<s>[INST] hello doc,I was visited by a patient 24/m who had blackish extremities(both palms and dorsum , both feet  and dorsum, tongue and both axillae) which was noticed initially as a small patch on one of his fingers before 3 years.It has been aggravating for the past 3 months.Pt has a h/o poor appetite since last month.Routine examinations suggest 12% of haemoglobin and decreased rbc count .6-7 pus cells in urine and 4-6 epithelial cells. His vit  b12 levels are less. What could be the possible diagnosis?Regards,Dr.anjali [/INST] Hello Dr. Anjali, however h/o patient is not suggestive of many things but possible one diagnosis is "MELANOGENESIS". This is a type of  melanoma ( nodular or pigmented), 2nd thing may be metastasis has stated in this patient. As far as concerned about pus cells in urine actually 5-6 are nearly normal ,loss of appetite, weakness are all indicator of melanoma so pl consider this thing also in your's diagnosis. </s>