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1,200 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Ruptured acute appendicitis"
},
{
"label": "B",
"disease": "Cecal inflammation with abscess"
},
{
"label": "C",
"disease": "Iatrogenic pancreas transplant thrombosis"
},
{
"label": "D",
"disease": "Hematoma"
}
] | C | [
"A 52-year-old man presented with a 2-day history of nausea and low-grade fever to a local hospital",
"He had a history of simultaneous pancreas-kidney transplantation 15 years ago and both grafts had been functioning well",
"Two days prior to presentation, he had a peripheral angiogram done to evaluate a nonhealing left foot ulcer by an interventional cardiologist, at which time a stent graft was deployed to the right common iliac artery for a pseudoaneurysm that was incidentally discovered",
"On examination, he was in no distress, had a temperature of 37° C, and blood pressure of 91/44 mm Hg",
"Two days after presentation, a computed tomographic scan of the abdomen and pelvis was obtained (Figure)",
"It showed an air-containing abscess and a stent in the common iliac artery",
"A stent can be seen in the right common iliac artery (A and C, arrowheads)",
"A gas-containing phlegmon was also evident (B and C, asterisks)"
] | [
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1,201 | What Is The Diagnosis? | [
{
"label": "A",
"disease": "Acute appendicitis"
},
{
"label": "B",
"disease": "Cecal diverticulum"
},
{
"label": "C",
"disease": "Carcinoid tumor of the appendix"
},
{
"label": "D",
"disease": "Appendiceal intussusception"
}
] | D | [
"A 26-year-old woman in the 11th week of gestation with a history of nephrolithiasis was admitted to our medical center reporting of right lower quadrant pain, loss of appetite, nausea, and vomiting occurring over 5 days",
"The pain was initially transient and colicky, but had increased in intensity and became constant",
"She denied having fevers, chills, or change in bowel habits",
"During examination, the patient had significant focal tenderness to palpation, but displayed no peritoneal signs",
"Her laboratory results were unremarkable, without any findings for leukocytosis or bandemia",
"Computed tomograpy (CT) scan and ultrasonography were inconclusive and revealed only mild haziness in the right lower quadrant and an abnormal-appearing cecum",
"The appendix was not visualized",
"Magnetic resonance imaging of the abdomen was then performed to further investigate the area surrounding the cecum (Figure, A)",
"Given these symptoms and findings, the decision was made to explore this patient laparoscopically",
"After careful intraoperative evaluation, it became evident that she would require an ileocecectomy",
"The removed specimen was sent to pathology for analysis",
"The histologic analysis is presented in Figure, B",
"A, Abdominal magnetic resonance imaging",
"Arrowhead points at the suspicious structure within the cecum",
"B, Histologic slide of the resected appendix shows positive progesterone receptor immunostaining (original magnification x400)",
"The patient recovered well and was discharged home",
"On postoperative day 11 she returned with symptoms of fever and increasing right lower quadrant pain",
"Imaging revealed an abscess near the ileocolic anastomosis, which was successfully treated with percutaneous drain placement",
"The patient recovered and was discharged",
"Weeks later, she presented to an outside facility with spotting and cramping",
"Intrauterine fetal demise was noted and the patient underwent an emergency dilation and curettage"
] | [
0,
19,
20
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1,202 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Langerhans cell histiocytosis"
},
{
"label": "B",
"disease": "Contact dermatitis"
},
{
"label": "C",
"disease": "Scabies"
},
{
"label": "D",
"disease": "Postscabetic acropustulosis"
}
] | C | [
"A 9-week-old girl had a rash on her back that had been present for 7 weeks",
"The rash was asymptomatic and started as red bumps that then evolved into pustules and blisters",
"On further questioning, it was discovered that the patient’s father worked in a nursing home that had experienced a recent outbreak of scabies",
"Shortly after the onset of the outbreak, the patient and all family members were treated with 2 once-weekly doses of permethrin, 5%, cream",
"All other family members had significant improvement with the treatment",
"however, our patient’s lesions continued to worsen during the subsequent 2 weeks",
"On physical examination, the patient had numerous erythematous macules, papules, and pustules on her back",
"Many of the lesions had superimposed hemorrhagic crust and surrounding scale",
"In addition, several grouped papules were noted, including some in a linear array (Figure 1A and B)",
"The rest of her cutaneous examination results were unremarkable except for a few fading pink papules noted on her left abdomen (Figure 1C)",
"Numerous erythematous papules and pustules on the back, many with overlying hemorrhagic crust and surrounding scale (A) and (B), and few erythematous papules on the left lower abdomen (C)"
] | [
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1,203 | What Is The Diagnosis? | [
{
"label": "A",
"disease": "Hepatic artery pseudoaneurysm"
},
{
"label": "B",
"disease": "Angioleiomyoma"
},
{
"label": "C",
"disease": "Neuroendocrine tumor"
},
{
"label": "D",
"disease": "Angiosarcoma"
}
] | B | [
"A previously healthy, 37-year-old man presented for a routine physical examination during which a pulsatile mass in his midepigastrium was palpated",
"Abdominal ultrasonography showed a well-defined hypoechoic lesion abutting the pancreas",
"Further imaging by contrast-enhanced computed tomography (CT) and 3-dimensional reconstruction revealed a well-circumscribed, 3-cm lesion surrounding the common hepatic artery (Figure, A and B)",
"The lesion demonstrated patchy arterial enhancement, and a small irregularity of the common hepatic artery was present within the lesion",
"Endoscopic ultrasonography demonstrated a hypoechoic, well-defined mass",
"fine-needle aspiration showed no abnormal cells within the paucicellular specimen",
"Surgical exploration revealed a firm, ovoid lesion surrounding the hepatic artery at the origin of the gastroduodenal artery (Figure, C)",
"Following resection, the lesion was bisected to reveal a smooth white arterial lumen surrounded by grayish fibrotic tissue with punctate hemorrhagic foci",
"Histologic sections of the specimen demonstrated small, singly dispersed vessels embedded in a background of fascicles of spindled cells with monotonous, fusiform nuclei and abundant eosinophilic cytoplasm",
"Focally, areas of myxoid degeneration were present",
"Despite extensive sampling, no mitotic activity, cytologic atypia, or areas of necrosis were identified",
"There was strong, diffuse cytoplasmic staining for desmin (Figure, D), and staining results for S100 were negative",
"Furthermore, CD34 stained strongly positive in vessels but failed to highlight the intervening stroma",
"A, Computed tomography of an enhancing mass (dotted circle) surrounding the common hepatic artery with emanating gastroduodenal artery, right hepatic artery, and left hepatic artery (arrowheads)",
"B, 3-Dimensional reconstruction of the location of the lesion (dotted circle) with relation to the involved vessels and surrounding structures",
"C, Intraoperative view of a 3-cm mass surrounding the common hepatic artery just prior to the trifurcation of the gastroduodenal artery, right hepatic artery, and left hepatic artery",
"D, The tumor cells showed strong cytoplasmic expression of the smooth-muscle marker desmin",
"Original magnification ×20."
