Derm/HEENT

A 19-year-old female patient presents to the PCP for a routine visit. There are three painful sores in the mouth that seem to have started during final exam week at college. On physical examination, there are three round ulcerations, all less than 1 cm in diameter; they involve the buccal mucosa and have yellow fibrinoid centers and a red halo surrounding the lesions. There is no evidence of bleeding, gingival inflammation, vesicles, scabbing, skin rashes, or cervical lymphadenopathy.

Aphthous ulcers

A 33-year-old African American man presents to the clinic with a 6-month history of an itchy rash on his chin every time he shaves. It has progressed to painful red pimples. On physical exam, the patient has coarse curly stubble on his face with inflamed tender pustules at the base of several hairs on his chin.

Applying skin moisturizers after shaving

A 72-year-old farmer presents for recurrent rough, dry, crusty spots on the face, scalp, and ears. He has used several over-the-counter creams, but nothing seems to help. He admits to picking off some of the rough spots on the face, but they always grow back. He reports that some of the spots have now become sensitive. On examination, there are extensive solar lentigines on the face, scalp, chest, and upper extremities bilaterally. The patient points out multiple rough sandpaper-like lesions and scaly red plaques on the face, scalp, and bilateral helices.

Actinic keratosis

A 16-year-old patient presents as an urgent consult for an itchy rash that has worsened over the past week. His mother reports that he was seen in the emergency department for an abscess on the cheek 2 weeks ago. He was placed on an oral antibiotic for 10 days when the rash broke out. The abscess has cleared.

Angioedema and tongue swelling

A 46-year-old male patient presents to the clinic with loss of hearing in the right ear for 6 months. It started when his son popped a balloon loudly next to his ear. He experiences a right-ear ringing sensation and ipsilateral facial numbness. He has recently noticed a sense of unsteadiness, but he denies rotational vertigo. He denies headache and early morning nausea and vomiting.

Absent corneal reflex on the right side

A 39-year-old female patient with a history of chronic rhinosinusitis presents with a bump inside the right nostril. During history and physical exam, a small nasal polyp is seen in the right nare.

Adhere to allergy medications.

A 55-year-old patient presents with an intensely itchy rash on the arms that developed after working in the garden 2 days ago. They have been using over-the-counter cortisone cream with mild improvement of the itch only. Physical examination reveals erythema with a few vesiculobullous lesions, some in a linear pattern on the upper extremities.

Allergies to drugs, food, or environment

A 3-year-old boy presents with his mother to the emergency department due to a button stuck in his nose. The patient is not mouth breathing and denies nasal pain. He is cooperative with examination using an otoscope. The right anterior nasal passage is not blocked. A small button is visualized in the right nasal passage located under the inferior turbinate. There is no bleeding or discharge observed. No objects were visualized in the left nasal passage. His ears were also examined and no foreign objects were seen.

Alligator forceps

A 55-year-old male patient presents with a 3-day history of a lesion, swelling, pain, and redness over the left leg. He was diagnosed as having diabetes 10 years ago and is on metformin. He lives with his wife and has one adult child. Temperature 99.9°F (37.7°C), pulse 90/min, blood pressure 120/81 mm Hg, respirations 18/min. Cardiovascular and respiratory systems examinations show no abnormalities. Examination of the leg reveals an erythematous, well-demarcated, raised lesion over the left lower limb that is tender on palpation. Small red streaks are seen in some areas. Laboratory studies show increased leukocyte counts, elevated ESR, and elevated CRP.

Amoxicillin

A 50-year-old man with no significant past medical history noticed some pressure in his ear on a flight when the plane descended. The pressure then turned into pain. He denies hearing loss. He recently had an upper respiratory infection.

Analgesic

A 38-year-old man presents with multiple small papules and pustules on the face, scalp, thighs, and inguinal areas. He has no history of serious illness and takes no medications. He reports that he shaves occasionally, mostly using a trimmer to trim his beard. He works as a roofer 5 days a week in hot weather. Refer to the image.

Avoid excessive perspiration.

A 60-year-old female pilot is rushed to the emergency room for severe dizziness, nausea, and disorientation that started upon the descent of her flight.

Bedrest with head elevation

A 75-year-old patient presents with a sudden eruption of blisters on her body. She reports itching with the blisters and denies any previous outbreaks. Medical history includes diabetes, well-controlled on the same medication for several years. She denies any changes in diet or personal hygiene products. She has been using over-the-counter antihistamine cream with no improvement in symptoms. The patient is afebrile with multiple scattered ruptured lesions in the antecubital fossa, neck, and back with a few intact bullous lesions scattered on the arms bilaterally.

Biopsy with direct immunofluorescence microscopy

A 65-year-old male patient presents for a scheduled follow-up. He presented to the ED last week due to vertigo, headache, nausea, vomiting, and imbalance. He received a diagnosis of posterior circulation stroke. He was discharged from the hospital after necessary initial treatment. Neurologic exam shows hypotonia of all four limbs, intention tremor, past-pointing, dysmetria, dysdiadochokinesia, and ataxic gait. Examination of the eyes shows the presence of spontaneous, primary position, horizontal jerk nystagmus with regularly alternating fast phase direction.

Baclofen

A 20-year-old patient presents to urgent care with right eye pain. They state the eyelid has been edematous and erythematous without known injury. They report no visual changes, itching, or drainage. On exam, the upper eyelid is diffusely edematous, mildly erythematous, and non-tender. The globe is normal in appearance with no photophobia, and there is crusting of the eyelashes. EOMI. Visual acuity is 20/20 bilaterally.

Blepharitis

A 12-year-old female patient presents with hearing loss in the right ear for 2 months. She gives a history of flu-like illness 8 weeks ago, which resolved, but the problem in the ear has persisted. On examination, bone conduction is better than air conduction. The tympanic membrane is dull and hypomobile. Air bubbles can be appreciated in the middle ear.

