omeprazole, Mylanta, Milk of Magnesia, Xanax, Albuterol, mucinex, Senna, Tylenol, Vitamin D and Calcium. On exam, his vital signs are stable. Diffuse circumscribed rash that is raised and erythematous is noted. The patient received a combination of anti-histaminics (H1 & H2) as well as steroids. His rash completely resolved by the next day. Which one of the following is the most likely diagnosis?

A. Urticaria
B. Morbilliform drug eruption
C. Severe atopic dermatitis
D. Erythema multiforme
E. Pityriasis rosea

Chest X-ray abnormality

2009-02-28T22:04:00.004-05:00

70 y.o. woman with h/o HTN, Hyperlipidemia, DM, PVD and CAD, is admitted to hospital with pneumonia. About 48 hrs after hospitalization the patient develops septic shock and rapid response team is called. Due to lack of good iv access, senior resident quickly places a lt. subclavian triple lumen catheter and the patient is transferred to the ICU. Subsequently, the patient also has an arterial catheter placed for close hemodynamic monitoring. 2 days later, the arterial catheter is removed. Patient continues to have borderline hypotension and the attending physician requests measurement of CVP. ICU nurse states that the TLC placement precludes her from measuring CVP. Based on the CXR findings, what was the reason of her statement?

A. She could see the arterial waveforms on the monitor- ANSWER
B. The TLC was significantly proximal and needed to be pushed further in, to get the measurement
C. The nurse was not trained to interpret CVP
D. The TLC was significantly distal and needed to be pulled back to get the measurement
E. The TLC was coiled up and needed to be replaced.

Had the patient developed a complication from the TLC placement and a law-suit was filed, which of the following individual(s) would receive a subpoena for deposition?

A. Attending Physician
B. Radiologist
C. Resident
D. Intensivist
E. All of the above- ANSWER

Bumps on the back

2009-02-16T16:34:00.003-05:00

30 y old Caucasian gentleman is found to have the skin findings on his back, as shown in the picture. What is the diagnosis?

A. Dermal melanocytic nevocellular nevi- ANSWER
B. Neurofibroma
C. Spitz nevus
D. Trichoepithelioma
E. Dermatofibroma

Rash after a hunting trip

2008-12-08T21:42:00.003-05:00

46y white man, with no PMH, comes to the office c/o skin eruptions that started after a hunting trip in the woods. The eruptions started on his ankles and have gradually spread all over his body. He denies taking any medications or recent change in detergents, soaps etc. On exam, he has multiple papules on his arms and legs, some of them unroofed, from scratching. What is the most likely diagnosis?

A. Allergic contact dermatitis
B. Insect bite reaction- ANSWER
C. Folliculitis
D. Scabies
E. Erythema migrans

Bump on the pelvis

2008-11-16T15:37:00.003-05:00

30 y white man comes to the office complaining of multiple lesions on his pelvic region that have developed over the past few months. He denies any local or systemic symptoms. He has not significant PMH and is not on any medications. He acknowledges having more than 6 sexual partners since being sexually active as a teenager. On examination, he has multiple dome-shaped papules with an umbilicated center.

Which of the following is the most likely diagnosis?

A. Condyloma acuminata
B. Syringoma
C. Sebaceous hyperplasia
D. Molluscum contagiosum- ANSWER
E. Keratoacanthoma

Discolored nails

2008-10-23T16:33:00.004-04:00

30 year old gentleman comes to the office stating “I have fungus on my nails”. He does not have any significant PMH and is currently not on any medications. He work involves cleaning dishes at a local restaurant. Review of systems is pertinent for red itchy skin rash behind both ears and in the inter-gluteal fold. As show in the picture, he has yellow discolored, pitted finger nails (and toe nails) with onycholysis and erythematous skin rash behind both the ears, with minimal scaling. A similar rash, without scaling is noted in the intergluteal fold extending up to the anal region.
Which of the following treatment options is most effective for his discolored nails?

A. Oral methotrexate
B. Topical methylprednisolone aceponate 0.1%- ANSWER
C. Oral Terbinafine
D. Topical Ciclopirox

Bullous eruption on the beach

2008-09-12T21:51:00.002-04:00

A 40-year-old man is brought to the emergency department because of a 1-day history of rapidly progressing pain, swelling, and erythema of his right leg associated with fever, chills, and delirium. The patient was vacationing on the Gulf Coast of Florida and feasting on seafood. One day ago, he noted redness and swelling of his right great toe in an area that had been abraded by an oyster shell. The area of redness quickly spread proximally and has now progressed to the calf. Hemorrhagic bullae formed, the skin on the foot and calf began to darken, and the patient became delirious. Medical history is unremarkable.

On physical examination, the patient is awake but is disoriented and is writhing in pain. Temperature is 39.8 °C (103.6 °F), pulse rate is 122/min, respiration rate is 24/min, and blood pressure is 88/40 mm Hg. The right leg show the changes described above. The remainder of the examination is unremarkable. Labs are notable for Hb:8, WBC: 3,000 with a left shift, platelets: 30,000, S. Na: 119, K: 3 and HCO3: 16.

Which of the following is the most likely pathogen responsible for patients problem?

A. Vibrio vulnificus
B. Mycobacterium Avium Complex
C. Vibrio cholera
D. Vibrio hemolyticus
E. Pasturella Multicoda

Intermittent rash in an old gentleman

2008-08-15T22:11:00.003-04:00

72y, AAM, h/o HTN, BPH and CRF, presents to the office with diffuse, highly pruritic rash that developed over the past couple weeks. He has had intermittent skin rash, similar to this in the past, which has responded to brief course of topical steroids. He denies exposure to any new topical chemicals (soaps, detergents etc) or over the counter medications/ supplements. He also denies recent travel outside Baltimore city. His current medications include a lisinopril, furosemide, doxazosin and amlodipine. On exam, his vital signs are stable. He has diffuse, well-demarcated polygonal plaques with evidence of excoriation and lichenification on upper and lower extremities, as well as the trunk. Biopsy report states that there was evidence of spongiosis, eosinophils and chronic lichenified spongiotic dermatitis in the submitted plaque specimen. PAS stain was negative for fungi

Which of the following is the most likely diagnosis?

