A Hand-Carried Diagnosis

A CLINICAL PROBLEM-SOLVING article by Clinton Greenstone from Veterans Affairs Ann Arbor Medical Center, in Michigan.
A 34-year-old black woman presented to a walk-in clinic with a 3-day history of malaise. Her colleagues had noticed yellowing of her eyes over the past few days.
The patient said she had no fever, chills, sweats, nausea, vomiting, diarrhea, abdominal or chest pain, cough, or dyspnea. She had had one sexual partner for the previous 2 years, and her last sexual contact occurred 6 months earlier without barrier protection. She had taken Ortho-Novum, her only medication, for the previous 2 years, but she discontinued this medication 5 months earlier when she broke up with her last partner because of his infidelity.
On examination, her temperature was 38.0°C, blood pressure 110/78 mm Hg, and heart rate 100 beats per minute. Skin examination revealed no rash or spider angiomas. She had scleral icterus. On abdominal examination, she had mild tenderness on deep palpation in the right upper quadrant.
The patient's hepatic laboratory values showed a cholestatic injury pattern.
The patient was sent home and advised to rest and increase her fluid intake while awaiting the test results.
The patient returned to the clinic 3 days later. She now reported a new rash, which she described as having started on her abdomen and then spread to her legs, arms and palms.

手掌の薔薇疹が決め手となりました。肝炎などを呈したのは、梅毒が"the great imitator"と呼ばれる所以です。 the great imitatorに関しては、英語版wikipedia、Zebra Cardsに詳しい記載があります。