Puzzles in Practice articles offer a brief case report of a patient's presenting symptoms in order for primary care physicians to determine a diagnosis. Authors are required to submit a very clear high-resolution image (e.g., clinical photograph, radiograph, etc.) of the patient. A signed author disclosure form is required before any submission can be published. As established in the AMA Manual of Style: A Guide for Authors and Editors (10th edition), we also require a signed informed consent statement for identifiable patient images, specifying that the patient is aware that they will be featured in the submitted Puzzles in Practice case report.