A. Lichen Planus- ANSWER
B. Nummular/ Atopic Dermatitis
C. Tinea Corporis
D. Psoriasis
E. Hypersensitivity vasculitis

Rash on calves

2008-07-21T21:52:00.003-04:00

56 y Puerto Rican woman presents to the office complaining of a non- pruritic skin rash on her calves. Apparently, she was at an arts festival over the weekend with an outside temperature of 96 degrees Fahrenheit. She acknowledges being on her feet for almost 8 hours. Her past history is significant for HTN and is stable on HCTZ and Diltiazem. On exam, she is very comfortable. Her vital signs are stable and except for an erythematous rash restricted to the calves, her exam is within normal limits.
What is the most likely diagnosis?

1. Contact dermatitis
2. Dermatophytosis
3. Superficial thrombophlebitis
4. Golfer’s vasculitis
5. Photodrug eruption
6. Polymorphous light eruption

Yard Rash

2008-06-16T21:36:00.002-04:00

70 y old gentleman was performing some yard work over the weekend. Over the next 48 hrs, he noticed a very pruritic rash that spread quickly from his arms to forearms, face and legs. His wife rubbed calamine lotion and OTC hydrocortisone, which provided some relief. His past history is relevant for HTN and BPH, well controlled on metoprolol, Enalapril and doxazosin. On exam, his vital signs are stable, although he looks miserable from extreme pruritus. He has large areas of weeping vesicular eruption on his face, arms and legs, surrounded by erythema and edema.

What is the first line of treatment for his condition?

1. Topical Clobetasol propionate 0.05%
2. Topical Pimecrolimus
3. Avoid contact with vesicles
4. Methylprednisolone dose pack tapered over 1 week
5. Prednisone taper over two weeks starting at 1mg/kg/day (Maximum 60mg/d)

Patchy back

2008-06-08T20:12:00.003-04:00

A car mechanic in his early 40’s came to the office complaining of skin rash. He has had the rash for several years with intermittent flare ups during summer months. He has a past history of hypertension, which is well controlled on a combination of metoprolol and hydrochlorothiazide. Exam shows scattered hypo-pigmented, salmon colored coalescing macules on his trunk, back and upper extremities. He lacks health insurance and requests the cheapest treatment option.

Which of the following appropriate treatment option is available for $4?

1. Diflucan 200mg 2 tab po x 1 dose
2. Selenium sulfide 2.5% lotion
3. Ketoconazole 200mg 2 tab po x 1 dose-ANSWER
4. Itraconazole 100mg 4 tab po x 1 dose

Facial rash

2008-05-12T08:27:00.001-04:00

27 y old friend calls from Philadelphia over the weekend, “I have had a rash on my face for almost 3 weeks, itches at times and it’s not going away despite using OTC Clotrimazole ointment, what do I do?” He does not have any medical problems, takes no meds and was in India about 3 months ago. He emailed the picture, as shown below.
What treatment is his PCP most likely to prescribe?
1. Continue Clotrimazole ointment for a few more weeks.
2. Topical Triamcinolone, along with Clotrimazole for 1 week.
3. Topical triple antibiotic cream
4. Short course of oral Griseofulvin, Terbinafine or Itraconazole- ANSWER
5. Oral Cephalexin course for 7- 10 days

Swollen thumb

2008-03-09T20:41:00.001-04:00

A middle-aged African American gentleman presents to the office with a lump on his Rt. thumb that has been progressively enlarged over the past few years. He does not recollect any trauma and does not have similar lump anywhere else on his body. Examination shows a 3- 4 cm, soft- firm, non-inflamed, relatively immobile and non-translucent lump on the dorsum of the Rt. thumb near the DIP.
Which of the following is the most likely diagnosis?

1. Tendon cyst
2. Epidermal inclusion cyst- ANSWER
3. Lipoma
4. Mucinoid cyst
5. Heberden’s node

Eyelid lesion

2008-01-21T14:36:00.002-05:00

35 yr. old man presents to the office complaining of a “red knot” over his Rt. upper eyelid that has developed over the past several months. He denies any pain or visual disturbances. Exam shows a non-tender, erythematous, rubbery nodule on the Rt upper eyelid.
Which of the following is the most likely diagnosis?

1. Chalazion- ANSWER
2. Hordeolum
3. Molluscum contagiosum
4. Basal cell carcinoma
5. Epidermal inclusion cyst

Blue Hands

2008-01-07T14:10:00.001-05:00

57 y, white gentleman, with PMH of Hepatitis C, comes to office as a new patient, complaining of constant pain in both hands accompanied by bluish discoloration for the past year. His previous PCP diagnosed him with SLE and prescribed Plaquenil (Hydroxychloroquine), which he discontinued because of inadequate relief and GI side-effects. He has used Oxycontin in the past with some relief. He has a 40 + pack-year h/o of smoking and drinks at least a dozen beers along with a pint of Vodka everyday. He has used IV drugs in the past, but claims to be off them for a long time. His family history is non-contributory. Review of systems suggest diffuse arthralgias, most pronounced in the feet. On exam, his vital signs are stable. He has pronounced seborrhea on the face. As shown in the picture, fingers of both the hands have a bluish hue, with a small superficial ulcer on the Lt index finger-tip. Lab results are as follows:
AST:214, ALT:124, Hep C Ab +, Type Ia, ANA +, speckled pattern >1:640,
Anti ds-DNA negative, C3:99, C4: 24, Cryoglobulins: negative (not collected in a frozen specimen), Anti Scl-70: negative, Anti-Centromere Ab: negative, Anti-Sm + 1.22 (nml <1.0), Anti-ENA: 6 (Nml <1.0), Anti-CCP: negative, RF + 1:160, Anti-Ro/ La: negative, HIV: negative, TSH: 1.6

Which of the following is the most likely diagnosis?