Broad-spectrum antibiotics

A 4-year-old patient's mother explains that the patient has had a cold for 1 week and woke up this morning due to pain in the left ear. The patient has a low-grade fever. History includes no drainage from the ear.

Bulging, erythematous tympanic membrane

A 62-year-old woman presents to the ED with right calf pain and erythema for the past 48 hours. She reports no fever, no trauma, and no vomiting. She has no history of similar occurrences. Vital signs are WNL. On exam, she has right calf erythema circumferentially with mild tenderness. Negative Homan's test and full ROM. Question You consider Well's criteria (a scoring system used to determine the likelihood of having a venous thrombus) and order what diagnostics to help you to determine the most likely diagnosis?

CBC, d-dimer, and venous duplex US

A 36-year-old woman presents with vertigo, vomiting, and gait impairment for 2 weeks. Past medical history is insignificant for ear disease and other systemic diseases. She had an upper respiratory infection a few weeks ago and has already received appropriate treatment. Physical examination reveals right-beating nystagmus in the dark with no signs of meningitis or focal neurological deficits.

CN VIII

A 77-year-old male patient presents with skin lesions over the face and back that developed suddenly over 2 months ago. These lesions are widespread, non-painful, and non-pruritic. The patient has been feeling fatigued, has had a decrease in appetite, and has lost over 10 pounds in the past few months. He does not have a fever, respiratory problems, or changes in his bowel and bladder habits. He does not have any past medical conditions. He denies tobacco, alcohol, and recreational drug use. He is a widower and lives with his daughter. Vitals, cardiovascular examiantion, and respiratory examination are unremarkable. On examination of the skin, the following findings are observed. Refer to the image.

CT abdomen with contrast

A 14-year-old male patient presents with a left-sided nasal bleed and mass for 2 weeks. He has a mild headache and a runny nose. There is no history of trauma to the nose. Temperature 36.9°C (98.4°F), respirations 20/min, pulse 96/min, blood pressure 100/65 mm Hg. Examination shows a red mass in the left nasal cavity and partial hearing loss.

CT scan

A 36-year-old man presents with nasal congestion, headache, fatigue, facial pain, and chronic post-nasal drip. He reports similar episodes of acute sinusitis occurring 3-4 times annually for the past several years, relieved with short courses of antibiotics, followed by recurrence of symptoms. The current symptoms have been present intermittently over the past 3 months. He experienced partial relief with a 14-day course of antibiotics. He is afebrile and nasal mucosa is inflamed with mucopurulent discharge noted bilaterally. The right maxillary sinus is tender to palpation. Lungs are clear to auscultation.

CT scan of the sinuses

A 42-year-old male patient presents to the clinic with progressive hearing loss for the past year and painless unilateral fluid leakage from the ear for the past month. He takes no medications. Temperature 37.1°C (98.8°F). Otoscopic examination shows an irregular brown mass and partial retraction of the tympanic membrane. An audiogram shows an air-bone gap in the right ear with expected bone conduction.

Cholesteatoma

A 27-year-old woman developed multiple small raised red dots on her neck and back after she started using her new treadmill. By the time she presented to the clinic an hour later, the rash is spontaneously fading, and the itching is almost resolved. You note several 3-5 mm erythematous raised lesions scattered about her neck, upper chest, and back. She is afebrile, and the rest of her physical exam is unremarkable.

Cholinergic urticaria

A 50-year-old man presents with painful swelling of the right ear for 1 week. He reports that the swelling was not present 10 days ago, and it has not increased in size during the week. Upon specifically asking, he reports that he usually sleeps on the right side and had acquired minor trauma to the site of the nodule approximately 10 days ago. He has no known medical disorder. Physical examination shows a single firm, tender, well-demarcated, approximately 10-mm, round nodule with a raised, rolled edge and central crust located on the apex of the helix of the right ear. Removal of the crust reveals a small channel. There is no regional lymphadenopathy, and the rest of the physical exam is normal.

Chondrodermatitis nodularis helicis

A 20-year-old male patient presents with fever, pain, and swelling in the right submandibular region for 3 days. There is no history of medical disorder or substance use, but there is a history of anaphylaxis to penicillin. Temperature 39.1°C (102.4°F), pulse 88/min, blood pressure 118/80 mm Hg, respirations 15/min. Examination shows swelling and tenderness over the right submandibular region with ipsilateral cervical lymphadenopathy. Massage over the right submandibular gland reveals purulent saliva at the ductal orifice. Total leukocyte count 13,000/mm3 with 88% of neutrophils. Hemoglobin and platelet count are within reference ranges. Ultrasonography rules out an abscess formation. Exudate from the duct is sent for bacteriological culture and sensitivity.

Clindamycin

A 27-year-old woman presents to the clinic because of skin lesions for 1 year. She has lesions over both her axilla in the folds under her breasts and the groin folds. The lesions are slightly painful. She claims that they are cosmetically disfiguring and have been bothering her for a long time. She is a smoker and smokes 1 pack of cigarettes every day for the past 8 years. She denies alcohol consumption and illicit drug use. She has a sedentary life and does not exercise. On examination, she appears to have an obese body habitus. Vitals are normal. Her axilla, groin, and breast folds show painful nodules, keloid formation, fibrotic bands, and thickened plaques. Examination findings of her groin folds are shown. Refer to the image.

Clindamycin

A 4-year-old boy presents with a "red rash on his cheek that is getting bigger" for the past month. He has had no recent illnesses or recent travel. Past medical history and family history are unremarkable. The family has 2 adult dogs and a 3-month-old kitten. On examination, the patient appears well, is afebrile, and has a slightly scaly annular erythematous lesion with central clearing and a papulovesicular border on his right cheek measuring 4 cm in diameter. There is no cervical adenopathy. The HEENT examination is unremarkable; lungs are clear to auscultation. Wood lamp examination without fluorescence.

Clotrimazole 1% cream

A 30-year-old male patient presents with pain and swelling on the left index finger around the fingernail for 3 days. He has no past medical history. Vitals are stable. On examination, there is erythematous swelling of the left index finger and the area is extremely tender. The swelling appears to fluctuate. The patient is prescribed amoxicillin and clavulanate and is advised to soak the fingers in warm water a few times each day. Symptoms resolve in a few days.