] | [
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1,204 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Hedrocele"
},
{
"label": "B",
"disease": "Rectal prolapse"
},
{
"label": "C",
"disease": "Anal neoplasm"
},
{
"label": "D",
"disease": "External hemorrhoids"
}
] | A | [
"A woman in her 50s was hospitalized for a painful anal mass",
"She had a history of hypertension and depression and was receiving omeprazole and paroxetine",
"The mass had appeared 2 days before presentation and was associated with vomiting",
"Additionally, the patient had not passed stools or had intestinal gas for 2 days",
"On physical examination, the mass was exteriorized through the anal canal",
"It was covered by hypoxemic rectal mucosa, but no digestive lumen could be identified inside the mass (Figure 1)",
"Furthermore, the patient had a distended abdomen, absent bowel sounds, and no tenderness to palpation",
"No abdominal scar was visible, and no groin hernia was palpable",
"Her blood pressure was 160/80 mm Hg and her temperature was 37.8°C",
"Results of complete blood cell count, coagulation tests, and basic chemistry panel were all within normal limits",
"An abdominal radiograph showed several air-fluid levels without pneumoperitoneum, confirming an intestinal occlusion",
"View of the mass exteriorized through the anus"
] | [
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9
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1,205 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Erythema nodosum"
},
{
"label": "B",
"disease": "Sarcoidosis"
},
{
"label": "C",
"disease": "Systemic lupus erythematosus"
},
{
"label": "D",
"disease": "Minocycline-induced cutaneous polyarteritis nodosa"
}
] | D | [
"An 18-year-old woman presented with a 4-week history of a solitary painful bullous skin lesion over the lower right anterior tibia accompanied by generalized myalgia, polyarthalgia, joint stiffness, paraesthesia, and episodic ankle swelling",
"The lesion first appeared as a skin-colored papule and, within a week, developed an erythematous halo",
"Her medical history includes asthma and acne",
"To our knowledge, there is no family history of this condition",
"Her medications included minocycline hydrochloride (for 25 months for acne), ranitidine hydrochloride, contraceptive pills, and iron supplements",
"An initial physical examination revealed mild synovitis in both ankles and an erythematous, raised papule overlying the distal aspect of the right anterior tibia",
"Treatment with prednisone acetate (10 mg daily) was initiated",
"Seven weeks later, the original skin lesion evolved into an ulcer with erythematous, raised borders (Figure 1)",
"The case patient had new eruptions of nonindurated, violaceous, nontender, reticulated patches overlying the skin on the bilateral anterior tibias, consistent with livedo reticularis",
"She denies any previous episodes, and the results of a review of mitigating factors were negative",
"Ulcer with raised border and erythematous halo in distal right shin",
"A laboratory workup revealed a positive antinuclear antibody 1:640 nucleolar pattern, an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and serum IgG levels",
"The results of the following laboratory studies were negative or normal: complete blood cell count, urinalysis, liver profile, Lyme disease, parvovirus B19, Monospot test, uric acid, rheumatoid factor, antistrepolysin antibody, anti-Scl70, antihepatitis C virus, hepatitis B surface antigen, hepatitis B core antibody, cytomegalovirus antibody, and human T-lymphotropic viruses 1 and 2 antibody",
"Culture results of the skin lesion were negative",
"The results from chest radiography were normal"
] | [
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1,206 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Biliary cystadenomas"
},
{
"label": "B",
"disease": "Amebic liver abscess secondary to Entamoeba histolytica infection"
},
{
"label": "C",
"disease": "Metastatic cystic neuroendocrine tumors"
},
{
"label": "D",
"disease": "Cystic hepatocellular carcinomas"
}
] | C | [
"A 74-year-old woman was seen by her primary care physician for dull epigastric and right upper quadrant abdominal pain of 1-year duration",
"Routine laboratory values were within normal limits",
"The patient underwent ultrasonography of the abdomen, and 2 cystic lesions were discovered in the liver",
"Magnetic resonance imaging of the abdomen revealed 2 multiloculated cystic lesions in segments IV and V of the liver (Figure, A)",
"Additional laboratory values included normal carcinoembryonic antigen and cancer antigen 19-9 levels",
"Percutaneous aspiration with a biopsy of one of the cystic lesions was performed that revealed atypical cells suspicious for malignancy",
"The patient was then referred for management to our institution, where she underwent an exploratory laparotomy and enucleation of these 2 complex multiloculated cystic lesions (Figure, B)",
"A, Axial image from abdominal magnetic resonance imaging",
"B, Intraoperative view of enucleated lesions in hepatic segments IV and V",
"Amebic liver abscess secondary to Entamoeba histolytica infection"
] | [
0,
1,
4,
9
] | [
2,
3,
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8
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1,207 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "A. Metastatic rectal adenocarcinoma"
},
{
"label": "B",
"disease": "B. Spindle cell sarcoma of the chest wall"
},
{
"label": "C",
"disease": "C. Metastatic breast carcinoma"
},
{
"label": "D",
"disease": "D. Desmoid tumor of chest wall"
}
] | B | [
"A 55-year-old woman presented to the clinic with a mass in her left breast that had been enlarging over the previous 3 months",
"The patient denied any antecedent trauma or infection",
"Her medical history was significant for hypertension and left breast invasive ductal carcinoma in 2007 treated with lumpectomy and adjuvant radiation as well as synchronous rectal cancer after neoadjuvant chemoradiation and abdominoperineal resection",
"As part of her treatment course, the patient received a total dose of 50.5 Gy pelvic irradiation and 60 Gy irradiation to the left breast and axillary basin",