1. Primary Raynaud phenomenon
2. SLE- ANSWER
3. Mixed cryoglobulinemia
4. Buerger’s disease/ TAO
5. Undifferentiated connective tissue disease

Man with facial rash

2007-11-12T10:37:00.001-05:00

44 y, white gentleman, with PMH of Hep C comes to the office with a facial rash for several years. He is a new patient to the practice and mentions that his previous primary care provider diagnosed him with “lupus”. He was started on Plaquenil, which he voluntarily discontinued to adverse GI symptoms. He smokes about 1- 2 ppd x 30 years and drinks at least 12 beers everyday. He acknowledges using illicit drugs in the 1970’s. On examination, his vital signs are stable. Face shows erythema and yellow-orange scaling of the forehead, cheeks, nasolabial folds and chin.

What is the most likely diagnosis?

1. SLE
2. Seborrheic dermatitis- ANSWER
3. Seborrheic keratosis
4. Mild psoriasis vulgaris
5. Acne Rosacea

Pamidronate and tooth ache

2007-11-06T21:18:00.000-05:00

A 57 years old White male is seen in the office with complaints of left sided tooth ache following a recent dental procedure.He has 6 Yrs history of Multiple Myeloma for which he is on Thalidomide maintainance therapy and IV pamidronate infusion every 4 months for the last 3 yrs. Vitals are stable except for a Temp 100 F. His oral cavity examination is shown

Sjogren and Rash

2007-10-31T08:44:00.000-04:00

A 58 year-old woman with a history of Sjögren’s syndrome (SS) for the last 10 years presented to Rheumatology Clinic with a skin rash involving in the lower extremities. She is very active and also had participated in the walk for Breast Cancer awareness recently. Clinical examination revealed bilateral parotid gland enlargement and palpable purpura over the extensor surfaces of the lower extremities. Antinuclear antibodies (ANA) were 1/1280 with a fine speckled pattern, IgM rheumatoid factor (RF) was 1/320 and antibodies to Ro (SSA) and La (SSB) were also positive
What is the most likely diagnosis?
A. Hypergammaglobulinemic purpura

B. Idiopathic thrombocytopenic purpura

C. Waldenström macroglobulinemia

D. T-cell lymphoma

"Lump" on the shoulder

2007-09-28T13:20:00.000-04:00

68 y, White gentleman, with PMH of HTN and COPD, comes in for a “lump” on his shoulder that has been present for several years. He mentions having similar “lumps” on his trunk and back. Skin exam shows an soft, compressible, violaceous, domed 1 cm lesion on the Rt shoulder. Please see the attached picture, before and after compression
What is the most likely diagnosis?

1. Pyogenic granuloma
2. Angiokeratoma
3. Nodular melanoma
4. Venous lake
5. Campbell de Morgan spot

Lady with a bump on her head

2007-08-24T12:38:00.001-04:00

70y old, white woman with PMH of depression, presents to the clinic for a routine check-up. Examination of her scalp shows a smooth, firm, dome-shaped 4- 5 cm nodule with no signs of inflammation or punctum. The patient states that she has had this tumor for “as long as I can remember”.

What is the diagnosis?

1. Epidermoid cyst
2. Trichilemmal cyst
3. Epidermal inclusion cyst
4. Dermatofibroma

Swollen elbow

2007-08-10T13:50:00.000-04:00

49 y white gentleman, with past medical history of mood disorder, NOS, presents to the clinic with progressively increasing swelling of the left elbow, after sustaining a direct trauma on the elbow a few weeks ago. He complaints of mild discomfort but denies and systemic symptoms- fever, chills and denies and restrictions in joint movements. On exam, his vital signs are stable. The left elbow displays are large cystic swelling on the posterior aspect, with mild superficial redness, without any warmth, tenderness or restricted ROM.

What is the most likely diagnosis?

1. Acute gout
2. Acute septic olecranon bursitis
3. Traumatic olecranon bursitis
4. Acute Monoarticular arthritis

Lady with itchy bumps

2007-07-27T12:13:00.000-04:00

57 yr old Caucasian lady with past history of depression and HTN presented with gradually worsening rash and itching for 4 days which started first on her both arms and later over her legs. She has been scratching and developed some healed ulcers over her arms and legs but denies any pain associated with it. She also denies any associated fever, cough, nausea, vomiting or diarrhea. She has been on Effexor XR 150 q daily and Lisinopril 20 mg q daily for last 1½ yr with out any problem. She denies smoking nicotine, drinking ETOH or using illicit drugs. She is a homemaker and lives with her husband. 2 weeks ago she returned from her travel with her husband from Nashville and Indiana. She went from Nashville to Indiana in a riverboat and stayed in hotels. She does not have pets at home and states that she usually takes hot showers. On exam she has several sub-centimeter papular eruptions, a few of them excoriated with surrounding cellulitis on upper and lower extremities, shoulder and back.

