Her previous menstrual cycles were regular, occurring every 28–35 days consistently.

Her past medical history reveals two uncomplicated and normal vaginal deliveries at term.

She has a 2-year-old boy and a 6-month-old girl.

The patient and her partner use the withdrawal method for contraception.

The patient does not have any other complaints currently.

The urine pregnancy test result is positive.

The patient returns to the clinic after 1 week expressing her desire to discontinue with the pregnancy and inquires about the possibility of an elective abortion.


His past medical history is significant for diabetes, hypertension, and early stage prostate cancer that was removed 10 years ago without recurrence.

He has smoked 1 pack per day for the past 55 years and drinks about 6 drinks per week.

He says that he used to enjoy playing golf with his friends but now he cannot walk for long enough to play.

The shortness of breath is now starting to complicate his ability to get around in daily life.

On presentation he is found to be breathing with pursed lips.

Physical exam reveals decreased breath sounds on auscultation, increased chest diameter, and hyperresonance to percussion.


He reports that over the past month he has become more easily “winded" to the point that he now sleeps in his living room because he can’t make it up the stairs.

A review of systems is notable for headaches and fatigue.

On physical exam you note decreased breath sounds and a dullness to percussion on the right.

A chest radiograph is obtained, which shows a right-sided pleural effusion.


This is her fourth loss in the second trimester and she is concerned about her inability to have a successful pregnancy.

She is otherwise healthy and has no acute complaints.

Her vitals are unremarkable and exam is notable only for a firm, asymmetric uterus.

Laboratory studies are ordered as seen below.


She has suffered from seasonal allergies for the past 2 years and takes diphenhydramine as needed when her symptoms worsen.

She has not yet seen a physician for her allergies.

Her past medical history is also notable for well-controlled asthma.

She uses an albuterol inhaler on an as-needed basis.

She reports that diphenhydramine has been helpful in controlling her symptoms, but she does not like feeling drowsy from the medication.

Her nasal turbinates are boggy and bluish-gray.

She has copious thin and watery nasal mucus.

Her temperature is 99.2°F (37.3°C), blood pressure is 120/70 mmHg, pulse is 76/min, and respirations are 16/min.

The physician suggests replacing diphenhydramine with fexofenadine to improve her drowsiness.


He reports that he worked in a naval shipyard for 10 years during his twenties.

His vital signs were within normal limits.

A CT scan of his chest shows diffuse thickening of the pleura and a diagnosis of mesothelioma is made.


He states that he has abstained from alcohol and attends a support group regularly.

He has not taken any new medications or encountered any sick contacts.

The patient's blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 15/min.

His physical exam is grossly unremarkable.

He has brought an gastroduodenoscopy report for review, which reveals that the patient has small esophageal varices with red spots.


Upon first inspection you note the man is drooling and his eyes are tearing excessively.

The patient seemed confused so the wife brought him in promptly, and states it has only been ten minutes since the patient was found down in the fields.

Physical exam is deferred due to a confused and combative patient who is speaking clearly yet his sentences do not make any sense.

Vital signs are currently being obtained.

The patient's wife explains that the man was tilling the fields on the family beet farm when she found him collapsed on a pile of freshly picked beets.

The patients clothes are removed in the ED.


The past medical history includes hypertension.

He had a brother who died at the age of 84 due to hematologic malignancy.

He has no complaints other than occasional knee pain.

The temperature is 36.8℃ (98.2℉), and the blood pressure is 125/85 mm Hg.

The physical examination shows no abnormalities other than a reduced range of motion and crepitus in both knees.

The laboratory test results are as follows:
Hemoglobin 15 g/dL
Leukocyte count 58,000/mm3
Platelet count 250,000/mm3
Flow cytometry on the peripheral blood reveals an absolute lymphocyte count of 50,000/mm3.

He has had knee osteoarthritis for several years and takes occasional acetaminophen for pain control.


He has a history of pulmonary tuberculosis.

Pulmonary examination shows inspiratory crackles at the left infraclavicular area.

An x-ray of his chest shows a radiopaque mass in the left upper lung lobe that shifts upon repositioning.

A sputum sample does not grow acid-fast bacteria despite multiple cultures.


She reports that he has required more time to reach developmental milestones compared to his older brother.

The patient's immunization records are not available.

He has not had fever, cough, or a runny nose.

He appears pale with blue eyes and has a musty odor.

He has been healthy, except for occasional eczema.