"The patient was followed up with yearly computed tomography of the abdomen and pelvis in addition to yearly digital mammography",
"Her last mammogram, 5 months prior to presentation, was unremarkable",
"On physical examination, she had a hard, well-circumscribed, fixed mass in the upper, outer quadrant of her left breast",
"The lesion was not tender to palpation nor was there any associated axillary or supraclavicular lymphadenopathy",
"Examination of the nipple as well as the contralateral breast and axilla was unremarkable",
"Computed tomography of the thorax revealed a 6.7 × 4 cm mass arising from the left chest wall distinct from the left breast with extent to the pleural surface of the left thorax (Figure, A)",
"Positron emission tomography revealed metabolic activity within the mass but did not reveal any distant disease",
"Core needle biopsy confirmed the diagnosis and the patient was offered resection with reconstruction",
"A, Computed tomographic axial section of the thorax illustrating a left chest wall mass measuring 6.7 × 4 cm apparently distinct from the left breast parenchyma with possible pleural invasion",
"B, Postresection wound including chest wall",
"Lung parenchyma adjacent to the chest wall reveals stippling and fibrosis consistent with previous irradiation",
"The patient underwent a left radical mastectomy including resection of the pectoralis major and minor and resection of the adjacent chest wall resulting in a chest wall defect spanning ribs 2 through 4 (Figure, B)",
"The patient underwent immediate reconstruction of the chest wall with 2-mm-thick expanded polytetrafluoroethylene and latissimus dorsi pedicle flap reconstruction of the soft tissue defect and breast mound",
"B",
"Spindle cell sarcoma of the chest wall"
] | [
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1,208 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Numular eczema"
},
{
"label": "B",
"disease": "Erythema annulare centrifugum"
},
{
"label": "C",
"disease": "Erythema chronicum migrans"
},
{
"label": "D",
"disease": "Tinea incognito"
}
] | D | [
"A 4-year-old, 15-kg girl presented with a 3-month history of a pruritic rash bilaterally on the cheeks, initially thought to be related to mosquito bites",
"Treatment with desonide, 0.05%, ointment twice daily proved to be ineffective",
"The patient’s rash also failed to clear with a therapeutic trial with griseofulvin liquid (125 mg/5 mL), 5 mL daily, and econazole, 1%, cream twice daily for 2 weeks and later ciclopirox, 0.77%, cream twice daily for 2 weeks, although the patient reported some improvement",
"The presence of persistent acneiform papules on the cheeks with postinflammatory hyperpigmentation led to a therapeutic trial of erythromycin, 400 mg/5 mL, 1.3 mL orally twice a day, with food",
"Test results for antinuclear antibody and rheumatoid factor were negative",
"Three weeks later, the patient presented with 2 slowly expanding, hyperpigmented, ringlike lesions with a tendency toward central clearing and peripheral scaling and erythema on the right cheek (Figure 1)",
"A 4-year-old girl presenting with two 5-cm-diameter annular patches (arrowheads) slowly increasing in size over 3 weeks on the right cheek"
] | [
0,
4
] | [
1,
2,
3,
5,
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1,209 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Glucagonoma"
},
{
"label": "B",
"disease": "Insulinoma"
},
{
"label": "C",
"disease": "VIPoma"
},
{
"label": "D",
"disease": "Skin amyloidosis"
}
] | A | [
"A 66-year-old man presented with a skin rash on his lower limb",
"He has been unemployed and bedridden for the last 3 years owing to his skin disease",
"He has a history of ischemic heart disease, familial Mediterranean fever, and arthropathy",
"He was treated with nonsteroidal anti-inflammatory drugs for pain relief and steroids for the skin disease",
"Except for the skin rash, he was newly diagnosed as having diabetes mellitus",
"On presentation, he noted anorexia and reported a 10-kg weight loss during the last 8 months",
"On physical examination, he appeared cachectic",
"His abdomen was soft with no palpable mass",
"A macular rash with multiple infected ulcerated areas and diffuse lower limb edema was noticed (Figure 1)",
"The remainder of his physical examination results were unremarkable"
] | [
0,
1,
3,
4,
8
] | [
2,
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9
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1,210 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Subacute bacterial endocarditis"
},
{
"label": "B",
"disease": "Warfarin-induced skin necrosis"
},
{
"label": "C",
"disease": "Calcific uremic arteriolopathy"
},
{
"label": "D",
"disease": "Buerger disease"
}
] | C | [
"A 52-year-old man with type 2 diabetes mellitus and end-stage renal disease presented with painful and progressive cutaneous necrosis of his fingers, toes, and calves and generalized muscle weakness with difficulty getting out of bed and walking",
"He had undergone hemodialysis for the past year and had a brachiocephalic fistula in his left arm",
"His medical history was also significant for peripheral vascular disease, hypertension, and antiphospholipid antibody syndrome for which he was receiving warfarin sodium since 2010. His other medications were epoetin alpha, ferrous gluconate, cinacalcet hydrochloride, paricalcitol, sevelamer carbonate, amlodipine besylate, labetalol hydrochloride, lisinopril, simvastatin, pentoxifylline, and Humalog and Lantus insulin",
"He did not smoke",
"The patient had a temperature of 37.6°C and a grade II/VI systolic ejection murmur",
"He had necrosis and eschar formation involving his fingers (Figure 1A), toes (Figure 1B and C), and left posterior medial calf (Figure 1D)",
"He had violaceous skin with central eschar on the posterior medial aspect of his right leg (Figure 1E) that was exquisitely tender with gangrenous change",
"He had normal femoral pulses with no distal pulses palpable",
"Both feet were warm with good Doppler signals in the dorsalis pedis and posterior tibial arteries",
"He had a palpable pulse and thrill in the brachiocephalic fistula in his left upper arm",