What is the most likely diagnosis?
1. Allergic contact dermatitis
2. Infectious folliculitis
3. Papular urticaria- ANSWER
4. Furuncular Myriasis
5. Cutaneous Necrosis

Young man with a rash on shoulder

2007-07-06T14:52:00.000-04:00

A young man in his 30’s, with no significant PMH, comes to the office after noticing a pruritic rash on the Lt shoulder and pain in the Lt axilla that started after working in his father’s basement yesterday. The symptoms started late in the evening and worsened over the past 12- 24 hrs. He denies fever, chills, nausea or vomiting. He thinks that he might have been bitten by an insect, but cannot say for sure. He also spent some time working in the back yard, a day earlier. He is not sure if he came in contact with chemicals while working in the basement. On exam, his vital signs are stable. He has a 5- 6 cm well demarcated, erythematous macular rash on the Lt shoulder with a linear extension to the Lt axilla. A solitary, tender, mobile lymph node is appreciated on the anterior axillary fold. What is the most likely diagnosis?

1. Ringworm infection
2. Cellulitis and secondary lymphangitis from an insect bite- ANSWER.
3. Contact dermatitis
4. Folliculitis
5. Erythema migrans

Sun rash

2007-06-01T11:42:00.000-04:00

74 y African American gentleman, h/o HTN, Hyperlipidemia, Prostate cancer and CRF, had a “cook out” over the weekend. He spent several hours in the sun that day and had a good time. Later in the evening, he developed red, painful, slightly pruritic rash over his hands and neck. The discomfort has been progressive over the past 48 hours. Denies any other systemic symptoms. His meds include Norvasc, Lisinopril, Doxazosin, Vytorin, Bicitra and Coumadin. No changes in his medications were made over the past several months. On exam, he has clearly demarcated, erythematous rash with fine blisters on his forearm.
What is the most likely diagnosis?

1. Sunburn- ANSWER
2. Polymorphous light eruption
3. Solar Urticaria
4. Drug induced photosensitivity
5. New onset cutaneous lupus.

Old lady with hand-foot rash

2007-05-11T11:54:00.000-04:00

66y, AA woman, h/o HTN, anemia and CRF, comes in c/o dark discoloration of her feet accompanied with pruritus for the past year. The rash started out as tiny vesicles, followed by progressive dark discoloration and thick, dry painful skin with fissures. For the past few months, she has had similar eruption involving her hands. She denies exposure to any new chemicals and there hasn’t been any change in her medications. She also denies any systemic symptoms. Her current meds include Procrit, Quinine, HCTZ, Lotrel and Zocor. On exam, her vitals signs are stable. Feet show brownish black confluent maculopapular rash, involving the medical aspect. The Rt. Foot also shows extensive scaling, fissures and lichenification.
What is the most likely diagnosis?

1. Dyshidrotic eczema with keratoderma
2. Psoriasis- ANSWER, confirmed by skin biopsy
3. Tinea pedis
4. Extensive Cutaneous Candidiasis
5. Contact dermatitis

Bumpy beard

2007-04-27T15:34:00.000-04:00

A young African American man with no medical history comes to the clinic with non-pruritic bumps with dark discoloration along his beard-line. This has been progressive over the past several years. He acknowledges shaving regularly and uses the reverse shave technique for the “extra-smooth feel”. On exam, he has firm, hyperpigmented papules and scattered pustules along his neck with some ingrown hair follicles.
Which of the following is the best course of action?

1. Topical Lotrisone bid, until complete resolution.
2. Doxycycline 100mg bid, for 3-4 weeks. Discontinue shaving for 3-4 weeks followed by use of “easy shave” gel, “PFB bump fighter” razors and avoiding reverse shaving- ANSWER
3. Tretinoin cream 0.025% for 10 weeks
4. Reassure, await spontaneous resolution.

Image adopted from: http://www.mamc.amedd.army.mil/referral/guidelines/derm_pfb_1.jpg

Changing colors.

2007-03-30T16:22:00.000-04:00

78 y, AAW, h/o nonspecific interstitial pneumonitis, undifferentiated connective tissue disease (ANA-1:640 speckled pattern, +Anti-Ro Ab), comes to the office with intermittent bluish discoloration of her fingers.

What is the diagnosis?

Raynaud's disease.

Yellow nails

2007-03-17T23:58:00.000-04:00

50 yr woman, employed at the Shopper’s deli, presents with fingernails discoloration for the past few months. She has a PMH of HTN, being treated with HCTZ and Enalapril.
Exam shows yellowish- brown, brittle and broken fingernails involving both hands.

Which of the following statements is true?

1. This is most likely a dermatophyte infection due to Trichophyton Rubrum
2. It is classified as superficial onychomycosis.
3. Most insurance companies do not require histopathological diagnosis for reimbursement of the treatment.
4. Itraconazole is superior to Terbinafine for this type of onychomycosis- Answer
5. This is a classic presentation of psoriatic nails.

Rash and dysuria

2007-02-23T14:14:00.000-05:00

48y, fork-lift operator, h/o tobacco and alcohol abuse, f/h of CAD and DM, recently diagnosed with HTN, comes in with dysuria, redness and irritation over the glans penis and discomfort on trying to retract the foreskin. These symptoms started about 4 days ago. He has been in a monogamous relationship and hasn't been sexualy active for over 6 months. He has been on HCTZ 25mg for about 6 weeks and was recently prescribed viagra for ED. On exam, the glans penis appears very erythematous, the prepuce non-circumcised, erythematous, with fissuring. Urine analysis showed 1+ protein and approximately 250mg% of glucose without any RBC or WBC. Random blood sugar was 201. His last meal was about 3 hours ago.
Which of the following treatments is most likely to be successful?

