Clinical Challenges

The patient is a 35-year-old male who presents with shoulder pain and weakness. He reports that the pain began when he had a “fender bender” 3 weeks ago. At the time, he didn’t think the pain was severe enough to warrant attention but he’s concerned that it’s “taking too long to get over this.” View the images taken and consider what your diagnosis and next steps would be.

The patient is an 8-year-old girl with a smattering of brown to black lesions on her arms. They’re not painful or causing discomfort, but her mother is concerned because they look darker than the average freckle. Exam reveals small (less than 0.5 mm), round, hyperpigmented macules.             View the image taken and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page. <

The patient is a 60-year-old female with no past medical history presents with intermittent exertional chest pain for 4 days. She reports the pain is substernal with radiation to her left arm, is associated with nausea and diaphoresis, and is worsened by exertion. The patient says she experiences pain every 4-5 hours, but currently is pain-free.             View the ECG taken and consider what your diagnosis and next steps would be. Resolution of the case …

The patient is a 46-year-old female with pain in her wrist. She reports that she heard a “snap” when she put all her body weight on her left hand during an exercise class.             View the images taken and consider what your diagnosis and next steps would be.

The patient is a 37-year-old male who presents with a red, round lesion with a fine, scaly plaque on his face which developed over the past month. He also reports seeing similar lesions on his scalp while combing his hair. None of the lesions are painful, though he describes them as “slightly itchy.” No history of injury to the area. View the image and consider what your diagnosis and next steps would be.

The patient is a 44-years-old previously healthy male who presents with continuous, typical cardiac chest pain of a few hours’ duration, with no associated symptoms. He reports that this is a first-time occurrence. He also relays that he is a nonsmoker, nonalcoholic with no family history of heart disease. On physical examination, you find his vital signs are stable. Cardiac auscultation reveals normal first and second heart sounds with no murmurs. Labs reveal slightly elevated …

The patient is a 42-year-old male who presents after referral from a diagnostic testing site with an abnormal ECG, obtained during a preoperative evaluation. He reports a history of hypertension and symptomatic inguinal hernia, and acknowledges chronic right groin pain. He is otherwise asymptomatic, including robust exercise tolerance. View the ECG and consider what the diagnosis and next steps would be. Resolution of the case is described on the next page. (Case presented by Tom …

The patient is a 58-year-old male who presents with a painful mass at the lower aspect of his right knee. He denies any impact to his leg, but reports that the pain started “some time ago,” getting progressively worse. Review the image taken and consider what the diagnosis and next steps would be. Resolution of the case is described on the next page.

  The patient is a 24-year-old male who presents for a pre-employment physical. While undergoing his exam, he mentions being “curious” about tiny papules he noticed recently in his mouth on the inside of his cheek. They seemed to be a group of slightly yellow lesions, present on both sides of his mouth. He reports that they have been there “for a few months,” but they have not caused discomfort so he hasn’t sought care. …

The patient is a 67-year-old male with no medical history who presents with severe chest pain radiating to his left arm that started 1 hour prior to arrival. The patient also endorses progressive dyspnea on exertion of six months duration. View the ECG and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page. (Case contributed by Gregory J Ducach, MD.) Figure 1. ECG upon urgent …