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Quizzes and Polls

JAMA Clinical Challenge
JAMA Diagnostic Test Interpretation

Latest Clinical Challenge

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July 19, 2014

Recurrent Erythema Multiforme

A 43-year-old African American woman with medical history of hepatitis C virus (HCV) infection was seen for a 2-year history of painful skin lesions on her legs and arms. Her lesions improved with prednisone but recurred when treatment was discontinued. No inciting factors were identified except a possible relation to her menstrual cycle.

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July 15, 2014

Erosive Plaque on Scrotum

A 61-year-old man presents with a painless plaque on the right side of his scrotum; the plaque first appeared 1.5 years ago and has been slowly enlarging since. The patient reports experiencing no fevers or chills since the plaque developed.

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June 17, 2014

Lung Opacification

A 16-year-old girl presents with acute left shoulder pain, left-sided chest pain, and shortness of breath, with a history of intermittent left shoulder and left-sided chest pain for 4 months following a dance recital. Chest radiography shows left lower lobe opacification obscuring the left hemidiaphragm and blunting of the left costophrenic angle.

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June 10, 2014

A Solitary Red Patch

A 25-year-old woman with type 2 diabetes mellitus comes to the emergency department for evaluation of a hyperpigmented lesion on the shin. The lesion appeared as a small reddish-brown macule 3 years ago and has gradually increased in size.

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June 3, 2014

Progressive Anemia and Left Upper Quadrant Pain in a Patient With Polycythemia Vera

A 72-year-old man with a 23-year history of polycythemia vera presents with a 2-week history of left upper quadrant pain. Three years earlier, red cell scintigraphy documented a splenic hemangioma, which remained stable on periodic computed tomography (CT) scans.

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May 20, 2014

Severe Lactic Acidosis in an Amnesic Child

An 8-year-old boy presented to the emergency department after he was found unconscious outside his church on a rainy day. An ambulance was called and paramedics noted a reduced Glasgow Coma Scale score of 3, trismus with normal respiratory effort, and a scalp hematoma on the left forehead.

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May 13, 2014

Eye Mass

A 60-year-old Nigerian man first noted a left eye mass 7 months ago that was progressively enlarging. In the past month, the mass significantly enlarged and became more red and painful, and he can no longer close his eye. He underwent ocular surface surgery, presumably for a pterygium, on the left eye 1 year ago.

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May 3, 2014

A Child With a White Pupil

A healthy 4-year-old girl presents to the ophthalmologist for evaluation of a white pupil. The parents had noted a white pupillary reflection in the left eye for the past 2 months.

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April 15, 2014

A Nodular Protuberance on the Hard Palate

A 66-year-old man presents with a slowly enlarging growth in his mouth that appeared more than 20 years ago. He denies pain and discomfort but is concerned because the mass has increased in size during the past year.

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April 1, 2014

Chronic Nail Pigmentation in a 50-Year-Old Woman

A 50-year-old white woman presents with subungual and acral pigmentation of the left middle finger. She first noticed a black streak down the middle of her nail 10 years prior to presentation. Subsequently, the pigmented band on the nail plate widened and darkened, with pigment spreading to the proximal nail fold and distal acral hyponychial skin.

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March 18, 2014

Oral Ulcers and Targetoid Lesions on the Palms

A 22-year-old woman presents with oral ulcers and a rash on her palms of 4 days' duration. Physical examination reveals shallow erosions with hemorrhagic crusts on the lips and widespread targetoid macules with dusky centers on the palms.

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March 4, 2014

An Immunocompromised Patient With Recent-Onset Skin Lesions

A 53-year-old gay man undergoing treatment for multiple sclerosis had received 2 doses of rituximab, with the last being 3 weeks prior to being hospitalized for worsening lower extremity weakness. He received high-dose intravenous methylprednisolone when he entered the hospital. One week before admission, he noticed tender skin eruptions adjacent to the anus and on the left shin.