Staphylococcus aureus

A 32-year-old man with a past medical history of allergic rhinitis and well-controlled asthma presents with a rash and pruritus on his left lower wrist associated with a "burning" pain. He denies any recent insect bites, travel, fever, chills, or change in detergent use, but he was recently given a new watch from his wife. The lesions seem to become worse when he scratches them. Physical exam reveals an erythematous rash with hyperkeratosis and rough-appearing erythematous plaques circumscribing his left lower wrist.

Contact dermatitis

An 8-year-old boy presents with his parents due to difficulty breathing, muffled voice, fever, sore throat, cough, and difficulty swallowing that started when he awoke this morning and has gotten worse. They were managing with hot honey-lemon tea and cold packs until he found it too difficult to swallow the tea. He has no significant medical history and takes no medications, but an inquiry about his vaccinations is met with a long pause before they state he is up to date. Vital signs are HR 102, RR 30, T 40°C, BP 114/72, O2 98% on room air. On physical exam, he appears rather anxious and toxic, seated, leaning forward on his outstretched arms with labored mouth breathing and drooling. His pharynx is erythematous, but attempts to visualize deeper with a tongue depressor are complicated by gag reflex. You quickly usher him to the X-ray room for a radiograph of his neck, shown below. On the way, you ask the parents about vaccination again, emphasizing its importance to his diagnosis and treatment. They tell you they have avoided vaccination due to concerns about developing autism. Paramedics arrive and transport the patient to a nearby hospital on supplemental oxygen via bag valve mask. The ED fully visualizes his epiglottitis, noting 70% occlusion of the airway.

Controlled endotracheal intubation in the OR

A 37-year-old woman presents due to right eye pain for 4 days. She has gradually noticed a worsening of "gritty" and irritating discomfort. She does not recall an inciting incident. She can no longer tolerate wearing her contact lenses due to these symptoms. She denies any significant past medical history and denies associated symptoms. On examination, sclerae are non-icteric. Pupils are 4 mm, round, and reactive to direct and consensual light bilaterally with no noted photophobia. Extraocular movements are intact bilaterally and are not painful. Fluorescein examination reveals a well-demarcated circular lesion on the right eye overlying the superior aspect of the iris.

Corneal ulcer

A 57-year-old Caucasian woman is seen in the office with left eye burning associated with foreign body sensation and blurred vision. Symptoms started 2 days after she accidentally fell asleep with soft contact lenses in place. She denies symptoms of eye discharge. She has history of hypertension, hypothyroidism, and myopia. She had an appendectomy at 14, dilatation and curettage at 30, and tubal ligation at 45. No known drug allergies. Usual medications include HCTZ 25 mg daily, Levothyroxine 75 mg daily, and Diltiazem CD 180 mg daily. She had 3 pregnancies, 2 miscarriages, and 1 live birth. Menstrual periods ceased approximately 4 years ago. She does not smoke or use illicit drugs. She occasionally has a glass of wine or a mixed alcoholic beverage. Her mother died at 82 following several strokes. Her father is 88 and has hypertension. No recent fever, chills, or sweats.

Corneal ulcer

A 1-year-old male patient presents with a 1-day history of rash over the face and neck and a 6-day history of fever, decreased appetite, cough, and cold. The family recently migrated from an underdeveloped African country, and his vaccination status is uncertain. Temperature 40.1°C (104.2°F), pulse 130/min, respirations 30/min, blood pressure 90/60 mm Hg. Examination shows bilateral conjunctival injection and blanching, erythematous, maculopapular rash at the hairline, on the sides of the neck, and behind the ears. The oral cavity reveals bluish-grey specks on a red base on the buccal mucosa opposite the second molars. The patient was prescribed vitamin A and drugs to control fever.

Decreased synthesis of retinol-binding protein

A 10-year-old boy with no past medical history presents due to left ear pain that started yesterday. He is on his school's swim team. On examination, there are no signs of trauma on the auricle and tragus. When the auricle is pulled, it elicits pain. Further examination with an otoscope shows the ear canal is edematous and erythematous. Yellow cerumen is present. The tympanic membrane is intact.

External otitis

A 22-year-old male patient has sneezing, nasal congestion, rhinorrhea, and an itchy nose for a few weeks. These symptoms developed around mid-spring and have worsened. He works as a heavy machine operator for 60+ hours a week and must be alert all day. The patient is afebrile with stable vitals. On examination, the patient has pale boggy nasal mucosa with a cobblestone appearance of the posterior pharynx. Laboratory studies show increased IgE levels.

Fluticasone nasal spray

A 36-year-old male scuba diver presents to the ENT physician with acute onset of left-sided earache, hearing loss, tinnitus, and dizziness. Vitals are within reference ranges. Physical examination reveals no obvious external injuries. Otoscopy shows a congested tympanic membrane. Hearing tests reveal high-frequency hearing loss in the left ear. Neurological examination is normal.

Difficulty in clearing the ears

A 29-year-old female patient presents to urgent care with left eye pain. She was working in her garden 3 hours ago when she accidentally flung a chunk of mulch into her eye. She reports pain, watering, and photophobia with foreign body sensation in the left eye. Vision is not affected. After anesthetizing the eye, a foreign body is removed. Symptoms persist after foreign body extraction.

Focal area of fluorescein uptake identified under Wood lamp

A 40-year-old male sex worker presents with watering and foreign body sensation in the left eye and dryness in both eyes. He cannot close the left eye. He underwent reanimation surgery for facial nerve palsy on the left side of the face 1 year ago. He has had diabetes and mild hypertension for 3 years. On examination, the lower eyelid is turned outward.

