Question of the Week # 479

479. A 57 year old female presents for second opinion of a left breast lesion that had been diagnosed as ‘eczema’ by her regular nurse practitioner, which briefly improved after a short course of topical steroids. On physical exam there is an erythematous, scaly lesion involving the left breast. Image is shown below. Her last mammogram was a year ago and it was “fine”. She does not report any family history of breast cancer. What is the next step in the patient’s management?

image br rash

A – Bilateral breast ultrasound

B – Bilateral mammography and punch biopsy of nipple

C – Maintain regular annual mammography appointment

D – Oral corticosteroids

E – Left breast MRI

Question of the Week # 475

A 2-week-old infant is brought to the office for a regular postnatal follow-up. She was born after an uneventful term pregnancy to a 29-year-old G2P2 woman. Mother reports that the infant is feeding well and seems active. No evidence of any fever. The parents are worried about the ‘rash’ that appeared over the infant’s left cheek. On examination, a lesion is noted on the infant’s left cheek as shown below. Vital signs are within normal limits. What is the most appropriate next step in management of this finding?

lesion

A Surgical excision of the entire lesion
B Biopsy of the lesion
C Laser removal of the lesion
D Reassurance and observation
E Topical 5-fluoro-uracil

Question of the Week # 424

424) A 3 day old male infant is evaluated for a rash that developed previous night and has been progressing. The rash first started on his face as flat red patches but now it has become bumpy and some of them have pus in it. The baby is breast feeding and there is no history of fever. The mother is healthy and none of the family members are sick at home. The baby was born by an uncomplicated vaginal delivery. On examination, he is afebrile. There are numerous small flat red patches along with yellowish-white papules and numerous pustules all over his trunk and extremities. The lesions on his face seem to be resolving. Palms and soles are not involved. A Wright-stained smear of pustular fluid shows numerous eosinophils and occasional neutrophils. A picture of the rash is shown below:

 

Which of the following is the most likely diagnosis?

A) Miliaria

B) Eosinophilic Pustular Folliculitis

C) Erythema Toxicum

D) Milia

E) Staphylococcal Pyoderma

Question of the Week # 423

423) A 14 month old male baby is brought to your office by his concerned mother for recurrent diarrhea over the past 2 months. He also developed a scaly rash around his mouth, on the cheeks and on buttocks. He has been exclusively breast-fed for about 8 months and has been started on gradual weaning process over the last four months. He is otherwise, a healthy child. There is no family history of eczema. On examination, he is afebrile and vitals are stable. Physical examination shows lesions around the ano-genital area as shown below :

Similar lesions are seen over his cheeks and around the mouth. Which of the following is indicated in this patient at this time?

A) Exclusive Breastfeeding

B) Serum Lead level

C) Serum Zinc level

D) Glucoagon level

E) Sweat Chloride Level

Question of the Week # 321

321)  A 45 – year-old obese woman presents to your office complaining of a skin lesion on her left shin. This lesion started spontaneously 3 weeks ago and appeared like a small bruise. Over the past two weeks, the lesion has enlarged and the overlying skin has become hardened and raised with reddish border. There is no pain or itching. She denies any recent trauma. She lives in  Texas but one month ago, she traveled to New England region to visit a friend. She is sexually active with one partner and occasionally, uses condoms.. Her past medical history is unremarkable. On physical examination, there is an oval shaped  lesion on her left shin. The border is indurated and red in color with yellowish, atrophic appearance in the center. An image of the lesion is shown below:

Which of the following investigations should be ordered next?

A) Lyme serology

B)  Hemoglobin A1C

C)  Anti-Myeloperoxidase ( P-ANCA)

D)  Colonoscopy

E)  Herpes Simplex Virus (HSV) Serology

Question of the Week # 319

319)  A 64-year-old man with history of diabetes mellitus and end-stage renal disease is admitted for complaints of weakness and contractures in his extremities associated with tight and thickened skin. He denies any past history of finger or toe discoloration on exposure to cold. He is dialysis dependent and undergoes hemodialysis three times in a week. His most recent dialysis was a day ago. His symptoms started 3 days prior to presentation and have progressively worsened. Three weeks prior to admission , the patient had a transient ischemic attack. An MRI with Gadolinium performed at that time did not reveal any abnormalities. He denies any neurological symptoms at this time. The patient’s medications upon admission include Aspirin, Insulin Glargine and Lisinopril. On physical examination, the patient appears chronically ill. He is afebrile,  blood pressure 120/70 mmHg and pulse rate was 82/minute. Skin examination reveals diffuse nonerythematous thickening and tightening of the skin over the abdomen, arms and legs. Chest and the face are spared. There are contractures in upper and lower extremities extremely limiting the range of motion of the involved joints. Erythrocyte sedimentation rate and C-reactive protein are elevated. Calcium is 8.0mg% and phosphorous 4mg% with calcium – phosphorous product of  32. An image of his upper extremity is shown below

Which of the following is the most likely diagnosis?

A) Systemic sclerosis

B) Calciphylaxis

C) Nephrogenic Systemic Fibrosis

D) Cryoglobulinemia

E) Eosinophilc Fascitis

Question of the week # 296

296) A 6 month old Asian infant  is brought by his concerned aunt for evaluation of dark blue areas on the child’s buttocks. She says she was called to baby-sit the infant since his mother found a new job 2 days ago. She noted the rash and became suspicious that the child may have been abused. The mother arrives in Emergency room an hour later and reports that the rash has been present since birth. The mother is divorced and lives alone with the child. On examination, there are bluish-green patches on bilateral buttocks and on the lower back. They are irregular in shape and  margins are indistinct. There is no swelling or tenderness. An image of the skin findings is shown below:

Which of the following is the most appropriate next step ?

A) Order Skeletal Survey

B) Reassure that rash may fade away in few years

C) Contact Child Protection services

D) Obtain Coagulation parameters

E) Obtain Platelet count

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