"There was also a weak distal radial pulse",
"He had good Doppler signals over the radial, ulnar, and palmar arch arteries bilaterally",
"Photographs of necrosis and eschar formation involving fingers (A), right (B) and left (C) toes, left posterior medial calf (D), and violaceous skin with central eschar on the posterior medial aspect of the right leg (E)",
"Laboratory studies revealed a white blood cell count of 13 900/μL (to convert to ×109 per liter, multiply by 0.001), a hemoglobin level of 7.7 g/dL (to convert to grams per liter, multiply by 10.0), a platelet count of 309 × 103/μL (to convert to ×109 per liter, multiply by 1.0), an international normalized ratio of 2.4, a blood urea nitrogen level of 88 mg/dL (to convert to millimoles per liter, multiply by 0.357), a creatinine level of 9.9 mg/dL (to convert to micromoles per liter, multiply by 88.4), a calcium level of 7.5 mg/dL (to convert to millimoles per liter, multiply by 0.25), an albumin level of 2.4 g/dL (to convert to grams per liter, multiply by 10), and an intact parathyroid hormone level of 349.7 pg/mL (to convert to nanograms per liter, multiply by 1.0)",
"A skin biopsy specimen of the calf showed epidermal necrosis, dermal hemorrhage, focal dermal intravascular thrombi, and subcutaneous intravascular and extravascular calcifications"
] | [
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1,211 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Pyoderma gangrenosum"
},
{
"label": "B",
"disease": "Ecthyma gangrenosum"
},
{
"label": "C",
"disease": "Wegener granulomatosis"
},
{
"label": "D",
"disease": "Meningococcemia"
}
] | B | [
"A 25-day-old newborn was admitted to our hospital with a diagnosis of bronchiolitis",
"During admission, the infant developed violaceous skin lesions with edema in inguinal and axillary regions (Figure)",
"Lesions became ulcerated within 3 to 4 days, with infarcted necrotic areas",
"Blood tests showed leukopenia (white blood cell count, 2460/μL) with neutropenia (neutrophil count, 220/μL) (to convert both to ×109 per liter, multiply by 0.001)",
"The lesions were biopsied and samples were sent for cultures and histopathological analysis",
"Intravenous floxacillin was started, followed by surgical debridement due to progression of the major lesions",
"Axillary inflammatory nodule (A) and inguinal inflammatory plaques with violaceous hue (B)",
"His mother was addicted to drugs, she had a known hepatitis C virus infection, and the pregnancy was unsupervised",
"Thirteen days before delivery, she visited the emergency department with flulike symptoms",
"Routine infectious screening revealed negative serology for syphilis, hepatitis B virus, and human immunodeficiency virus (HIV) types 1 and 2 by enzyme-linked immunosorbent assay (ELISA)",
"The infant was born at 40 weeks’ gestation by forceps delivery"
] | [
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1,212 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "A. Prostate cancer"
},
{
"label": "B",
"disease": "B. Recurrent colon cancer"
},
{
"label": "C",
"disease": "C. Internal iliac artery aneurysm"
},
{
"label": "D",
"disease": "D. Primary lymphoma of the urinary bladder"
}
] | C | [
"An 88-year-old man with a history of hypertension, atrial fibrillation while receiving warfarin sodium, congestive heart failure, extended right hemicolectomy for colon cancer, and abdominal aortic aneurysm repair visited the hospital with epigastric pain of 3 days’ duration",
"In addition, the patient had worsening lower back and lower extremity pain, treated as sciatica on an outpatient basis, for 3 months",
"The patient had constipation, urinary incontinence, and generalized weakness but no fever, nausea or vomiting, or change in bowel movements",
"Physical examination revealed a firm, nonpulsatile, slightly tender mass in the left lower quadrant and significant perineal ecchymosis",
"Vital signs were normal",
"Laboratory test results were remarkable for white blood cell count (13 800/μL [to convert to ×109 per liter, multiply by 0.001]), blood urea nitrogen level (72 mg/dL [to convert to millimoles per liter, multiply by 0.357]), creatinine level (4.2 mg/dL [to convert to micromoles per liter, multiply by 88.4]), hemoglobin level (9.8 g/dL [to convert to grams per liter, multiply by 10.0]), and international normalized ratio (2.7)",
"Computed tomography of the abdomen and pelvis was performed (Figure)",
"Computed tomographic images of the abdomen and pelvis",
"A, Axial imaging shows that the bladder (black arrow) is displaced to the right, and a Foley catheter is located anteriorly",
"The rectum (white arrow) is compressed posteriorly",
"B, Coronal imaging shows that the bladder (arrow) is severely displaced, and a Foley catheter is located medially"
] | [
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1,213 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "A. Pulmonary aspergilloma"
},
{
"label": "B",
"disease": "B. Pulmonary tuberculosis"
},
{
"label": "C",
"disease": "C. Squamous cell carcinoma"
},
{
"label": "D",
"disease": "D. Pulmonary hydatid cyst"
}
] | C | [
"A 62-year-old man was admitted to our hospital with a concern of productive cough, profuse hemoptysis, and intermittent breathlessness for about 5 months",
"He had a 50-year history of cigarette smoking and had stopped smoking 5 months prior to being seen",
"When the symptom of hemoptysis occurred 5 months earlier, chest radiography and computed tomography (CT) revealed a ground-glass opacity in the left upper lobe",
"The patient was treated with an antifibrinolytic agent (tranexamic acid), and the hemoptysis gradually improved and follow-up chest radiography showed resolution of the lesion (Figure 1)",
"However, about 1 month later, hemoptysis reoccurred and increased volume and frequency over the following 4 months",
"After treatment with an antifibrinolytic agent, a ball-like mass with an air crescent sign in the left upper lobe was noted",
"On physical examination, sonorous rhonchi were audible in the bilateral lungs",
"Chest CT revealed a cavitary lesion with a central contrast-enhanced ball-like mass at the site of the prior ground-glass lesion",