Ectropion

A 35-year-old female patient presents with pruritic lesions on the antecubital fossa and other flexures of the limbs that have been present for a few weeks. They are intensely pruritic and prevent her from getting a full night's sleep. She does not have any other presenting problems. She has a past medical history of asthma, well-controlled with medication. She denies tobacco, alcohol, and recreational drug use. Vitals are unremarkable. Breath sounds are equal bilaterally without wheeze or adventitious sounds. S1 and S2 are unremarkable with no mururs. Antecubital fossa shows a darkly pigmented, non-tender lesion with some papules. Examination of the antecubital fossa is shown. Refer to the image.

Eczema due to atopic dermatitis

A 4-year-old boy presents to the ED. His parents report that he was "left alone for just one second" an hour ago and swallowed at least one small plastic block. They are not sure how many small blocks the patient tried to swallow. The patient is in minimal distress. He is wheezing and having some difficulty controlling secretions.

Emergent intubation

A 7-year-old boy presents to the emergency department with severe sore throat and fever of 104°F since last night. He is experiencing difficulty swallowing, and his mother has noted increasing drooling. His mother reports that he is not current on his immunizations. Physical examination is remarkable for an ill-appearing child sitting up and leaning forward slightly on the bed, with a small amount of drooling noted. Lateral neck x-ray reveals an edematous protrusion from the anterior hypopharynx.

Epiglottitis

A 6-year-old female patient presents with a rash. On examination, the patient has a lacelike erythematous maculopapular rash on the trunk and extremities and erythematous cheeks. According to the patient's mother, the rash first appeared on the cheeks and then spread. 5 days before the appearance of the rash, she had 2 days of fever, coryza, headache, and sore throat. The mother is not aware of any sick contacts, but the child does attend school 5 days a week.

Erythema infectiosum (fifth disease)

A 10-year-old girl presents with a history of ulceration on the upper and lower lip for 1 week. The lesions are also present on extensor aspects of the arms and legs. She had a history of HSV infection 3 weeks ago. On physical examination, the papules are identified as target lesions. The lesions have a central area of dusky erythema. Refer to the image.

Erythema multiforme

An 8-year-old boy presents with his parents due to difficulty breathing, muffled voice, fever, sore throat, cough, and difficulty swallowing that started when he awoke this morning and has gotten worse. They were managing with hot honey-lemon tea and cold packs until he found it too difficult to swallow the tea. He has no significant medical history and takes no medications. He is not up-to-date on vaccinations. Vital signs are HR 102, RR 30, T 40°C, BP 114/72, O2 98% on room air. On physical exam, he appears anxious and toxic, seated, leaning forward on his outstretched arms, with labored mouth breathing and drooling. His pharynx and epiglottis appear erythematous when examined with a tongue depressor.

Establish an airway.

A 68-year-old male patient presents with a lesion over the upper back. He does not remember when it appeared. He has a history of melanoma over the chest 10 years ago; it was excised. Vitals are non-contributory. Examination reveals a 1 × 1.5 cm darkly pigmented papule, a sharply demarcated lesion with a waxy stuck-on appearance. The clinician suspects a benign pathology but is concerned about the patient's history of melanoma.

Excisional biopsy

A 41-year-old male patient who works as a landscaper presents to the emergency department for right ocular pain after using a string trimmer and edger without wearing proper eye protection. He states he has been irrigating the eye without success and has 9/10 ocular pain. He is unable to open his eye due to blepharospasm. The PA instills topical anesthetic eye drops, enabling them to perform an adequate visual acuity examination, which is found to be 20/20 bilaterally. He denies any significant past medical history or history of contact lens use.

Fluorescein eye stain testing

A 65-year-old man presents with pain and fullness in the right ear and fever for 1 week. He has been diagnosed as having type 2 diabetes mellitus for 20 years. Temperature is 40.1°C (104.2°F). Palpation of tragus and traction over pinna on the right side produces pain. At the slight introduction of the otoscope into the canal, the patient jumps with severe pain. Examination of the right external auditory canal reveals edema, erythema, and narrowing of the canal, with presence of greenish-colored purulent discharge. The tympanic membrane is inflamed. Neurologic exam is completely normal. Screening tests for hearing suggest conductive hearing loss in the right ear. The physician sends the discharge sample for Gram staining and culture.

Fluorodeoxyglucose PET-MRI

A 9-month-old boy presents to the pediatrician with redness in the right eye for 3 days. There is no history of sticky eye discharge or mattering of eyelids. There is no history of fever, vomiting, feeding difficulty, or respiratory symptoms. He is otherwise healthy with no known medical disorder. Physical examination of the right eye shows follicular conjunctivitis with thin watery eye discharge; two vesicular lesions are present over the skin of the right eyelid. The left eye is normal and the rest of the physical exam is normal. Refer to the image.

Herpes simplex virus

A 42-year-old man presents for evaluation of right eye pain since this morning, describing it as a constant gritty feeling. Over the weekend, he was building a treehouse for his son in the backyard; they have been working on it for several weeks. The patient has tried irrigating the eye, but this only provides momentary relief. The eye has been tearing up all day. The patient denies itching, photophobia, fever, chills, and chronic medical conditions. He does not use corrective lenses. Visual acuity is 20/20 in both eyes with Snellen and Rosenbaum charts. The right eye has moderate conjunctival injection. The globes are soft to palpation bilaterally. Pupils are 4 mm, round, and reactive to light bilaterally. Slit lamp examination reveals a sliver of a brownish material, and fluorescein stain reveals a glow along the border of the material.

Foreign body

A 65-year-old female patient with a past medical history of diabetes sustained a 10-cm laceration to the right leg after a fall from standing 2 weeks ago. She had primary suture repair of the laceration and was prescribed a 7-day course of cefalexin 500 mg QID. She presents for a wound check.

Glucose control

A 20-year-old patient presents with a sore throat for 2 days. They feel like they have a fever but has not checked with a thermometer. Their roommate has had similar symptoms. The patient denies cough and rhinorrhea. On exam, there is 2+ tonsillar edema with erythema and exudates bilaterally. There is no peritonsillar fullness. Anterior cervical lymphadenopathy is present.