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February 11, 2014

Abdominal Pain and Subcutaneous Nodules

A 63-year-old man is admitted for evaluation of recurrent abdominal pain and a 2-month history of tender nodules on the extremities. He has a history of hepatitis B, hepatocellular carcinoma, and idiopathic pancreatitis. The lesions are initially very painful and slow to resolve. New lesions tend to appear with, or immediately after, episodes of acute pancreatitis.

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January 21, 2014

Exercise-Induced Leg Pain and High Blood Pressure

A 52-year-old woman presents with exertional right buttock and thigh pain that resolves within 2 minutes of rest. Exercise tolerance has worsened over the past year and is now limited to several blocks. Previously she was able to run 5 to 6 miles per day. Hypertension was diagnosed several months ago and is controlled with lisinopril (5 mg daily). She has no other cardiovascular risk factors.

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December 24, 2013

Multiple Cerebral Infarctions and Intracranial Vessel Abnormalities

A 65-year-old woman noted relapsing fevers, night sweats, fatigue, and a 16-kg weight loss. In the weeks before her hospital admission, she developed subacute cognitive deterioration and progressive headaches. On presentation she has difficulties initiating speech (nonfluent aphasia) and responds slowly and inconsistently to questions.

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December 17, 2013

Annular Vesiculobullous Eruption in a Healthy Young Man

A previously healthy 20-year-old man presents with a mildly pruritic, progressive rash. The eruption began in his scalp and subsequently spread over 9 days’ time to his neck, back, and chest. The physical examination is notable for numerous grouped vesicles and relatively monomorphic tense bullae, coalescing into markedly annular plaques, superimposed on erythematous bases with central clearing and scale.

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November 26, 2013

Jaw Lesion and Discomfort

A 57-year-old woman reports experiencing discomfort and a lesion around her mandibular incisor teeth for the past 3 months. She had received the bisphosphonate zoledronate for treatment of metastatic renal carcinoma for several months before the lesion appeared.

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October 22, 2013

A Persistent Red Crusted Plaque on the Back

A patient has an irregular, red plaque on his back, which has been present since he sustained a puncture wound at the site 4 years ago. He was initially diagnosed with eczema and treated with topical hydrocortisone cream without improvement. On examination, the plaque is elevated and covered in waxy white crusts.

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October 8, 2013

Abnormal Gallbladder Finding in a Septic Patient With Blood Loss

A 58-year-old man with fever, night sweats, elevated white blood cell count, anemia, and elevated troponin levels was admitted to the hospital. A transthoracic echocardiogram showed mitral valve vegetations. Despite 4 days of systemic antibiotics, his leukocytosis and anemia worsened. A CT scan showed air trapped in a gallstone.

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September 24, 2013

Necrotic Black Eschars in a Patient With Cancer

A 57-year-old woman with stage IIIC ovarian cancer presents with painful leg ulcerations of 3 months' duration. She denies fevers, chills, and other systemic symptoms.

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September 10, 2013

Scalp Pustules in a Patient Receiving Chemotherapy

A patient with stage IV lung cancer developed erythematous follicular papules and pustules on the scalp while undergoing treatment with an epidermal growth factor inhibitors. Potassium hydroxide examination of the lesions was negative.

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September 3, 2013

A 4-Day-Old Neonate With a Widespread Vesicular Rash

An infant born at 36 weeks’ gestation by cesarean deliver developed a widespread vesicular rash shortly after birth. The mother denied a history of sexually transmitted infections, cold sores, or genital lesions.

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August 27, 2013

Acute Abdominal Pain and Abnormal CT Findings

A 28-year-old previously healthy man had a 1-day history of persistent midepigastric and supraumbilical abdominal pain with some nausea. On examination, he had bilateral lower abdominal tenderness and voluntary guarding to palpation. He was afebrile and had elevated leukocyte count.

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August 13, 2013

A Painful Bulge in the Left Flank

A 73-year-old man who had herpes zoster for several weeks in the left T11-T12 dermatome developed a painful, progressive bulge in the left flank. The pain was more prominent while he stood, coughed or strained. Computed tomography showed convexity of the left abdominal wall but no intra-abdominal mass or fluid accumulation.