"Sputum examinations for acid-fast bacilli smear and culture, fungal culture, and cytology showed negative results",
"Fiberoptic bronchoscopy revealed blood clots over the orifice of the left upper lobe bronchus, but no endobronchial lesion was detected",
"The chest CT finding, characteristic of a fungus ball-like shadow with an air crescent sign, highly suggested a pulmonary aspergilloma",
"However, the contrast enhancement was present within the mass, and lung malignancy could not be excluded",
"Because of persistent massive hemoptysis, the patient underwent left exploratory thoracotomy",
"A whitish, firm nodule about 2 cm was noted in a cavity in the left upper lung"
] | [
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1,214 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Congenital melanocytic nevus"
},
{
"label": "B",
"disease": "Epidermal nevus"
},
{
"label": "C",
"disease": "Nevus sebaceous of Jadassohn"
},
{
"label": "D",
"disease": "Inflammatory linear verrucous epidermal nevus"
}
] | C | [
"A 15-year-old male presented to the dermatology clinic with a lesion that had been present on his right nasal sidewall since birth",
"At puberty, the lesion expanded in size, became irritated, and developed a papillated, rough texture",
"The patient otherwise had no significant medical history and was in good health",
"On physical examination, there was a 3.6-cm × 1.5-cm verrucous skin-colored to light-brown plaque on the right nasal sidewall (Figure)",
"Clinical photograph of a 3.6-cm × 1.5-cm verrucous skin-colored to light-brown plaque on the right nasal sidewall"
] | [
2
] | [
0,
1,
3,
4
] |
1,215 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Carcinoma of the cecum"
},
{
"label": "B",
"disease": "Ileocecal intussusception"
},
{
"label": "C",
"disease": "Intussusception of the appendix"
},
{
"label": "D",
"disease": "Diverticulum of the cecum"
}
] | C | [
"A 32-year-old woman presented to the hospital complaining about having colicky abdominal pain for the last 2 weeks",
"The pain was usually generalized but sometimes radiated to the right iliac fossa",
"The pain got worse with meals and was associated with nausea but no vomiting",
"In the last 2 days, the pain was associated with loose stools, but there was no mucus or blood",
"She had no comorbidities, such as diabetes mellitus or hypertension, and no previous admission to the hospital",
"She is married and has 4 children",
"her last child was born 40 days prior to her presentation to the hospital",
"On examination, her vital signs were normal (temperature, 37.1°C",
"pulse, 86 beats/min",
"and blood pressure, 121/86 mm Hg)",
"Her abdomen was soft and lax",
"There was mild tenderness in the right iliac fossa, but no lump or lumps were felt",
"Bowel sounds were not exaggerated",
"Her white blood cell count was 8500/μL (to convert to ×109 per liter, multiply by 0.001), her hemoglobin level was 1.3 g/dL (to convert to grams per liter, multiply by 10.0), and her platelet count was 361 × 103/μL (to convert to ×109 per liter, multiply by 1.0)",
"The results of renal and liver function tests were normal",
"Abdominal ultrasonography revealed a 4.2 × 4.2-cm mass in the midabdominal region lateral to the gall bladder fossa",
"The mass has the “donut sign” with central echogenicity (Figure 1A)",
"An abdominal computed tomographic scan (Figure 1B) showed a 8.2 × 4 × 2.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon",
"The oral contrast agent can be seen around, proximal, and distal to the defect, with no obstruction noted",
"Abdominal ultrasonographic image revealing a 4.2 × 4.2-cm mass with central echogenicity, the “donut sign” (A)",
"Abdominal computed tomographic scan with oral contrast agent revealing a 8.2 × 4 × 2.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon (B)",
"The contrast is seen around, proximal, and distal to the defect, with no obstruction noted"
] | [
0,
1,
2,
3,
4,
5,
6,
7,
8,
9,
10,
11,
12
] | [
13,
14,
15,
16,
17,
18,
19,
20,
21
] |
1,216 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Duplicate gallbladder"
},
{
"label": "B",
"disease": "Biliary cystadenoma"
},
{
"label": "C",
"disease": "Type 1 choledochal cyst"
},
{
"label": "D",
"disease": "Hydatid cyst"
}
] | C | [
"A 30-year-old female immigrant from Laos was referred to our institution after admission to an outside hospital for right upper quadrant abdominal pain with associated nausea and vomiting",
"Her imaging results from the outside hospital included abdominal magnetic resonance cholangiopancreatography revealing a cystic abnormality in the region of the porta hepatis (Figure 1A)",
"The patient denied any previous medical or surgical history",
"On examination, the patient had mild right upper quadrant tenderness to palpation without signs of peritonitis",
"Routine laboratory values were within normal limits, except for a mildly elevated amylase level",
"A computed tomographic scan was obtained to further delineate the abnormality (Figure 1B)",
"Magnetic resonance cholangiopancreatography (A) and abdominal computed tomography (B) revealing a cystic lesion in the region of the porta hepatis (arrowheads)",
"F indicates feet",
"H, head",
"L, left",
"and R, right"
] | [
0,
1,
3,
4,
5,
6
] | [
2,
7,
8,
9,
10
] |
1,217 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Supernumerary nostril"
},
{
"label": "B",
"disease": "Nasal encephalocele"
},
{
"label": "C",
"disease": "Proboscis lateralis"
},
{
"label": "D",
"disease": "Cerebro-oculo-nasal syndrome"
}
] | C | [
"A 10-day-old, full-term girl presented with a trunklike projection from the medial canthus of the left eye (Figure)",
"There was no other craniofacial anomaly and bilateral nasal cavities were normal",
"The trunk was 2.5 cm in length connected with a thin pedicle",
"There was mucus discharge from the opening",
"There was no history of teratogenic exposure, no family history of congenital defects, and no history of consanguinity",
"Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed no other associated craniofacial abnormality",
"Full-term, 10-day-old girl with a trunklike projection from the medial canthus of the left eye"