Group A strep

A 56-year-old patient presents with a "miserably itchy scalp" that started 1 month ago. They have been under more stress at work lately and were unsure if it was related. History includes dandruff that is usually controlled with over-the-counter dandruff shampoo. The patient has had the roots of their hair colored every 6 weeks for 10 years and had it retouched 6 weeks ago. Physical examination of the scalp reveals extensive excoriation of the posterior scalp and neck. Mild pinkness is noted in the excoriated areas of the scalp with no evidence of scaling, papular, or pustular lesions. Evaluation of the hair shows small white ovoid structures firmly attached to the hair shaft.

Head lice

A 60-year-old male patient presents with a sensation that the room is spinning. He feels this way episodically, each time associated with nausea and vomiting. These episodes last less than 1 minute and usually begin when he gets out of bed and stands up. He has no loss of hearing or ringing sensation in the ears. He has a 2-year history of diabetes and is taking metformin. Neurological examination shows horizontal nystagmus. Cerebellar tests are unremarkable.

Head positioning maneuvers

A 3-year-old boy presents to the pediatrician due to a change of voice for 2 weeks. There is no history of fever, nasal symptoms, or breathlessness. Respirations are 30/min. Speech suggests hoarseness of voice, and inspiratory stridor is present. Examination with a flexible fiberoptic nasopharyngoscope shows the presence of multiple sessile, grape-like, pinkish-to-white projections in the larynx.

Human papillomavirus

A 42-year-old man presents with episodes of severe room-spinning sensation and ringing in his ears. With these episodes, he has associated symptoms of hearing loss along with nausea and vomiting. Episodes can last anywhere from 30 minutes to several hours, and he is unable to do anything when an episode occurs. Outside of these episodes, he feels well but remains fearful of when another episode may occur.

Hydrochlorothiazide/triamterene (Dyazide/Maxzide)

A 45-year-old man presents to your primary care clinic. He has had nasal congestion and runny nose for the past 10 days. He states that he thought he was beginning to recover at the end of the first week, then he woke up yesterday with a low-grade fever and general malaise, along with worsened nasal congestion and thick drainage. Past medical history includes seasonal allergies for which he normally takes daily antihistamines and nasal steroid spray, but he admits he has not been using either of these agents for the past several months. He is otherwise healthy.

Periorbital edema

A 40-year-old man presents due to red "blood vessels" on the inside of his right thigh. He states that the areas are not painful but "look ugly." The patient has a history of venous insufficiency for which he wears compression stockings. The patient is wondering what causes these spots.

Increased pressure buildup dilates small blood vessels.

A 25-year-old male patient presents with severe pain in the left ear with occasional foul-smelling discharge. The left cheek is swollen. The pain worsens while eating. On examination, he is febrile and has a tender swelling behind the ear. Hearing tests reveal a conductive type of deafness.

Infection of the middle ear spreads to mastoid air cells.

A 48-year-old man presents to the emergency room with worsening right eye pain and redness for 12 hours. Patient states the eye pain began as irritation, but now it is severely painful. He has noticed sensitivity to light on the right and feels that his vision is blurry. Patient wears contact lenses and admits he recently forgot to take them out before sleeping at night. He is wearing his glasses now. Corrected visual acuity is 20/20 for the left eye and 20/70 for the right eye with Snellen and Rosenbaum charts. The right eye has moderate conjunctival injection, and a small amount of mucopurulent drainage is noted. Slit lamp and fluorescein examination reveal a well-demarcated circular corneal lesion over the right pupil that demonstrates uptake of fluorescein. There is a small collection of white fluid at the inferior aspect of the anterior chamber on slit lamp examination.

Initiate topical antibiotic and consult ophthalmology.

A 15-year-old boy presents to the ED with bleeding from the right nostril for 30 minutes. He reports persistent nasal obstruction and intermittent headache on the right side for 3 months. There is no history of rhinorrhea, sneezing, or cough, and he has no known medical disorder. After initial treatment of epistaxis, plain radiogram shows a nasopharyngeal mass on the right side with opacification and bowing of the posterior wall of the right maxillary sinus. Contrast-enhanced computed tomography scan shows an avidly enhancing soft-tissue mass in the posterior nasal cavity.

Juvenile nasopharyngeal angiofibroma

A 22-month-old previously healthy male patient has decreased vision in both eyes with strabismus. He has completed his milestones unremarkably. The patient's maternal uncle died in infancy due to an eye tumor, and childhood osteosarcoma was diagnosed in the patient's mother. A genetic disorder predisposing to multiple tumors is suspected in the patient.

Leukocoria

A 3-year-old girl is brought to the ED by her mother with a history of accidental insertion of a peanut in the left nostril about 1 hour ago. The child is irritable and crying; she has a malodorous discharge from the left nostril. A topical anesthetic with vasoconstrictor is instilled in the nostril, and anterior rhinoscopy is gently performed. The peanut appears to be firmly lodged deep within the nasal cavity.

Mechanical extraction with probe

A 26-year-old pregnant patient at 30 weeks gestation presents for a regular follow-up. The patient is feeling well, takes prenatal vitamins, and takes a daily walk for exercise. The patient is concerned about a rash that has progressively developed over the face. There are dark brown patches becoming confluent on the cheeks and bridge of the nose. They report having the same rash a few years ago while on oral contraceptives pills (OCPs).

Melasma

A 67-year-old woman presents with progressive severe pain and discharge from her left ear for the past 2 days. She has had type 2 diabetes mellitus for 15 years and admits to being noncompliant with her medications and follow-up appointments. On physical examination, moving or touching the pinna of the left ear produces extreme pain. Otoscopic exam shows granulation tissue in the left ear canal with a slight amount of purulent discharge. The tympanic membrane is clear, and there is no middle ear effusion. ESR is 85 mm/hr (N 0-29 for FMs). Initial cultures from the left ear show a gram-negative rod.