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August 6, 2013

Foreign Body in Right Side of Chest

A man, who was shot in the face, had an entrance wound over the right mandible with no visible exit wound. Breath sounds were clear and equal in all lung fields. The patient had a persistent, dry cough. Chest radiography showed a foreign body in the right side of his chest.

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July 23, 2013

Severe Intractable Postprandial Chest Pain

A 44-year-old man with a 3-year history of chest pain and odynophagia reports an exacerbation over 2 months and weight loss of 8.1 kg. Diagnostic tests show food stasis and high swallowing pressure.

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July 9, 2013

Generalized Cutaneous Papules and Nodules

A 43-year-old man presents with a 6-month history of multiple nonpruritic, nonpainful papules and nodules. The lesions appear on his face, scalp, ears, neck, trunk, and shoulder.

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June 25, 2013

Vulvar Swelling, Plaques, and Nodules

A 26-year-old woman has a 5-week history of vulvar swelling; she also reports occasional constipation and bloody, mucoid diarrhea. Examination reveals labial swelling and multiple perineal and perianal nodules.

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June 11, 2013

Ptosis, Erythema, and Rapidly Decreasing Vision

A 63-year-old man presents at the emergency department with a swollen right eye and complete ptosis. Three weeks earlier, he had been treated for sinusitis with oral prednisone, but his condition worsened and cultures revealed Enterobacter aerogenes.

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May 21, 2013

Sudden Purpuriform Rash in an Infant

A 10-month-old boy presents with erythematous swelling of both ears and right eyelid and erythematous perioral macules following a respiratory infection.

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April 30, 2013

Abdominal Swelling in a Teenaged Girl

A 16-year-old girl with 3 months of abdominal pain and swelling that increase after eating reports increased urinary frequency and slight weight gain but is not pregnant or bulimic.

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April 16, 2013

Edematous Erythema, Subcutaneous Plaques, and Severe Pain in the Lower Extremities in an Immunocompromised Patient

A woman with a renal transplant for 10 years is admitted for lower-extremity edematous erythema, subcutaneous plaques, and severe pain. Three courses of intravenous antibiotics have not dissipated her fever. Blood cultures are negative.

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March 26, 2013

Cervicodorsal Lipodystrophy (Buffalo Hump)

A 51-year-old man with a history of HIV and currently taking abacivir/lamivudine/zidovudine presents with a cervical lipodystrophy.

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March 12, 2013

Chest Pain and an Angiographic Abnormality

A 55-year-old man is admitted from the emergency department with 1 month of progressively worsening dyspnea and exertional angina.

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February 26, 2013

Acute Onset of Retrosternal and Epigastric Pain

A 15-year-old boy presents to the emergency department with acute onset of severe pleuritic retrosternal and epigastric pain after swallowing a mouthful of cold soda.

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February 12, 2013

Unilateral Proptosis

A 40-year-old man has a 2-month history of left periorbital swelling and pain without trauma, fever, or recent sinusitis. Examination reveals chemosis and proptosis. Neurological examination and laboratory studies are unremarkable.

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January 22/29, 2013

Hypopigmented Patches on the Skin

A 47-year-old man with a mildly pruritic eruption on his trunk and extremities has hypopigmented round patches with fine cigarette-paper scaling on his arms, hips, thighs, lateral chest wall, and flanks. His skin scrapings are negative for hyphae and he has no palpable lymphadenopathy.

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January 8, 2013

Diffuse Calcification and a Draining Wound

A 46-year-old man admitted because of dyspnea and altered sensorium and who was receiving chronic hemodialysis was noted to have “milky” secretions draining from a hip wound. A hip radiograph showed bulky, extra-articular calcifications.

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December 25, 2012

Upper Body Papules and Recurrent Pneumothorax

A 31-year-old woman presents with a 10-year history of facial and upper body papules, confirmed as fibrofolliculomas, a condition she shares with her immediate family. Her father also has a history of recurrent pneumothorax.

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December 11, 2012

Antibiotic Refractory Sinusitis

A man with a history of chronic sinusitis presented with unilateral periorbital swelling and subtle ptosis. Symptomatic improvement followed antibiotic treatment for presumed sinusitis, but within 1 month, increased periorbital swelling and persistent ptosis were noted.