] | [
0,
1,
2,
6
] | [
3,
4,
5
] |
1,218 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Liposarcoma"
},
{
"label": "B",
"disease": "Gossypiboma"
},
{
"label": "C",
"disease": "Mesenteric cyst"
},
{
"label": "D",
"disease": "Uterine leiomyoma"
}
] | B | [
"A 28-year-old woman presented with a complaint of a painless abdominal mass that had been increasing in size during the past few years",
"Several different physicians had evaluated the patient previously without a definitive diagnosis or treatment",
"Her only significant medical history was a routine cesarean section 4 years earlier",
"Physical examination findings revealed a firm, mobile, nontender, midline abdominal mass",
"A computed tomographic (CT) scan was performed, which showed a well-circumscribed, 10-cm mass (Figure 1)",
"The patient was scheduled for elective exploratory laparotomy and resection",
"Scout (A) and cross-sectional (B) images from a computed tomographic scan of the abdomen",
"A large, well-circumscribed mass (white arrow) is shown on the cross-sectional image"
] | [
0,
1,
2,
3,
5
] | [
4,
6,
7
] |
1,219 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Lymphoma"
},
{
"label": "B",
"disease": "Pheochromocytoma"
},
{
"label": "C",
"disease": "Cystic neoplasm of the pancreas"
},
{
"label": "D",
"disease": "Rhabdomyosarcoma"
}
] | B | [
"A white woman in her late 40s presented to her primary care physician for her routine annual checkup and was noted to have abdominal distention",
"The patient had been experiencing early satiety and heat intolerance",
"Physical examination was significant for orthostatic hypotension and an immobile, nontender abdominal mass",
"An abdominal computed tomographic scan was obtained (Figure, A)",
"Based on these findings, the patient underwent surgical resection (Figure, B)",
"Coronal imaging illustrating a large heterogeneous mass in the left abdomen (A)",
"Specimen after resection (B)"
] | [
0,
1,
2
] | [
3,
4,
5,
6
] |
1,220 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Herpetiform dermatitis"
},
{
"label": "B",
"disease": "Pemphigus"
},
{
"label": "C",
"disease": "Linear IgA dermatosis"
},
{
"label": "D",
"disease": "Erythema multiforme"
}
] | C | [
"A 5-year-old girl presented with a 2-week history of pruritic, bullous skin lesions that had started on her lower limbs",
"She had been treated with topical mupirocin and oral amoxicillin–clavulanate potassium for a suspected superficial skin infection",
"She presented for evaluation because new lesions of similar appearance appeared on the upper limbs, trunk, vulva, and perineum despite antibiotic therapy",
"Physical examination revealed many large, tense bullae filled with clear fluid, rounded with an erythematous base and “rosette-like” blisters (Figure)",
"Some of them appeared superinfected",
"Also the vulva and perineum had an intense erythematous rash",
"She was apyretic and vital parameters were normal",
"Laboratory tests showed a normal white blood cell count and lymphocyte subpopulations, erythrocyte sedimentation rate, and C-reactive protein level",
"Test results for anti-transglutaminase and antiendomysial antibodies were negative"
] | [
0,
1,
2,
3,
4,
5
] | [
6,
7,
8
] |
1,221 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Splenic artery aneurysm rupture"
},
{
"label": "B",
"disease": "Non-Hodgkin lymphoma with associated hepatosplenomegaly"
},
{
"label": "C",
"disease": "Spontaneous rupture of the spleen"
},
{
"label": "D",
"disease": "Pancreatitis with fluid collection"
}
] | C | [
"A 23-year-old otherwise healthy man presented to the emergency department after a 3-hour flight with complaints of headache and severe abdominal pain",
"His symptoms followed a 1-day discharge from a recent hospital admission for a viral illness",
"He denied any history of trauma, and the remaining medical history was unremarkable",
"At the time of evaluation, he reported associated left shoulder pain and was in noticeable distress",
"Physical examination revealed a distended abdomen with associated diffused peritoneal signs",
"He was afebrile, with a heart rate of 77 beats/min, blood pressure of 96/46 mm Hg, oxygen saturation of 100% in room air, and a respiratory rate of 16 breaths/min",
"Abdominal ultrasonography was performed (Figure 1)",
"Ultrasonography image of the right (A) and left (B) upper quadrants of the abdomen"
] | [
0,
1,
3,
4
] | [
2,
5,
6,
7
] |
1,222 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Acute appendicitis with colon diverticula"
},
{
"label": "B",
"disease": "Acute appendiceal diverticulitis"
},
{
"label": "C",
"disease": "Appendiceal diverticulum"
},
{
"label": "D",
"disease": "Appendiceal mucocele"
}
] | B | [
"A 50-year-old man presented to the emergency department with a 4-day history of right lower quadrant pain that did not migrate during that period of time",
"On examination, he tested positive for the Blumberg sign",
"Blood analysis showed leucocytosis, neutrophilia, and an increased level of C-reactive protein",
"Ultrasonographic (Figure, A) and computed tomographic images (Figure, B) showed a thickened wall outpouching arising from a discreetly thickened appendix and inflamed surrounding fat",
"Right-sided colonic diverticulosis was also seen",
"The patient underwent an appendectomy with gross findings as shown in Figure, C",
"Ultrasonographic image of the right lower quadrant (A) and sagittal reformatted computed tomographic image (B), both showing a thickened wall outpouching (arrow) arising from the vermiform appendix (arrowheads) with inflammatory changes in the surrounding mesenteric fat (asterisk)",
"C, Gross findings of excised appendix (arrowheads) reveal an inflamed wall outpouching (arrow) and mesenteric fat (asterisk)"
] | [
0,
1,
2,
4
] | [
3,
5,
6,
7
] |
1,223 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Keratosis pilaris"
},
{
"label": "B",
"disease": "Filiform verrucae"
},
{
"label": "C",
"disease": "Virus-associated trichodysplasia spinulosa"
},
{
"label": "D",
"disease": "Phrynoderma"
}
] | C | [
