Skin rash and Weight Loss

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

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

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

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

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

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

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