A 58-year-old man presented for care when he noticed a flat, dark area on his left upper arm. The lesion was set against a background of fairly severe photodamage. Family history was positive for melanoma (mother and 1 of 4 sisters).

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The elderly patient has had type 2 diabetes for 15 years is now home bound after a stroke. Her HbA1c is 9.6; random blood sugar, 450; triglycerides, 350; HDL, 40; LDL, 110 (calculated); total cholesterol, 220; and non-HDL,180. She takes only metformin. Would you consider more aggressive treatment of her elevated HbA1c? If so, why—how, and to what level? Would you do anything to treat her lipids?

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Joint hypermobility; “cigarette-paper” skin; keloid scars; and pectus and scoliosis: to what common diagnosis do these disparate findings in 3 different patients point?

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Skin lesions in the outer ear—the pinna, the concha, and the external auditory meatus—may be trivial or potentially malignant. Here we consider a flesh-colored swelling with a central white spicule; a tan papillary lesion; a fluctuant swelling; a red berry-like papule; an elevated pink lesion.

A 26 year-old African-American woman was concerned about the gradual onset of mildly tender, but severely distressing facial lesions. She had not sought medical attention previously because of a lack of insurance and assurances by her mother that this was only “bad acne.”

Does this look like acne to you?
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Jose is 47-year-old Hispanic male who comes to your office for a “check up.” His only symptom is that he notices he does not have the energy he once had but thinks “it’s because of his weight.” He has worked at a desk for 3 years and has gained 12 pounds.

He has several paternal aunts and uncles with Type 2 diabetes and his father died at age 49 from an MI. His BMI is 29, blood pressure, 143/88 mm Hg, and his waist circumference is 42 in.
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A 31-year-old woman presents for evaluation of an asymptomatic, firm plaque on the forehead. Lesions of similar size and consistency were present at the nape of the neck and on the chest. The patient was in overall good health. A biopsy performed to rule out cutaneous lymphoma revealed almost pure sheets of plasma cells in the dermis. What are your diagnostic suspicions and what would your next step be?
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A 33-year-old man seeks attention for his abnormal toenails, having already failed full treatment courses of both terbinafine and itraconazole. Review of systems reveals complaints of painful “eye irritation” as well as chronic low back pain severe enough to warrant daily ingestion of aspirin. What diagnoses in addition to onycomycosis would you consider given this picture?
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A 14-year-old boy presented with vomiting and dull, aching, generalized abdominal pain made worse by movement. Vomit was bilious, with a total of 10 episodes over 3 days. The boy had had no bowel movement for 5 days. His abdomen was distended, rigid, and diffusely tender, with normal bowel sounds and no organomegaly. He denied fever, trauma, previous episodes of abdominal pain, or surgeries. What do you suspect is going on, and what tests would you order?
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Swelling and redness have progressed over the past 16 hours in this 5-month old boy. Would you consider child abuse in your differential diagnosis?
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