"A 5-year-old boy, known to have acute lymphoblastic leukemia since the age of 3 years, presented with a 3-week history of asymptomatic skin lesions primarily affecting the face and to a lesser extent the trunk and extremities (Figure, A and B)",
"He had been undergoing a maintenance chemotherapy regimen consisting of vincristine sulfate, 6-mercaptopurine, methotrexate, and high-dose prednisone",
"He did not undergo bone marrow or stem cell transplant as part of his treatment",
"Multiple topical medications including keratolytics were applied to the affected areas without effect",
"Skin examination and microscopy analysis of punch biopsy specimen",
"A and B, Multiple tiny, spiny, follicular hyperkeratotic papules on the face",
"C and D, Microscopy showed abnormal maturation of anagen hair follicles with excessive inner root sheath differentiation (original magnification ×4 [C] and ×40 [D])",
"Skin examination revealed multiple 1- to 3-mm, spiny, follicular, flesh-colored to erythematous hyperkeratotic papules predominantly on the face and to a lesser extent on the trunk, and extremities, with fine hairlike spicules emanating from most of them (Figure, A and B)",
"Alopecia was also noted involving the eyebrows and the eyelashes, but the scalp was spared",
"A punch biopsy specimen was taken (Figure, C and D)"
] | [
0,
1,
2,
3
] | [
4,
5,
6,
7,
8,
9
] |
1,224 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Acute cholecystitis"
},
{
"label": "B",
"disease": "Gallbladder polyp"
},
{
"label": "C",
"disease": "Gallbladder cancer"
},
{
"label": "D",
"disease": "Gallbladder volvulus"
}
] | D | [
"An 89-year-old woman presented to her geriatrician with abdominal pain for 2 days",
"The pain was localized to her right abdomen, both upper and lower quadrants, with acute tenderness to palpation",
"She had some nausea and vomiting",
"Ultrasonographic findings gave concern for acute cholecystitis",
"A computed tomographic scan was ordered by her primary care physician after admission to the hospital (Figure)"
] | [
0,
1,
2
] | [
3,
4
] |
1,225 | What Is The Most Likely Diagnosis? | [
{
"label": "A",
"disease": "Disseminated herpes simplex"
},
{
"label": "B",
"disease": "Primary varicella"
},
{
"label": "C",
"disease": "Staphylococcal pustulosis"
},
{
"label": "D",
"disease": "Rickettsialpox"
}
] | D | [
"A previously well 7-month-old male infant presented to our emergency department with 1 week of loose stools, 4 days of fever up to 39.2°C, and 2 days of skin rash",
"His parents reported several pink papules that first appeared on his trunk and spread to his extremities within 24 hours",
"His increasing irritability and poor oral intake led to his admission for further evaluation",
"The patient’s vaccinations were up to date",
"He had no history of perinatal infections, sick contacts, recent travel, or pets",
"The family lives in an apartment in New York City",
"On physical examination, the patient had fewer than 20 pink papulovesicles, some with hemorrhagic crust, scattered on the upper chest, abdomen, lower back, and extremities (Figure, A and B)",
"His palms, soles, and oropharynx were otherwise unremarkable",
"Clinical and histologic images of papulovesicles",
"The clinical images show scattered pink papulovesicles, some with overlying hemorrhagic crust (A and B)",
"C, A histologic section (hematoxylin and eosin, original magnification ×10) of a papule shows a focally eroded epidermis (asterisk) with a relatively dense and diffuse perivascular and interstitial dermal infiltrate (arrow) of predominantly mononuclear cells and a few neutrophils, with changes indicative of a mild vasculitis",
"Laboratory test results were notable for a mild leukopenia with a white blood cell count of 4.6 × 109/L (normal, 6.0-18.0 × 109/L) with 18% monocytes",
"C-reactive protein was slightly elevated at 3.38 mg/L (normal, <2.9 mg/L)",
"He was started treatment with intravenous ceftriaxone and intravenous acyclovir",
"Blood, urine, and wound cultures were taken, and a skin punch biopsy was performed (Figure, C)"
] | [
0,
1,
2,
6,
7,
9,
10
] | [
3,
4,
5,
8,
11,
12,
13,
14
] |
1,226 | What Is Your Diagnosis? | [
{
"label": "A",
"disease": "Perforated bowel"
},
{
"label": "B",
"disease": "Crohn disease"
},
{
"label": "C",
"disease": "Cholecystocolonic fistula"
},
{
"label": "D",
"disease": "Gallstone ileus"
}
] | C | [
"A 64-year-old woman presented to the emergency department with a 1-day temperature of 38.9°C (102°F)",
"The patient had some accompanying cough, nausea, and arthralgias but denied having dyspnea, emesis, and chest or abdominal pain",
"She had a complicated medical history that was significant for non-Hodgkin lymphoma, chronic diarrhea, myelodysplastic syndrome treated with chemotherapy, and Behçet syndrome treated with prednisone acetate (6 mg daily)",
"Her surgical history was significant for a previous right-sided hemicolectomy due to recurrent right-sided diverticulitis",
"On examination, she was alert and awake with appropriate mental status",
"Her vital signs were as follows: blood pressure of 150/59 mm Hg, heart rate of 127 beats per minute, respiratory rate of 20 breaths per minute, temperature of 38.5°C (101.3°F) (oral), and an oxygen saturation as measured by pulse oximetry of 99% in room air",
"The physical examination was unremarkable",
"Significant laboratory data included a white blood cell count of 2700/μL (reference range, 4800-10 800/μL",
"to convert to ×109 per liter, multiply by 0.001), a lactic acid level of 19.8 mg/dL (to convert to millimoles per liter, multiply by 0.111), and a platelet count of 72×103/μL (to convert to ×109 per liter, multiply by 1.0)",
"Urinalysis showed trace blood, positive nitrite, +1 leukocyte esterase, and a white blood cell count of 2000/μL to 5000/μL",
"A urine culture came back positive for Klebsiella pneumonia, and a blood culture came back positive for Enterobacter sakazakii (now know as Cronobacter sakazakii)",
"There was concern about the source of the bacteremia, so an infectious disease consult was ordered, and a computed tomographic scan of the abdomen/pelvis with contrast was performed",
"Figure 1 shows a coronal, reformatted image of the scan",
"The patient was scheduled for surgery, and the findings are shown in Figure 2."