1. Topical Clotrimazole 1% bid and wash with warm water 4-5 times/ day- ANSWER.
2. Topical Triamcinolone 0.1% bid.
3. Stop HCTZ and Viagra- this is possibly fixed drug eruption
4. Cefixime 400mg po x 1 and Doxycycline 100mg bid x 7 days
5. Pimecrolimus 1% topical bid

Dry soles

2007-02-09T12:47:00.000-05:00

25 y, white man, presents to the office with excessively dry soles, a problem for the past 7 years. He complains of excessive sweating restricted to his feet. It seems to impair is daily activities and sometimes needs to change his socks several times in the course of a day. He acknowledges exacerbation of his symptoms in stressful situations and in summer. He denies nocturnal sweats, fever, cough, anorexia, wt loss, skin rash, arthralgias, anxiety or depression. He denies travel or exposure to new chemicals. None of the over the counter remedies seem to help. He has seen multiple physicians for the problem with no avail. He does not take any medications. On exam, his vital signs are stable. He has excessively dry and macerated soles. No involvement of palms or axillae is noted. What is the most likely diagnosis?

1. Icthyosis
2. Tylosis
3. Bazex’s syndrome
4. Focal hyperhidrosis- ANSWER
5. Undiagnosed anxiety disorder
6. Hyperthyroidism

Warty growth on the scalp!

2007-02-01T13:07:00.000-05:00

50 y white man, with no PMH, presents to the office with a growth on the scalp for several years. On exam, the patient has a 2 cm filiform eruption on the scalp. What is the most likely clinical diagnosis?

1. Verruca vulgaris- answer
2. Squamous cell carcinoma
3. Basal cell carcinoma
4. Actinic keratosis
5. Keratoacanthoma

Hand findings in an elderly lady

2007-01-19T15:46:00.000-05:00

77y, white woman, nursing home resident, PMH of HTN, DM, CHF, A fib and DJD, was hospitalized earlier this month for anorexia, diarrhea and weakness for the past several months. She is being treated with Lasix, Prevacid, Toprol, Oxycodone, Coumadin, L-thyroxine, Spironolactone, Glipizide, Effexor, Colchicine and Probenecid. On exam, she is dehydrated corroborated by a BP of 90/40 and pulse rate of 80 - 100/m. The following findings are noted on her hands.
What is the most likely diagnosis?

1. Heberden’s and Bouchard’s nodes
2. Rheumatoid nodulosis with possible “geodes”
3. A description by Dr. Thomas Syndenham in the 17th century- ANSWER (tophaceous gout).
4. Calcinosis cutis

Journalist with a rash

2007-01-04T15:51:00.000-05:00

62 y, white man, editor of a local newspaper, with PMH of HTN and Hyperlipidemia, presents today complaining of recurrent, non-pruritic rash over his flanks, back and groin. He reports that the rash tends to recur in summer months and also after his exercise routine, if he does not get to the shower in a few hours. He denies any exposure to new chemicals, topical or systemic. He also denies any systemic symptoms.
On exam, he has sharply marginated, brownish-red slightly scaling macular eruption involving his back, flanks and intertriginous skin.
Which of the following organisms is the most likely culprit?

1. Malassezia
2. Candida species
3. Corynebacterium minutissimum- correct answer
4. S. Aureus
5. Human Herpes Virus 7

Pulmonary findings in HIV patient

2006-12-14T17:07:00.000-05:00

40-year-old patient with h/o HIV, most recent CD4 count of 100 ⋃/ ml, presents to the ER complaining of fever, chills, dyspnea and dry cough for the past week. He has been non compliant with his HAART regimen and other prophylactic medications. On exam, his temperature is 102.5‧ F, HR: 120/m, BP: 88/59, RR: 32/m with sPO2: 92% on 4 LPM supplemental O2. Chest X-ray findings were reportedly non-specific. BAL fluid analysis using Methenamine silver stain, as seen under the microscope, is shown below.
What is the most likely diagnosis?

1. Cryptococcus neoformans
2. Pneumocystis jiroveci- Answer
3. Mycobacterium avium complex
4. Cytomegalovirus infection
5. Toxoplasma gondii

Plaque on temple

2006-11-10T18:10:00.000-05:00

49 y WM, with h/o COPD, presents to the office for a routine follow up. Skin exam reveals several waxy, cobbled, tan, warty papules on the chest, back and the right temporal region. He has been asymptomatic has had these lesions for several years. The lesion on the temple is shown in the picture. Which of the following is the most likely diagnosis?

1. Seborrheic keratoses- correct answer
2. Solar lentigo
3. Spreading pigmented actinic keratosis
4. Malignant melanoma
5. Pigmented Basal Cell carcinoma
6. Verruca Vulgaris

Rash on the neck

2006-10-28T15:37:00.000-04:00

33 y, African-American woman with h/o HTN and morbid obesity, s/p gastric bypass surgery 6 months ago and subsequent weight loss of 100 lbs, presents to the office for a routine follow up. Since the surgery, her HTN has resolved and she is off all her medications.
On exam, her vital signs were stable. Head and neck exam shows graying plaques with prominent skin lines on the nape of the neck. Which of the following statements is false?

1. The skin pathology is associated with PCOS, DM, Cushing’s syndrome, hypothyroidism and acromegaly.
2. Rapid development of this lesion with involvement of palms/ soles and mucous membrane is suggestive of underlying GI malignancy
3. Metformin and Rosiglitazone have not been effective in treatment of this pathology.
4. Skin biopsy needs to be done to rule out melanoma
5. Treatment of the underlying cause is most definitive.

Another groin rash

2006-10-20T11:42:00.000-04:00

A man in his early 30’s, with no PMH, presents to the office complaining of pruritic rash in his groin for the past few weeks. He acknowledges that he “sweats like a pig”. Exam shows sharply marginated, slightly raised erythematous rash with minimal scaling in the inguinal region. Based on the clinical presentation, which of the following is the most likely diagnosis?

