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According to the American College of Physicians, we are facing "a looming collapse of the nation’s primary care."

The Collapse of Primary Care?

The annual meeting of the American College of Physicians showcased dedicated primary care physicians and clinical milestones finally reached.

In Praise of Physicians

No labs, no biopsies . . .  you can make this Doorway Diagnosis just by looking.

Pictured is the posterior right knee of a 69-year-old woman showing a rounded protuberance at the popliteal fossa.

No labs, no biopsies, no imaging -- only your seasoned clinical judgement is required to make a diagnosis in this case. 

Bulge Behind the Knee 

A 3-year-old boy is seen for unilateral swelling on the left side of the face, in front of and behind the left ear. Findings on examination of ears, oral cavity, and teeth are normal. He is afebrile (temp, 37°C [98.6°F]), cooperative, and in no distress. He is otherwise healthy. Past medical history includes 1 MMR vaccination.

The child is bright and alert and has no fever. The swelling is on the left side of the face only. Find other clues to a diagnosis in the accompanying video.  

3-Year-Old Boy With Unilateral Facial Swelling 

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"?

This image of the dorsum of the tongue of a 42-year-old African American woman shows parallel linear black coatings.

After a “swig” of  Kaopectate, this patient noticed tongue discoloration. Is this coincidental, or is there a clinical connection? 

Black Coating on a Woman’s Tongue

An 89-year-old woman with a history of biopsy-proven actinic keratosis on her scalp is seen for a new erosion on the right frontal area. Two weeks of twice-daily mupirocin has brought no improvement and now crusting and purulent exudate are seen. Skin cultures taken show normal flora.

C. Erosive pustular dermatosis of the scalp

E. Chronic actinic damage with secondary infection

An 89-year-old woman is seen for an erosion on the frontal area of the scalp. History is positive for actinic keratosis. What's your Dx?

Crusty Scalp Lesion 

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

Steve Murata

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