A 58-year-old man with type 2 diabetes, nephrolithiasis, and benign prostatic hyperplasia presented with bilateral periorbital ecchymoses and left subconjunctival hemorrhage. The ecchymoses had spontaneously appeared 3 days earlier; the patient had no history of trauma or falls. He also had difficulty in voiding, characterized by increased... More »

A 37-year-old man was brought to the emergency department (ED) after he had 2 near-syncopal events. The first occurred in the morning and rapidly resolved; the second occurred later in the day at work. The night before he had a headache and neck pain. In the ED, he reported left arm and leg weakness and was noted to have left facial droop.More »

For 4 months, a 41-year-old woman had pain in the pulp of her fingers and dorsa of her feet that was associated with transient maculopapular lesions at different sites. During this period, she had been hospitalized twice for the same complaint. Findings from an extensive rheumatological workup were negative. She also had an unintentional 20-lb... More »

During a routine physical examination, multiple, randomly distributed, fleshcolored nodules were noted on the trunk, arms, and face of a 62-year-old man. The lesions measured 0.5 to 1.0 cm and appeared slightly pedunculated. The patient had had the lesions since he was a teenager; they were not painful. He also had hypertension, for which he was... More »

During a flight from Houston to New York, a 46-year-old man had fever, chills, rigors, and body aches. After he landed, he sought treatment at a local hospital. The patient was on his way back to Liberia, where he works. He had been at home in Houston for several weeks. In the emergency department, he complained only of subjective fever. More »

This lesion had appeared in the right groin of a 60-year old man and had slowly enlarged over a month (A). Two years before this evaluation, he had undergone total prostatectomy with lymph node dissection for prostate carcinoma. Metastatic disease was found in a resected lymph node, and he underwent multiagent chemotherapy.
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For 3 months, a 63-year-old man had experienced progressively worsening dyspnea. He denied fever, weight loss, and hemoptysis. Eight months earlier, he had had a right thoracotomy to drain a right empyema. Comorbidities included morbid obesity, type 2 diabetes mellitus, hypertension, and obstructive sleep apnea. However, he did not have any... More »

A 68-year-old woman with a history of hypertension, hyperlipidemia, and tobacco use presented with her third stroke in the past 7 years. Neurological deficits included dysarthria and left-sided motor and sensory loss. A previous transthoracic echocardiogram with a bubble study did not reveal any cardiac source of embolism. Axial MRI of the brain on... More »

Two weeks after being treated for a fracture of the left humerus and several palpable breast lesions, a 63-yearold African American woman was hospitalized for generalized weakness and confusion. She had a history of type 2 diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease, and low-grade B-cell lymphoma (which had been... More »

This rash erupted on the upper body of a 58-year-old woman in late August. It was mildly pruritic and nontender. The patient had not started any new medications and was not taking photosensitizing drugs. She had Sjögren syndrome; the rest of her history was noncontributory. Subacute cutaneous lupus erythematosus (SCLE) was diagnosed. SCLE typically... More »

A 7-year-old girl was brought to the emergency department because of moderate pain on swallowing and mild upper abdominal discomfort. A few hours earlier, she had been given a piggy bank in order to save money for a family trip planned for the next day. On shaking the piggy bank upside down above her head, a few coins fell out. The child admitted to... More »

Right upper quadrant pain of 24 hours’ duration prompted a 20-year-old man with a history of gastritis to seek medical attention. The pain was sharp and nonradiating, with no alleviating or aggravating factors. The patient occasionally consumed alcohol and regularly smoked cigarettes (tobacco and marijuana). He denied nausea, vomiting, diarrhea, and... More »

A 51-year-old man was hospitalized for subacute alteration of mental status. The patient had a history of alcohol abuse. He had no other medical disorders. Vital signs were normal. The patient scored 15 out of 30 on the Mini-Mental State Examination. He had an ataxic gait; all other physical findings were normal. The family reported that he had been... More »

These joint deformities occurred in a 61-year-old man with chronic tophaceous gout. The patient had had joint pain and swelling since he was 40 years old; the symptoms began in 2 fingers and were initially mild. He did not seek medical attention. Within 5 to 10 years, joint abnormalities had developed in the fingers and then in the left elbow and... More »

Diffuse abdominal pain with nausea, vomiting, and constipation developed in a 69-year-old man with poorly differentiated mesothelioma several days after he was hospitalized for left-sided intractable pleuritic chest pain that warranted opiates. Vital signs were normal. The abdomen was distended, mildly tender, and hypertympanic with positive bowel... More »

This lesion appeared on the left outer thigh of a 28-year-old man after he took amoxicillin. The antibiotic had been prescribed for an upper respiratory tract infection with fever. Two years earlier, a lesion had appeared in the same anatomical region after ingestion of amoxicillin. A skin biopsy of the current lesion confirmed the diagnosis. More »

For 18 months, a 50-year-old man had sporadic epistaxis that had worsened and become uncontrollable. The patient also had saddle-nose deformity, with erosion of the surrounding structures of the face, and reddish discoloration of the skin with severe dryness. The skin was thickened with ulcers around the nasal bridge. He had no major medical... More »

A 36-year-old man presented with persistent right shoulder weakness and pain (4 out of 10 on the visual analog scale). He also had an “odd pulling sensation” with arm adduction. During a wrestling match 2 years earlier, his arm was abducted and extended, after which he heard a popping noise and felt burning pain in his shoulder. More »

During a new-patient evaluation, a 49-year-old Hispanic man was found to have several nontender, hard nodules protruding from the lingual area. The nodules had evolved slowly over several years. The patient reported no trauma to the area. He was a long-time smoker and took no medications. His medical and family histories were unremarkable. More »

These extensive, smooth, irregular masses of pigmented tissue on the earlobes of a 28-year-old woman are keloids. The patient had her ears pierced at age 6 years; the masses began to develop when she was about 9 to 10 years old. The right earlobe mass arose first and is larger. She had one other keloid of 1 cm on her chest that had developed after a... More »