A. Erythrasma
B. Dermatophytosis
C. Cutaneous Candidiasis
D. Inverse psoriasis
E. Pityriasis versicolor

Discoloration on the elbow

2006-09-29T10:47:00.000-04:00

67 y, AA woman, h/o HTN, GERD and recurrent UTI presents to the office with skin discoloration over her Lt elbow that started about 5 weeks ago. She denies any discomfort or pruritus at the site. She does not have similar lesions anywhere else on the body. Her current meds include Enalapril, Aciphex, Valium, Vaginal estrogens and Ciprofloxacin.
Exam shows a 4-6 cm hypopigmented macule over the lt. elbow. Neurological exam was normal.
Which of the following statements is most appropriate?

1. This is a complication of treatment she received for tennis elbow 3 months ago.
2. She has pityriasis alba.
3. Tuberculoid leprosy should be considered as the most likely diagnosis.
4. This is a ash-leaflet hypopigmented macule suggestive of tuberous sclerosis
5. This is a new onset vitiligo, she might respond to topical steroids.

Insect bites or psychogenic lesions

2006-09-21T11:16:00.000-04:00

56 y man, no significant PMH, presented to the office with diffuse skin lesions that he states started with some insect bites sustained a few days ago. He has been picking on the lesions and cleaning with alcohol, taking multiple showers everyday to get rid of the eggs and larvae that might be present in the lesions. His wife has been helping him with the entire “cleansing process”. He cannot say for sure if all these lesions started after insect bites or whether some were created in an attempt towards digging under the skin with nails and other sharp instruments to remove the suspect eggs and larvae. On exam, he has multiple superficial skin ulcers with excoriations on his chest and upper extremities.

Which of the following is the appropriate statement?

1. Patient is suffering from neurotic excoriations
2. He has delusions of parasitosis
3. It is too early to state if he has a psychological disorder- ANSWER
4. Factitious syndrome is a likely diagnosis.
5. Body dysmorphic disorder should be considered.

Old lady with ptosis

2006-09-08T16:24:00.000-04:00

67 y relatively healthy white woman presents to the ER with progressive Lt temporal headache over the last 7 to 10 days followed by Lt eye ptosis that she noticed on the day of presentation. Exam shows profound Lt eye ptosis and restricted extraocular movements without pupillary involvement. Which of the following is the correct statement?

1. The lesion has spared the oculomotor nerve nucleus- ANSWER.
2. Instilling topical cocaine in the eyes will confirm the suspected diagnosis.
3. Unilateral ptosis makes the diagnosis of ocular myasthenia gravis unlikely.
4. Patient has Kearns- Sayre syndrome
5. Efficacy of steroids has been demonstrated through several randomized placebo-controlled studies.

Peruvian farmer with multiple skin ulcers

2006-08-13T14:31:00.000-04:00

An 18 yr old male Peruvian farmer presents to the clinic with multiple lesions on his arms and legs. He denies any water exposure and states that a single lesion erupted on his right arm 3 months ago. Since its onset, multiple other lesions have erupted throughout his right arm and legs as well. He denies any pruritis, or any secretions from the ulcerated lesions. He also has attempted some home remedies including herbals without any relief.
On physical exam, he is afebrile and his vital signs are stable. Skin exam reveals multiple ulcerations and crusts on the posterior side of his right arm, of different sizes. These lesions have well defined borders, with an erythematous base, and no secretions.

What is the most appropriate treatment of this condition?
1. Clarithromycin 500mg twice daily
2. Pentavalent Antimony for 20 days- ANSWER
3. Penicillin G - 2 million units q3hrs IV for 7 days
4. Itraconazole 200mg daily for 3-6 months.

Swelling on the foot

2006-08-06T12:14:00.000-04:00

56 y, white gentleman, working as a mechanic for the MTA, comes in for slowly progressive asymptomatic swelling on the dorsum of his Right foot, over the past few years. He does not recollect any trauma.
Exam shows a 4-5 cm, non- inflamed, firm swelling, with very limited mobility and with definite transillumination, on the dorsum of the foot along the lateral aspect.

What is the most likely diagnosis based on the available information?

1. Bible cyst- ANSWER.
2. Lipoma
3. Neuroma
4. Epidermoid cyst
5. Surfer’s nodules

Man with hand discoloration

2006-07-29T14:45:00.000-04:00

33y, African-American man, working as a manager at Under-Armor, with h/o HTN, relatively well controlled on Labetalol, presents with the depigmentation on his hands. He has had this problems for a few years and has spread progressively.
Exam shows depigmented symmetrical macules on the extensor surface of his hands involving IP and MCP joints.
Which of the following statements is true?

1. The disease presents in the second-third decade of life with a 10-20% likelihood of spontaneous repigmentation- ANSWER.
2. It is likely that the patient has a genetic disorder with defective migration of melanocytes. He is likely to have a white forelock.
3. Antibodies to DNA topoisomerase II appear to be very prevalent in this disease.
4. The patient has lichen sclerosus
5. He could have had this secondary to exposure to certain chemicals at his job.

A man with a lesion in his ear

2006-07-17T09:20:00.000-04:00

42 y, white man, with recurrent lt ear infections, h/o myringotomy in childhood, comes in c/o otalgia, purulent otorrhea, deafness, vertigo and constant headache. Exam findings are displayed in the picture
Owing to insurance issues, he hasn’t been seen by a physician for almost 2 years.

Which of the following statements is false?

1. It seems that he has otitis externa from this hearing aid, it needs to be replaced (Correct Answer)
2. He is likely to have conductive hearing loss
3. The pathology in the picture can herald the presence of a cholesteatoma
4. A CT scan of the temporal bone is a part of management of his current problem.
5. He needs a referral to the ENT specialist for surgical treatment

Identify the type of dermatitis

2006-07-06T22:07:00.000-04:00

Case-A: 68y man who lays bricks and is exposed to several chemicals at work on a regular basis presents with a chronic pruritic rash on his left hand. Exam shows dry, erythematous skin with some fissures
Case-B: 55y man who recently bought a waist belt a few weeks ago presenting with a pruritic rash around his umbilicus. Exam shows a well demarcated erythematous rash with some superficial scabs formed after excessive scratching.