Motile and oxidase-positive

A 56-year-old male patient presents for a scheduled follow-up. A severe dermatological condition was diagnosed 1 year ago, when he presented with multiple vesicles, erosions, and bullous lesions on erythematous skin over the face, scalp, trunk, groin, and armpits. The skin lesions were preceded by intraoral blisters, which would rupture and leave painful erosions. Medical records indicate that direct immunofluorescence on normal-appearing perilesional skin showed intercellular deposition of immunoglobulin G on the surface of the keratinocytes in and around the lesions throughout the epidermis. He was initially treated with systemic corticosteroids, which were discontinued because he developed glaucoma and cataract. 3 months ago, he was prescribed azathioprine, which required discontinuation due to hepatotoxicity. Now, he has painful intraoral lesions and multiple skin lesions over the face and trunk. He cannot afford rituximab with his current finances.

Mycophenolate mofetil

A 30-year-old woman has developed three patches of hair loss over the scalp over the last month. Physical examination shows smooth and slightly erythematous patches of hair loss on the scalp and presence of hairs that are tapered near the proximal end at the margins of the patches.

Nail pitting

A 20-year-old patient presents to student health with bilateral erythema with matting of exudate in the eyelids in the morning. They report routine contact lens use. Question You ask if they ever wear contact lenses. What is the appropriate treatment plan given the response from the patient?

No history of contact lens use. This is likely a self-limiting viral process; recommend good hand hygiene, throw away eye makeup, and do not share towels or pillows.

A 35-year-old male patient presents to the clinic for a routine health maintenance examination. He has a 20-year history of seizure disorder characterized by sudden-onset periodic jerking movements of both arms and lip-smacking. He has a history of intravenous cocaine use. Temperature 37.1°C (98.8°F), pulse 80/min, respirations 13/min, blood pressure 130/75 mm Hg. Examination shows gingival tissue covering the upper third of the teeth. There is bleeding of the gums when touched with a fine instrument. The remainder of the examination is unremarkable. Hemoglobin13 g/dLLeukocyte count6000/mm3Platelet count300,000/mm3Serum bilirubin0.9 mg/dLBUN13 mg/dLCr0.9 mg/dL

Phenytoin

A 65-year-old female patient presents with discoloration over the toenails for a few months. She states that they seem to break frequently for about 4 months. She does not have any pain, redness, swelling, discharge, or any other presenting problems. She was diagnosed as having diabetes mellitus 15 years ago. Medications include metformin. She denies alcohol use and recreational drug use. She used to smoke a pack per day for 30 years, but she quit 5 years ago. She consumes a balanced diet and exercises for 45 minutes daily. She lives with her spouse of 40 years. She has two adult children. Vitals are unremarkable. Cardiovascular and respiratory examinations show no abnormalities. Refer to the image.

Onychomycosis

A 68-year-old man was prescribed a 5-day course of amoxicillin 500 mg three times a day for a urinary tract infection 6 days ago. He now presents with non-pruritic erythematous eruptions on the extremities. Dermatologic examination reveals 2-3 mm erythematous papules and plaques on the extremities and the trunk with no mucosal involvement. Temperature is 36.8°C (98.4°F) and blood pressure is 124/80 mm Hg. The symptoms of urinary tract infection have been resolved.

Oral antihistamine and topical steroids

A 35-year-old male farmer presents for an eye exam. Past medical history is negative except for a broken arm 3 years ago from falling off a tractor. Patient spends most of his time outside. A few weeks ago, he noticed a yellowish spot on "the side of his right eye towards his nose." He thinks that it grew slowly but stopped. He describes his eyes as dry, and he feels like there is sand stuck in it. He denies vision changes.

Prescribe lubricating eye drops and discuss lifestyle modifications.

A 21-year-old man presents with dry and itchy skin for the past 1 month. The patient says that itching worsens at night. Dermatologic examination reveals follicular papules and burrows on the wrists, axillae, buttocks, webbed spaces of the fingers, and genital area. The skin scraping of the burrows does not find mites, feces, or eggs. Refer to the image.

Prescribe topical permethrin.

A 28-year-old man has developed fever, malaise, and pain over the right leg within 48 hours of swimming in seawater. He recollects an accidental traumatic injury by knife to the same area 4 days ago. He is not immunocompromized and does not have diabetes mellitus. Physical examination shows an edematous, tender, warm, violaceous-colored area with several hemorrhagic bullae in the lower third of the anterior surface of the right leg.

Real-time PCR assay on the specimen

A 2.5-year-old boy is brought to the pediatrician's office by his mother because of mouth sores. She reports he was very irritable 2 days ago and he was not sleeping or eating very well. She states that he is his normal self today, but he has numerous sores in his mouth and on his tongue. On physical examination, the patient is afebrile and vital signs are stable. Oral examination reveals numerous vesicles surrounded by a thin halo of erythema on the tongue and buccal mucosa measuring 2-3 mm in diameter. Further examination reveals the presence of a maculopapular rash involving his palms and soles of his feet. No other skin lesions were noted and the remainder of the examination was normal.

Reassurance and supportive care

An 84-year-old woman presents to the primary care clinic with unilateral hearing loss. She reports right hearing loss that has been progressive over the last 2 weeks with a sensation of fullness in the same ear. She reports wearing hearing aids and that she cleans her ears daily with a cotton swab.

Right ear bone conduction longer than air conduction during Rinne test

A 15-year-old male patient presents with pain and swelling of the left eye and the surrounding area for 3 days. He has trouble opening his eyes and has double vision. He gives a history of recurrent sinusitis, with the most recent episode 2 weeks ago. He had a sore throat 4 days ago. Oral temperature 102°F. Orbital exam reveals edema, tenderness, and conjunctival chemosis, with cellulitis of the area around the eye.

Sinus edema causing poor drainage and infection spreading to orbital tissue

A 68-year-old man presents with pigmented, tender, thickened, scaly, rough, skin lesions on the forehead. The patient states that these lesions have been present for 3 years and are enlarging with time. The patient has a history of chronic exposure to the sun due to his occupation. On physical examination, the lesions are >1 cm in diameter, indurated, ulcerated, and rapidly growing. Refer to the image.