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November 27, 2012

Neck Mass in a Returning Traveler

Three months after travel in Asia and the Middle East, a patient with diabetes had a painful, fluctuant neck mass. Outpatient incision and drainage were scheduled and empiric oral clindamycin initiated. Eight days later he returned with worsening neck pain.

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November 13, 2012

A Right Wrist Lump

A patient with a 30-year history of an enlarging, painless wrist mass has functional limitation. Ultrasound examination shows a cystic-appearing mass with no arterialized flow and angiography reveals delayed contrast enhancement.

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October 23, 2012

Multiple Cutaneous Swellings Associated With Sudden Collapse

A 77-year-old man without trauma or back pain or bowel, bladder, or radicular symptoms develops an acute inability to walk and presents with multiple upper body blue-black cutaneous swellings. Bilateral leg weakness develops.

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October 9, 2012

Familial History of Bone Tumors

A 61-year-old man presents with progressive chronic pain in his lower extremities and episodes of dysthesia. Examination shows that he has bony masses on both legs.

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September 25, 2012

A Florid, Tiny, Discrete Eruption on the Penis

A 13-year-old presents with asymptomatic papules on his penis and reports no other symptoms or sexual activity.

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September 11, 2012

Short Fourth and Fifth Metacarpals

A 9-year-old has uncontrolled seizures since age 7 months, brachydactyly, and x-ray evidence of fourth and fifth metacarpal shortening.

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August 21, 2012

Cutaneous Nodule in a Young Man

A 21-year-old man presents with an enlarging nodule on his chest, upper abdominal pain, diarrhea, and recent weight loss.

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August 14, 2012

Ocular Trauma

A 35-year-old man presents to the emergency department (ED) with painful vision loss, tearing, and photophobia after being struck in the left eye by a plastic pole 3 days earlier.

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August 7, 2012

Silvery-Gray Hair in a Newborn

A term newborn, born via spontaneous vaginal delivery, had abnormally light skin and silvery hair that is dark at the roots and light at the tips.

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July 22, 2012

A Crusted Plaque on the Right Nipple

A healthy heterosexual man presents with a crusted plaque on his nipple, which formed after a bite during sexual intercourse, and a generalized macular rash.

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July 10, 2012

A Pain in the Neck

A 68-year-old woman with small cell lung cancer has a bulging area behind her ear. She previously had resection and radiation therapy for a recurrent hemangioblastoma.

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June 26, 2012

A Violaceous Plaque in an Immunosuppressed Patient

A 56-year-old man with acute myelogenous leukemia with complications of neutropenia and fever of unknown origin developed a violaceous plaque on his neck.

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June 12, 2012

A Young Patient With Persistent Gingival Bleeding

A 13-year-old girl who practices good oral hygiene is seen for evaluation of oral ulcers, gum erythema, and a "peeling off" sensation in her gums.

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May 22, 2012

Progressive Confusion, Memory Loss, and Gait Ataxia in an Adult

A 62-year-old woman is seen in the emergency department for progressive confusion, memory loss, and gait instability over a 6-month period with noticeable worsening over the last 2 months.

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May 8, 2012

Corneal Trauma in a 6-Year-Old Boy

A 6-year-old boy presents with worsening photophobia, irritation, and redness in his right eye for 5 days.

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April 24, 2012

Episodic Abdominal and Chest Pain in a Young Adult

A 49-year-old man with a history of severe eczema presents to your office with slightly eroded, erythematous scaly patches on the his face, chest, and back.

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April 10, 2012

Vesicular Eruption

A 49-year-old man with a history of severe eczema presents to your office with slightly eroded, erythematous scaly patches on the his face, chest, and back.

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March 27, 2012

Blue Sclerae

A 60-year-old man with a history of multiple fractures after minor trauma presents for evaluation of anemia with a hemoglobin level of approximately 9 g/dL.

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March 13, 2012

Rapidly Expanding Facial Eschar in a Severely Injured Trauma Patient

A 21-year-old woman presents to the trauma resuscitation unit via helicopter transport following a motor vehicle crash.