Which of the following statements is true?
1. Patient “A” has irritant” contact dermatitis while “B” has “allergic” contact dermatitis
2. Patient “A” has “allergic” contact dermatitis and “B” has “irritant” contact dermatitis.
3. Both patients have “allergic” contact dermatitis
4. Both patients have “irritant” contact dermatitis

A writer's rash

2006-06-24T15:11:00.000-04:00

39 y, white man, working as a writer with a publishing company, no significant PMH, no h/o tobacco, alcohol or illicit drugs, in a monogamous relationship for the past year, presents with intensely pruritic, spreading rash involving the lateral aspects of the trunk, Rt more than left for the past few days.
Apparently, he had a two small macular eruptions in the Rt axilla, about 5-6 weeks ago, that responded to topical emollients.
Does not recall any exposure to new chemicals; travel outside Baltimore or recent febrile illness. HIV test done few months ago was negative.
Exam shows erythematous maculopapular rash extending from the axilla to the iliac crest.

Which of the following statements regarding the pathology is incorrect?

1. The most likely mechanism of the rash is contact irritation.
2. This pathology is an important common cause of occupational disability
3. About 1/3rd of patients with chronic venous stasis develop contact dermatitis to neomycin.
4. Treatment includes avoidance of exposure and medium to strong potency topical steroids.
5. Patch testing is helpful in diagnosis of chronic cases to identify specific allergens.

Man with a lesion in his mouth

2006-06-17T15:13:00.000-04:00

53y, AA man, with PMH of GERD, Insomnia, Erectile dysfunction and primary syphilis (diagnosed and treated at least 25 years ago), presents to the office frustrated by recurrent painful mouth sores, which are not preceded by blisters. For the past several years, he has been told to have recurrent herpes labialis and is being treated with Valacyclovir suppressive treatment.
On exam, he has few round sub-centimeter superficial ulcers on an erythematous base scattered on the palate and upper lip.
Which of the following statements about this pathology is false?

1. The pathogenesis of these lesions is not clearly identified, although it could be predisposed by stress, immune dysfunction or toothpaste detergent.
2. It would not be inappropriate to culture the base of the ulcer and send for Tzanck smear and culture.
3. Given the history of syphilis in the past, a diagnosis of oral syphilis can be made based on the history and exam- CORRECT ANSWER
4. Although Amlexaonox is slightly more expensive than Triamcinolone in Orabase, it is considered to be more effective and should be used as first-line agent.
5. The diagnosis of HSV appears dubious and Valacyclovir should be discontinued.

Discoloration of toes

2006-06-02T12:10:00.000-04:00

65 y, white man, with h/o CAD and tobacco dependence, presents to the ER with dyspnea and angina. He is compliant with his medication regimen, which includes ASA, Enalapril, Metoprolol and Lovastatin. On exam, his vital signs were stable and no cardio-pulmonary abnormalities were noted. Extremities show brownish-black discoloration of his toes, with evidence of dry gangrene. Peripheral lower extremity pulses are absent. On further questioning, he mentions developing the discoloration 2 years ago. Which of the following historical clue is the most important in determining the likely cause of the pathology?

1. History of PTCA- CORRECT ANSWER.
2. Tobacco dependence, 3 ppd for 40 years.
3. History of Rt sided endocarditis
4. History of Frostnip 2 years ago, while on a cruise to Alaska

Groin Rash

2006-05-19T10:50:00.000-04:00

55y man with h/o questionable recurrent genital herpes, presents with mildly pruritic rash in his groin for the past few weeks. Pelvic exam displays erythematous macular lesions in the groin with some satellite pustular lesion on the medial aspect of the thigh.

What is the most likely diagnosis?

1. Erythrasma
2. Tinea Cruris
3. Genital candidiasis- CORRECT ANSWER
4. Eczema
5. Lichen Planus
6. Recurrence of genital herpes

Psoriasis

2006-05-12T09:14:00.000-04:00

61y, white woman, h/o HTN, CAD, severe vasculopathy- s/p coronary stents and renal arterty stents, bilateral moderate carotid stenosis and psoriasis comes in for a routine follow up. She is asymptomatic on her current drug regimen- Diovan-HCT 160/12.5mg qd, Metoprolol XL 100mg qhs, ISMO 60mg qd, Lovastatin 40mg qhs, Calcipotriene topical bid, Lasix 20mg qd, ASA and NTG s.l. prn. Her vital signs are stable. Exam reveals psoriatic plaques on both the elbows, with mildly erythematous base and rim with superficial silvery scales. She has similar smaller plaques on her legs. Which of the following statements is false?

1. She has a 30% likelihood of having psoriatic arthritis
2. Arthritis precedes skin lesions in 15% of patients with psoriasis
3. She is on a medicine that could exacerbate her skin lesions
4. Calcipotriene, although very effective, is extremely expensive as compared to topical steroids.
5. She has guttate variant of psoriasis, commonly linked to Streptococcal infections - CORRECT ANSWER

Old man with hand muscle wasting

2006-05-05T12:01:00.000-04:00

68 year old African-American man, with h/o HTN and early prostate cancer, presents with "muscle thinning" in both the hands and progressive weakness, although symptoms seems to be more prominent on the Lt hand. He does not volunteer any symptoms of paraesthesias. He continues to work as a manual laborer with a construction company. He smokes a pack every day and is intermittently compliant with his meds- Verapamil, Enalapril and HCTZ
On exam, his vitals are stable. Hand shake displays a weak grip. Hand exam shows mild clawing of the left hand, wasting of the interossei (prominent guttering of the back of the hand), of the web-space between thumb and index finger and softening and flattening of the hypothenar eminence, more prominent on the left hand. Tinel’s sign was positive. Reflexes were bilaterally symmetrical at 1+. Sensory exam was not done. Forearm and arm muscles did not show signs of atrophy.
Fasting Blood sugar in January 2005 was 120. Prostate biopsy done in 8/03 showed high-grade neoplasia. He has not followed up with his urologist since then.