Skin biopsy

A 3-year-old girl presents with a fluctuant warm mass in the medial canthal area of the left eye. Visual acuity is not affected. Past medical history is negative for trauma or systemic disease. Examination of the area reveals tenderness, edema, and erythema over the medial canthus. There is a purulent discharge from the swollen area on digital pressure over the lacrimal sac. Ultrasound reveals a well-circumscribed round lesion filled with anechoic fluid with punctate echoes.

Staphylococcus aureus

A 24-year-old man presents with a 2-week history of monomorphic papulopastules located on the trunk and extremities. The patient's medical history is significant for asthma, and he has been taking prednisolone for an acute exacerbation. The remainder of the physical examination shows no abnormalities.

Steroid-induced acne

A 38-year-old man presents to your clinic for an annual exam. He notes a painless swelling in his left cheek. He says he noticed the swelling several months ago, but he believes it has been present for almost a year. He says the swelling has been unchanged. He denies any loss of facial sensation, fevers, chills, vocal change, or weight loss. He denies consuming alcohol and says he quit smoking 15 years ago, but he was a 5 pack-year smoker prior to that. He takes no medications and is up to date on his vaccinations. He denies any pertinent family or medical history. Vital signs are normal. On exam, you are unable to find any focal neurologic deficits, no lymphadenopathy, and no point tenderness. Palpation of the swelling reveals a firm 1 cm x 1 cm round nodule that is mobile, non-erythematous, non-tender, and smooth. CBC and BMP are unremarkable. You conduct a head and neck CT scan, which shows an encapsulated solitary nodule without evidence of local invasion. Suspicion is confirmed with a fine needle aspiration.

Superficial parotidectomy

A 45-year-old man presents to the emergency department after accidentally spilling hot grease on his right foot at work (fast food restaurant). On physical exam, you note a 4.5 x 3 cm erythematous, edematous area on the dorsal aspect of the foot. There is an intact bulla 2.5 x 2.5 cm filled with serous fluid. Capillary refill is intact, and blanching of the affected skin is noted. He reports extreme pain.

Superficial partial-thickness burn

A 4-year-old boy presents with papules on the palm, foot, and perioral area for the past day. His mother states the patient has had a fever for the past 2-days and is now experiencing discomfort while eating. Patient body temperature is 38.3°C (101°F). Physical examination reveals red macules and papulovesicular lesions on the perioral area, hands, feet, and knees. Intraoral examination reveals ulcers of 2-3 mm with an erythematous base involving the buccal mucosa, posterior third of the palate, and tongue. Refer to the image.

Supportive care with antipyretics

A 60-year-old man patient presents with concern for skin lesions on the lips. You notice small dilated blood vessels on the oral mucosa. He reports a history of GI bleeding and epistaxis. You see that he is taking pantoprazole, iron, and a daily vitamin.

Telangiectasia

A 65-year-old man presents with change in voice for 3 months and difficulty in swallowing for 1 month. He has no known medical disorder to date except for obesity. Medical records suggest that he had been treated for condyloma acuminata at age 25. He smoked from ages 20 to 36, then he switched to smokeless tobacco. He has been a social drinker since age 18; his alcohol intake is limited to 3-4 drinks in a typical month. After the necessary evaluation, direct laryngoscopy is performed, detecting a laryngeal tumor. Histologic examination of the sample obtained by biopsy of the tumor shows presence of dysplastic squamous cells and keratin beneath the basement membrane. There is invasion of lymphatics by the cells.

Tobacco cessation

You are managing a seasonal urgent care for campers near a lake in the southeastern United States. A 24-year-old man presents to you with very itchy, swollen arms and feet that started after he woke up from a 30-minute nap 1 hour ago. He intermittently scratches at his arms, but he says he tries not to. The affected areas are mildly sore but not tender, and he denies fevers, chills, excessive sweating, malaise, shortness of breath, nausea, vomiting, headaches, or diarrhea. He denies being aware of any insect bites, but he reminds you that he was napping. Social history is notable for sporadic alcohol use (4 drinks/week) and rare marijuana use (1 joint/month), with last use for both within the last 24 hours. He does not take any medications, and his medical/family history are otherwise negative. He denies any known allergies. Vitals are within normal limits. On exam, he is well-appearing and calm, occasionally scratching at his arms/legs, which are exposed in his current outfit. Inspection of the affected areas reveals several raised circular wheals 2-6 cm in diameter without necrosis or vesicles. The lesions are non-pitting. The remainder of his exam is entirely unremarkable.

Topical calamine lotion

A 41-year-old man presents due to unrelenting "jock itch" that has gotten worse since onset a few days ago. He goes on to describe intensely itchy red spots between his thighs that are occasionally painful. Despite trying over-the-counter topical antibiotic and steroid creams, it has gotten bad enough that he can no longer go for his daily runs. He denies any recent changes in his soaps or detergents and denies any allergies. He currently works at a local bakery. Medical history is notable for diabetes mellitus with an A1c of 8.7%. He remarks that he was homeless for the past year after losing his job and health insurance, but he has been back on his feet and watching his blood glucose over the past few months. When you ask about his runs, he mentions that he wears loose-fitting basketball shorts. Vital signs are unremarkable. Physical exam reveals a BMI of 31 and inguinal folds containing erythematous, macerated plaques and erosions with fine peripheral scaling. There are erythematous satellite plaques and pustules as well. Gently palpating the pustules causes many of them to rupture.

Topical nystatin

A 50-year-old male patient presents with painful skin lesions over the chest, abdomen, back, arms, and face for 2 days. He feels feverish and fatigued. There is peeling of the mucous membrane over the lips. He had symptoms of a urinary tract infection 2 weeks ago—he was prescribed sulphamethoxazole and trimethoprim for 3 days. He does not have any other significant past medical history. Temperature 38.8°C (102°F), pulse 98/min, blood pressure 100/70 mm Hg, respirations 22/min. Cardiovascular and abdominal examinations are unremarkable. He has extensive lesions over the face, trunk, back, chest, and arms. The lesions are tender, and the skin appears desquamated. Refer to the image.