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February 21, 2012

Patient With a Rash, Abdominal Pain, and Weight Loss

A 49-year-old man presents with right iliac fossa pain of 36 hours' duration. He reports loss of appetite, weight loss, and increasing lethargy over the preceding 10 months.

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February 7, 2012

Rash in an Immunocompromised Patient

A 48-year-old man with low-risk acute promyelocytic leukemia (APL) undergoes induction chemotherapy with daily all-trans retinoic acid (tretinoin), cytarabine (days 1-7), and daunorubicin (days 1-3).

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January 24, 2012

Papules, Plaques, and Nodules in an Immunocompromised Patient

An 85-year-old man is admitted for evaluation of multiple papules, plaques, and subcutaneous nodules on his face, trunk, and extremities.

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January 10, 2012

Purple Urine

An elderly frail woman with dementia was admitted to the internal medicine service because of malfunction of her percutaneous gastrostomy tube.

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December 20, 2011

Decreased Vision Following Eye Trauma

A 52-year-old man presented to the emergency department (ED) for evaluation after several days of increasingly blurred vision in the right eye.

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December 6, 2011

Right Femoral Neck Fracture

A 23-year-old woman was referred for evaluation of a right femoral neck pathologic fracture.

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November 22, 2011

Acute-Onset Reticulated White Lip

A 62-year-old woman returns to your office with a diffuse, pruritic rash on her lips, palms, and upper back 2 weeks after starting lisinopril.

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November 1, 2011

Indurated, Purplish Plaque on a Newborn

A female neonate carried to term and born weighing 2.87 kg was delivered spontaneously to a 29-year-old woman with no medical illness.

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October 2011

Lower Abdominal Swelling and Scrotal Enlargement

A 24-year-old man reports progressive, right lower abdominal swelling and right scrotal enlargement over 2 years.

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September 2011

Periocular Rash

A healthy 5-year-old boy presented with a 3-month history of an erythematous rash around his left eye.

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August 2011

Skin Fragility and Blister Formation

A 3-year-old girl native of the tribe Ngöbe-Buglé (Panama) was referred for evaluation of a history of skin fragility and blister formation since adoption 2 years earlier.

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July 2011

Frontal Headache

A 47-year-old Brazilian woman presented to a walk-in clinic reporting a headache of 8 days' duration that started in the frontal area and evolved into a holocranial headache.

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June 2011

Superficial Corneal Growth

During a routine office visit, you notice that your patient, a 70-year-old white man, has a small superficial growth on the surface of his right eye that you do not remember seeing before.

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May 2011

Lower Extremity Purpura

A 50-year-old woman comes to your office for evaluation of a vasculitic-appearing cutaneous eruption of unknown duration on the lower extremities.

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Latest Diagnostic Test Interpretation

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July 8, 2014

Aldosterone-Renin Ratio in the Assessment of Primary Aldosteronism

A middle-aged patient with diabetes and hypertension presented to his primary care physician for regular health assessment. His blood pressure was 183/116 mm Hg despite taking lisinopril (40 mg/d) and verapamil (180 mg/d). As part of the workup for secondary hypertension, plasma aldosterone concentration and plasma renin activity were measured.

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Test your knowledge with previous versions of the JAMA Diagnostic Test Interpretation.
June 24, 2014
Diagnostic Challenges of Hepatitis C

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June 24, 2014

Diagnostic Challenges of Hepatitis C

A healthy woman in her 50s without diabetes or obesity presented for an annual physical examination. Her primary care physician recommended hepatitis C virus (HCV) testing because she was born between 1945 and 1965. The patient’s hepatitis C antibody (anti-HCV) result was positive.

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May 20, 2014
B-Type Natriuretic Peptide for the Evaluation of Volume Status in Elderly Postoperative Patients

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May 20, 2014

B-Type Natriuretic Peptide for the Evaluation of Volume Status in Elderly Postoperative Patients

A 92-year old man developed paroxysmal tachycardia after hemicolectomy. His B-type natriuretic peptide level was 311 pg/mL (normal <100).

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