1. Occupation induced carpal tunnel plus cubital tunnel syndrome- CORRECT ANSWER
2. Inclusion body myositis
3. Syringomyelia
4. Cervical disc disease
5. Unrecognized diabetes

Lady with a lid lesion

2006-03-23T14:47:00.000-05:00

48y, white woman, comes in concerned about a lesion on her Rt eyelid. She has had the lesion for several years and denies any associated ocular or systemic symptoms associated with it. Her PMH is significant for anxiety and occasional muscle spasms for which she receives alprazolam and carisiprodol.
Exam shows a 1.2 cm, slightly raised, greasy, brown-grayish, plaque with some fine superficial desquamation.
What is the most likely diagnosis?

CORRECT ANSWER: Seborrheic Keratosis

19 year old man with penile rash

2006-03-10T10:12:00.000-05:00

19-year-old AAM, comes to the clinic for a physical. He denies any symptoms except for some lumps on his penis for the past 7-8 years. He denies any systemic symptoms, local discomfort, dysuria or penile discharge. He denies being ever sexually active.
On examination, he has rows of small, flesh-colored, smooth, dome-topped to filiform papules situated circumferentially around the corona and sulcus of the glans penis.

What is the best approach of management?

1. Refer to dermatologist for biopsy
2. Start topical Lotrisone cream, f/u in 2-3 weeks.
3. Start topical Imiquimod, f/u in 2-3 weeks
4. Reassure and counsel about safe sexual practices- CORRECT ANSWER
5. Topical podophyllin bid for 3 days, followed by 4-day rest period. Repeat cycle up to 4 times.
6. This appears to be molluscum contagiosum, check his HIV status.

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An accountant with scaling rash

2006-02-25T00:02:00.000-05:00

25y man, works as an accountant at T. Rowe Price, no significant PMH, comes in for progressively spreading rash over the entire body, mostly in the feet for the past 4 weeks. He denies any exposure to new chemicals precipitating the rash. He has tried OTC anti-fungals with partial relief.
Exam shows small to large, scaling, sharply marginated plaques without pustules on the torso. Feet show considerable erythema with superficial scaling and excoriations.

What is the diagnosis?

1. Inflammatory urticaria
2. Pityriasis rosea
3. Erythema migrans
4. Diffuse inflammatory epidermal dermatophytosis- CORRECT ANSWER
5. Eczema

Discussion

Young male with vesicular forearm rash

2006-02-12T09:43:00.000-05:00

31y man with no significant PMH, developed a skin rash while working in his yard last week. He has been self-treating himself with OTC hydrocortisone and Benadryl, with poor response.
On examining his lt forearm, he had linear erythematous rash with vesicular and bullous eruptions.
What is the diagnosis?

1. Poison ivy/ Oak dermatitis- CORRECT ANSWER
2. Early herpes zoster
3. Erysipelas
4. Inflammatory epidermal dermatophytosis
5. Insect bite

Discussion by Raj

Oral cavity lesion

2006-01-27T23:44:00.000-05:00

50y old man, with h/o tobacco abuse presents to the office complaining of a lesion in his oral cavity that he has had for a very long time. He is asymptomatic. The lesion is pedunculated, exophytic and papillary in appearance.
What is the diagnosis?

1. Squamous papilloma- CORRECT ANSWER
2. Verruciform xanthoma
3. Papillary hyperplasia
4. Condyloma acuminatum
5. Squamous cell cancer

Discussion by Sun

Pruritic skin rash

2006-01-16T02:21:00.000-05:00

37 y, woman, with h/o mild mental retardation, comes in with progressively spreading, intensely pruritic skin rash. Her mom was told that the patient had inadvertently shared a bed with her cousin (with h/o Down’s syndrome) who was found to have Scabies. Rash is shown in the picture.

Which of the following statement is false?

1. If the patient was African-American, she would be unlikely to develop scabies.
2. The skin rash most likely represents a hypersensitivity reaction, rather than a foreign body reaction.
3. It is a sexually transmitted disease
4. Absence of burrows in the inter-digital space makes the diagnosis unlikely- CORRECT ANSWER
5. Permethrin 5% topical, single application, is sufficient.

Nodular Lesion on the palm

2006-01-07T18:59:00.000-05:00

69y brick-layer with history of DM, HTN, DJD and tobacco-induced COPD presents with painful hands, thickening in the palm and limitation of 4th and 5th finger movements.
Exam shows nodular lesion on the volar surface of the hand at the metacarpophalangeal joints of primarily the fourth and partially fifth finger.

What is the diagnosis?

1. Volkmann’s contractures
2. Trauma
3. Intrinsic joint disease
4. Dupuytren’s contracture- CORRECT ANSWER
5. Diabetic Cheiroarthropathy

40 Yrs old with rash on his back

2005-11-30T23:20:00.000-05:00

40 year old white man with no significant past medical history presents to the office concerned about a non-pruritic rash on his back that has been progressively spreading. He takes no medicines and acknowledges past use of intravenous drugs. His exam findings are normal except for the rash.

Which of the following statements is correct?

A. History of STD’s should be elicited, since the rash resembles one seen in secondary syphilis
B. This appears to be a mild case of pityriasis rosea, which requires no treatment
C. Initiate treatment with oral Terbinafine
D. The causative organism is saprophytic yeast, a part of the normal skin flora, which produces azelaic acid to inhibit skin pigmentation- CORRECT ANSWER.
E. Patient has tinea corporis/ ring-worm infection, which will respond well to Griseofulvin