Toxic epidermal necrolysis

A 3-year-old boy is brought in by his mother for evaluation. The mother, upset, thinks the patient has had an object in his nose for a week. This morning, the patient's older sibling mentioned witnessing him inserting a small eraser into his right nostril. When you ask the patient, he is quiet and denies putting anything into his nose. He is well-appearing but seems nervous when you try to examine him. He is afebrile. Lung and cardiac examinations are unremarkable.

Unilateral foul-smelling nasal drainage

A 62-year-old man presents with a 5 × 4 mm skin lesion on his left nose tip. The histopathological examination of the lesion reveals a locally-advanced basal cell carcinoma (LaBCC) with a depth of around 2 mm. The patient refuses to undergo surgery and radiotherapy.

Vismodegib

A 24-year-old female patient presents with a white-colored skin lesion over the right knee joint for 1 year. She says the lesion grew in size over the first 6 months but has been static since then. She has no significant past medical history. Pulse 88/min, respirations 15/min, blood pressure 118/78 mm Hg. Examination shows a single 3 × 4 cm, well-demarcated, oval-shaped, milky-white macule with a convex border just above the right tibial tuberosity. The surrounding skin is unremarkable. When examined under Wood's lamp, the lesion emits a bright blue-white fluorescence. Dermoscopy of the lesion shows a diffuse white structureless area with reduced perifollicular pigmentation within the lesion. Scales and vessels are absent.

Vitiligo

A 19-year-old patient presents with a painless rubbery lump in the right eyelid. They deny fever or vision changes.

Warm compresses multiple times daily; ophthalmology for incision and curettage if it recurs

A 4-year-old boy with no past medical history presents with his mother due to left ear pain for the last 2 days. He has a sensation of "fullness" and hears a popping sound. His parents have not noticed any signs of hearing loss. Vital signs are normal. On examination of his left ear, there is gray-colred fluid behind the tympanic membrane.

Watchful waiting

A 32-year-old woman who was prescribed valproic acid 2 days ago is admitted with maculopapular and bullous eruptions on the face and neck with variably sized target-like lesions on the trunk. Physical examination reveals ulcerations on the oral mucosa, subconjunctival hemorrhages, and vaginal lesions.

Wear a medical information bracelet.

A 42-year-old man presents for evaluation of right eye pain since this morning, describing it as a constant gritty feeling. Over the weekend, patient was building a treehouse that he has been working on for several weeks. Patient has tried irrigating the eye, but this only provides momentary relief. The eye has been tearing up all day. Patient denies itching, photophobia, fever, chills, and chronic medical conditions. Patient wears daily disposable contact lenses. Visual acuity is 20/20 in both eyes with Snellen and Rosenbaum charts. The right eye has moderate conjunctival injection. The globes are soft to palpation bilaterally. Pupils are 4 mm, round, and reactive to light bilaterally. Slit lamp examination reveals a sliver of a brownish material, and fluorescein stain reveals a glow along the border of the material.

Wear protective eyewear.

A 38-year-old patient with obesity presents with hyperpigmented velvety skin plaques behind the neck and under the arms. The patient says that this condition has been worsening over the past couple of years and is cosmetically bothersome. There is no pain or itching. The patient currently takes no medications. Blood work is unremarkable, including a fasting glucose of 98.

Weight loss

A 56-year-old man presents due to headache, left ear pain, fullness, and decreased hearing that started a few days ago. He rates the pain as a 4/10 that improves mildly with ibuprofen. A chart review shows he emigrated from Hong Kong 20 years ago with his wife and 2 children; he works as a supermarket chain executive. He denies drinking, smoking, or illicit drug use. He takes a men's multivitamin and an herbal tea containing green tea extract and birthwort. He denies having ear infections before. He eats a diet rich in traditional foods like cured meats and vegetables, dumplings, and rice noodles. He also admits to eating dairy occasionally. His surgical history is unremarkable. Family history is generally unremarkable, though he mentions an older brother who passed of an unknown cancer shortly before he left. His vitals are normal. On exam, you note an overall well-appearing slender man who is pulling at his ear to try to alleviate the symptoms. Ear exam shows a mildly cloudy right tympanic membrane. The left TM is erythematous and bulging. There is firmly palpable non-tender swelling of the left anterior cervical lymphatics. The remainder of the exam is normal. You prescribe a course of antibiotics and refer him for an MRI of the head and neck, which reveals a growth in the pharyngeal recess with local extension into the lymphatics. An endoscopic biopsy confirms the diagnosis. A qualitative lab study for plasma EBV DNA is negative.

cured foods

A 67-year-old female patient presents with a bright red macule on the scalp that she noticed 2 months ago while brushing her hair. Family history is significant for malignant melanoma in her brother and mother. On examination, a small, bright, cherry-red macule is present on the scalp. A red-clod pattern is seen on dermoscopy, and a punch biopsy demonstrates numerous venules in a thickened papillary dermis.

reassurance

A 55-year-old female patient presents with redness and flushing of the face for a few years. She has never sought medical attention for it. She has persistent redness of the face. She notices that flushing increases with hot beverages. She has no other presenting problems. Past medical history is not significant. She lives with her husband and two children. She has been pregnant twice and has delivered two healthy children with no antenatal or postnatal complications. Vitals are stable. Cardiovascular and respiratory examinations are unremarkable. Examination of the skin reveals a non-tender lesion on the face. Refer to the image.

rosacea

A 9-year-old male patient is brought to the clinic with lesions over the face over the last week. He has no past medical history and has received all age-appropriate immunizations. On exam, he is afebrile and vitals are stable. He has multiple painful pustules around the lips and nose. Several are crusted over with a golden appearance. Others are oozing with surrounding erythema. Question What treatment will most likely benefit this patient?

topical mupiricin