He rejects his null hypothesis and concludes that low birth weight is associated with obesity.

He conducts a study with a 95% confidence interval with a p-value of 0.049 to disprove his null hypothesis.


The patient has a past medical history of anxiety and depression and is currently taking fluoxetine.

The patient states that she has been experiencing watery diarrhea for weeks now.

During this same period she states she has been constantly thirsty and does not have the same energy levels that she once had.

Her temperature is 99.5°F (37.5°C), blood pressure is 110/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Laboratory values are obtained and shown below.

She was recently treated for a middle ear infection and sinusitis with amoxicillin-clavulanic acid one week ago.


The patient was born at term and had his first bowel movement at 50 hours of life.

He has since had one bowel movement daily.

He is at the 50th percentile for length, 10th percentile for weight, and 40th percentile for head circumference.

The vomitus is greenish in color and smells strange.

His parents have tried to feed him every 4 hours, but the patient often spits up or refuses to eat.

He does not appear to be in acute distress.

His temperature is 36.9°C (98.4°F), pulse is 140/min, respirations are 40/min, and blood pressure is 90/60 mm Hg.

Physical examination shows that the patient has small, low-set ears, a broad and flat nasal bridge, and a large space between the first and second toes bilaterally.

When the finger is removed following a rectal exam, there is an explosive release of stool from the patient's rectum.

An x-ray of the abdomen shows a section of dilated colon followed by a segment of colon without stool or air.


His mother has been giving him ibuprofen at night for “growing pains,” but his symptoms have not improved.

One week before the pain started, the patient was hit in the thigh by a baseball, which caused his leg to become red and swollen for several days.

Examination shows marked tenderness along the left mid-femur.

Laboratory studies show a leukocyte count of 21,000/mm3 and an ESR of 68 mm/h.

An x-ray of the left lower extremity shows multiple lytic lesions in the middle third of the femur, and the surrounding cortex is covered by several layers of new bone.

A biopsy of the left femur shows small round blue cells.


During your meeting, you note that the patient is exhibiting the defense mechanism of suppression.

You intend to discuss the results from his recent surveillance colonoscopy, which showed no remaining cancer, no polyps, and a well-healed anastmosis.


The past medical history is significant for hypercholesterolemia, for which he takes lovastatin.

He smoked as a youth but quit at 40 years of age.

The pain radiates to his left shoulder and is associated with sweating.

On arrival at the emergency department, the vital signs were as follows: pulse 58/min, respiratory rate 22/min, and blood pressure 90/56 mm Hg.

The jugular venous pulse is visible 2.5 cm above the sternal angle.

Auscultation reveals soft S1 and S2 heart sounds with an added S4 and bilateral inspiratory crackles at the lung bases.

The electrocardiogram shows ST-elevations in leads V1 and V2.

The patient was given aspirin on the way to the hospital.

He is started on dopamine, morphine, nitroglycerin, and streptokinase.

A diagnosis of an anteroseptal infarction is made.


He has a history of chronic progressive dyspnea over the past five years.

His past medical history is notable for hyperlipidemia and hypertension.

He drinks alcohol socially and has a 45 pack-year smoking history.

He uses oxygen at home and was seen in the emergency room two months prior for an exacerbation of his dyspnea.

His temperature is 98.6°F (37°C), blood pressure is 140/75 mmHg, pulse is 110/min, and respirations are 22/min.

On examination, increased work of breathing is noted.

The physician decides to start the patient on an additional medication that has both mucoactive and anti-oxidative properties.

He was discharged following stabilization.


Her two other children were born after uncomplicated vaginal deliveries at 41 and 42 weeks' gestation, respectively.

Her only medication is a prenatal vitamin.

She is 165 cm (5 ft 5 in) tall and weighs 86 kg (200 lb); BMI is 33 kg/m2.

Her temperature is 36.8°C (98.4°F), pulse is 90/min, respirations are 14/min, and blood pressure is 110/80 mmHg.

Examination shows a nontender, soft uterus consistent in size with a 42-weeks' gestation.


She was found unconscious on a park bench by a bystander.

The pupils are constricted, and a response to light cannot be determined.

Vitals include a pulse of 64/min, a respiratory rate of 7/min, and a blood pressure of 110/70 mm Hg.

On examination, the patient is unresponsive to voice and touch but shows a flexor response to pain.


After a thorough workup, you determine that the patient has pancreatic cancer.


Past medical history is significant for well-controlled schizophrenia.