] | [
0,
1,
4,
5,
6
] | [
2,
3,
7,
8,
9,
10,
11,
12,
13
] |
1,227 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Exophytic solitary giant cavernous hemangioma of stomach"
},
{
"label": "B",
"disease": "Complicated cyst"
},
{
"label": "C",
"disease": "Gastrointestinal stromal tumor"
},
{
"label": "D",
"disease": "Neurilemmoma"
}
] | A | [
"A 23-year-old woman had a progressively enlarging mass associated with abdominal distention and a dragging type of discomfort for 1 week",
"She denied any history of hematemesis or hematochezia",
"On abdominal examination, an irregular mass measuring 20 × 10 cm without tenderness was found, and no bruit was heard on auscultation",
"No other vascular anomalies were detected on systemic examination",
"All laboratory test results were within normal limits",
"Upper gastrointestinal endoscopy showed normal gastric mucosa",
"Nonenhanced computed tomography of the abdomen showed a partially well-circumscribed, mixed cystic and solitary mass that partially enveloped the stomach and compressed adjacent organs, likely arising from the stomach (Figure 1)",
"Axial nonenhanced computed tomographic image showing a mixed cystic and solitary mass that partially enveloped the stomach"
] | [
0,
1,
2,
3
] | [
4,
5,
6,
7
] |
1,228 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Hydatid cyst"
},
{
"label": "B",
"disease": "Infected biliary cystadenoma"
},
{
"label": "C",
"disease": "Hepatic abscess"
},
{
"label": "D",
"disease": "Inflammatory pseudotumor of the liver"
}
] | C | [
"A 26-year-old man was admitted to our institution for a fever (temperature, 39°C) and abdominal pain on the right side of his hypochondrium",
"He complained of nausea, vomiting, and asthenia as well",
"His medical history was significant for pharyngitis associated with scarlet fever that he had a month before",
"the pharyngitis was treated by his general practitioner with clarithromycin (500 mg twice daily for a week)",
"No throat culture or rapid antigen test for group A streptococci was performed at that time",
"On physical examination, he presented with mild right upper abdominal quadrant tenderness",
"He met all the criteria for systemic inflammatory response syndrome, and his blood tests showed a marked increase in inflammatory markers",
"Blood and urine cultures were obtained, and the results were negative",
"Empirical antibiotic therapy with ampicillin sodium/sulbactam sodium was started",
"His chest radiograph was normal",
"An abdominal ultrasonographic examination revealed a 6-cm, solid, inhomogeneous mass in liver segment 6. A contrast-enhanced computed tomographic scan of the abdomen (Figure 1) showed that the lesion was hypodense with numerous septa without contrast enhancement",
"Magnetic resonance imaging (Figure 2) evidenced a mixed solid-liquid lesion, with some septa delimiting large areas of necrosis",
"The results of a serological detection test for echinococcosis were negative",
"His carcinoembryonic antigen, carbohydrate antigen 19-9, and α1-fetoprotein blood levels were normal",
"Serological markers for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative",
"A study of leukocyte populations and immunoglobulin electrophoresis did not reveal any disorder of the immune system",
"Computed tomographic scan showing a large, hypodense, multiloculated lesion in liver segment 6.Magnetic resonance imaging scan showing an heterogeneous, capsulated lesion, with numerous septa delimiting large areas of necrosis"
] | [
0,
1,
2,
3,
4,
5,
6,
7,
8
] | [
9,
10,
11,
12,
13,
14,
15,
16
] |
1,229 | What Is the Diagnosis? | [
{
"label": "A",
"disease": "Malignant bone tumor"
},
{
"label": "B",
"disease": "Aneurysmatic bone cyst"
},
{
"label": "C",
"disease": "Primary hyperparathyroidism with multiple brown tumors"
},
{
"label": "D",
"disease": "Giant cell tumor"
}
] | C | [
"In April 2010, a 19-year-old soccer player presented with a 4-week history of pain after a tap against his right knee",
"Medical and family histories were unremarkable and no abnormalities were found on physical examination",
"A radiograph of the right knee showed osteolytic lesions in the distal femur and the head of the tibia",
"On magnetic resonance imaging, the epiphyseal lesions were visualized as cystic and nonsclerotic and extended to the articular surface of the distal femur and proximal tibia (Figure 1)",
"Soft tissue extension was suspected from the tibia",
"Laboratory test results showed normal blood cell count, renal function, and concentration of C-reactive protein",
"Aneurysmatic bone cysts were suspected and a biopsy was performed",
"Histopathological examination detected spindle cell infiltrates with hemorrhages, fragmented trabecular bone, and numerous osteoclastic giant cells proliferating at a rate of 10% suggesting an aggressive giant cell lesion",
"Since it was still not determined whether the lesions were malignant, flourodeoxyglucose F 18 positron emission tomography/computed tomography was performed and found additional lesions in the left distal femur and the left mandible",
"Biopsy of the mandible showed the same type of tissue as seen in the right femur and tibia"
] | [
0,
1,
4,
5,
9
] | [
2,
3,
6,
7,
8
] |
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