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Pigmented lesion on an elderly man's lip

Pigmented lesion on an elderly man's lip

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FigureThe Case
An 89-year-old hemiplegic man is seen for a routine physical examination. Major right brain stroke produced permanent dense left-sided motor deficit years ago. Has related vascular dementia. Completed full isoniazid prophylaxis for newly positive PPD skin test 2 years back; underwent concomitant pyridoxine repletion. Has benign prostatic hyperplasia, urolithiasis, and esophageal reflux disease. Takes 14 medications, including warfarin, sotalol, tamsulosin, tizanidine for spasticity in the left hand, and quetiapine.

More History/Physical
Man whose smile is evident and winning, notwithstanding left central facial palsy. Scabbed 1 cm basal cell carcinoma on right temple (neither he nor family wants it treated). Left hemiplegia. Flexion contracture at wrist, with padding and splint to prevent injury and retard progression. Verbal output sparse but mostly appropriate. Mouth as shown. Dentition and gums unremarkable for age.

Laboratory Findings
INR, 2.8 (target therapeutic range for this patient, 2 to 3).

What's Your Diagnosis?

Addison disease
Basal cell carcinoma
Mucocele
Peutz-Jeghers syndrome
Organic psychosis
Venus lake

(Answer on next page.)

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