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The purple-stained urine bags and tubing of 2 elderly patients are shown here. Neither patient received urine-discoloring medications.

Purple Urine Bag Syndrome

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. She has a history of multiple non-melanoma skin cancers.

Squamous cell carcinoma in situ (Bowen  disease)

Lichenoid keratosis (an inflammatory variant of seborrheic keratosis)

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. What does this look like to you?

Clinical Topics

What's This "Red Spot"?

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Rash Around the Mouth of a 5-year-old Child


This intensely itchy, blistering rash on the forearms and upper chest of a 13-year-old girl occurred after a day at the beach. The girl had polymorphic light eruption (PMLE), the most common abnormal reaction to UV light.

A. PMLE classically presents as a papular or papulovesicular eruption on the arms and anterior chest

B. The reaction usually begins 12 to 24 hours after an initial exposure to light of a suddenly increased intensity

C. Some parts of the body are severely involved while similarly exposed areas are paradoxically spared

D. The rash resolves after 7 to 10 days, often leaving whitish scarring

What are the characteristics of this blistering rash caused by exposure to UV light? 

Intensely Pruritic Rash After Sun Exposure in a Tween Girl 


These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite.

These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite. What creature did the biting?

Swollen Hands-What’s Biting?

Pain is often severe in patients with adhesive capsulitis, or frozen shoulder, and motion is restricted. Distinguishing between frozen shoulder and osteoarthritis may be difficult. Internal rotation of the shoulder is measured by the highest vertebral level that the tip of the thumb may reach with the arm behind the back.

The patient’s reach with his thumb helps distinguish between frozen shoulder and osteoarthritis. How high is enough to tell?

Thumbs Up or Down on Shoulder Pain?

An 11-year-old boy went down a pool slide, head first, and struck the back of his head on the pool bottom. He reports he had immediate pain in his back at approx T5-6, but could move all his limbs. C-collar was placed at scene; pain meds given at ED. GSC, 15; vital signs, WNL. Watch this video interview with the patient.

C.  Injuries to the thorax or back (eg, myocardial contusion)

The pain was immediate at T5-6 after he struck his head on the pool bottom. Can you Dx his injury based on the video interview?

Young Boy with Back Pain after Diving Accident 

Edwin Pimentel-brugal, MD

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