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Dermclinic: A Photo Quiz to Hone Dermatologic Skills

An 85-year-old man was hospitalized because of lower GI bleeding. He was hemodynamically stable. Because gastroscopy and colonoscopy failed to reveal the source of the bleeding, push enteroscopy was performed. This study showed an ulcerated tumor in the proximal jejunum.

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

A 45-year-old man comes to see you for a routine physical.He has no complaints and no significant medical history.However, while questioning him you discover that he usedintravenous heroin until about 10 years ago-and sometimesshared needles. He also drank 6 or more beers a day for about 20 years, a practicehe stopped at the same time that he quit using illicit drugs. He has multiple tattoos,which were done at commercial parlors. He is married but has no children. His wife hasno history of hepatitis. Physical examination is unremarkable.

A nonhealing ulcer recently developedin a painful facial rash that hadworsened over several months. The44-year-old patient is a heavy drinkerwith a history of elevated liver functionlevels. She has had numerousunprotected sexual contacts over theyears.

The parents of this 5-month-old boy were concerned that his eyes wereturned in toward the nose. The infant was otherwise healthy. Physical findingswere normal. In particular, when a light source was projected onto theeyes, the light reflex was centered in both eyes.

The "Quick Take" on water fluoridation states that "fluorideprevents caries primarily after tooth eruption" (CONSULTANT,March 2001, page 472).

How can you readily determinewhether your patient with bronchitismay benefit from an inhaled bronchodilator?

Advise patients to use moist heat totreat spinal or extremity injuries duringthe first 48 hours.

Although widely regarded as a raredisorder, hereditary hemochromatosisis the most common genetic disease inCaucasians. In certain populations ofnorthern European descent, 1 of every200 persons is homozygous for thecausative mutation.1

As many as 300,000 sportsrelatedconcussions arediagnosed each year inthe United States.1 Thisfigure underestimatesthe true incidence, however, becausemany concussive injuries are notrecognized by the injured persons,trainers, or physicians. A recentstudy found that 4 of 5 professionalfootball players with concussionwere unaware that they had sufferedthis injury.2

Endobronchial foreign bodies can be life-threatening, but once they are detected, they can usually be removed, leading to prompt resolution of symptoms. Chest radiography and CT scanning can be helpful in some cases, but bronchoscopy is necessary for definitive diagnosis and treatment.

Pressure ulcers occur frequently in elderly, hospice, and spinal cord injury patients. They affect 5% to 10% of patients in all health care facilities and add substantially to health care expenses.

Six months ago, I prescribed allopurinol for a patient with a history of podagra, several tophi in one toe, and an elevated uric acid level.

Abnormal uterine bleeding can be defined as bleeding that deviates from the patient's normal pattern; it may be heavier, more frequent, or abnormal in timing. Bleeding of any kind in a postmenopausal patient should be considered abnormal unless she is receiving hormonal therapy that is associated with regular cyclic withdrawal bleeding.

A 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.

35-year-old woman presents to the emergency department with palpitations and chest pain. She is aware of her heart beating fast but not irregularly. She notes associated discomfort in the center of her chest.

22-year-old man is hospitalized because of severe hypertension. In addition, he reports exertional retrosternal pressurelike pain, with a severity of 5/10, that lasts for 2 to 3 minutes.