He takes a low-potency typical antipsychotics and a multivitamin every day.

He has been compliant with his medication and has regular follow-up visits.

He complains of mild vision impairment over the last 6 months.

His vision has continued to slowly deteriorate and his condition is now affecting his night driving.


The patient denies any smoking history, alcohol consumption, or illicit drug use.

The patient’s family says that he had been high functioning but has had significant behavioral changes over the past year.

He is irritable, paranoid, and delusional but denies any hallucinations.

An unstable, wide-based ataxic gait is noted.

His vital signs include: blood pressure 90/50 mm Hg without postural changes, pulse 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).

Physical examination reveals a poorly groomed, disheveled, thin man.

Laboratory results are significant for the following:
Hb 6.1 g/dL
MCV 109 fL
Platelets 90,0000/mm3
Total count 3,000/mm3
Reticulocyte count 0.8%
A peripheral blood smear demonstrates hypersegmented neutrophils.

Anti-intrinsic factor antibodies are negative.


He has recently migrated from Sweden and has not had any checkups in the last 3 years.

He first started having back pain 3 years ago, but his pain has begun to be excruciating in the mornings.

He is no longer able to get relief with over the counter medications.

He also feels stiff every morning and this usually lasts between 30 minutes and an hour.

Both of his knees are also very painful, particularly upon standing up from a seated position.

His pain improves when he moves around, so he tries to be somewhat physically active.

He also reports that he cannot use his hands for long periods of time due to joint pain and stiffness.

Upon physical examination, his wrist and proximal interphalangeal (PIP) joints are warm and swollen.

His father and sister also have joint issues, and his mother was recently diagnosed with osteoporosis.


Prior to the onset of the symptoms, he attended a bachelor party where he lost several drinking games.


She has recently avoided drinking alcohol and eating spicy food because it worsens her diarrhea and causes episodes of heart palpitations and reddening of the face and neck.

Her temperature is 36.5°C (97.7°F), pulse is 98/min, and blood pressure is 149/90 mm Hg.

The abdomen is soft, and there is mild tenderness to palpation with no guarding or rebound.

Laboratory studies show an increased urine 5-hydroxyindoleacetic acid concentration.


Medical history is significant for hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD).

He has smoked approximately 1 pack of cigarettes per day for the past 45 years.

His cough has been increasing in frequency and severity over the course of 3 days, and his sputum production has increased in volume.

The color of his sputum is yellow-green.

He denies any chest pain or palpitations but has experienced worsening shortness of breath with exertion and at rest, which is above his baseline.

His temperature is 102°F (38.9°C), blood pressure is 156/94 mmHg, pulse is 101/min, and respirations are 26/min with an oxygen saturation of 85% on room air.

On physical exam, the patient has difficulty speaking, and there is asynchronous motion between the chest and abdomen with respiration.

Wheezing is appreciated on pulmonary auscultation.

An ECG demonstrates normal sinus rhythm.

He is started on ipratropium, albuterol, and methylprednisolone.

He has not noticed any changes in his weight or edema in his lower extremities.

He denies any recent history of long travel.

He has been hospitalized four times for similar symptoms within the last year.


His past medical history is unremarkable.

He reports he has lost 4 kg (8.8 lb) in the last two months with no changes in his diet.

He has also been suffering from mild to moderate joint pain in the left knee for the last year.

His vitals include: blood pressure 120/70 mm Hg, temperature 37.0℃ (98.6℉), pulse 70/min, respiratory rate 14/min.

Physical examination is significant for nasal ulcers.

Diffuse crackles are present over all lobes of the lung bilaterally.

Laboratory findings are significant for the following:
Hemoglobin 12.9 g/dL
Hematocrit 37.7%
Leukocyte count 5500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 μm3
Platelet count 190,000/mm3
Erythrocyte sedimentation rate 35 mm/h
C-reactive protein 14 mg/dL
Creatinine 3.09 mg/dL
The patient is prescribed a corticosteroid nasal spray and oral antibiotics but returns in 2 weeks without any clinical improvement.


The patient is found to be tachycardic and has marked edema and waxy discoloration in his legs.

Serum analysis shows increased levels of T4 and T3, as well as the presence of thyroglobulin-stimulating immunoglobulins.


The patient was born at 35 weeks gestation to a 27-year-old gravida 4.

The patient is of Ashkenazi Jewish descent, and the patient’s parents denied all prenatal genetic testing.

The pregnancy was uncomplicated until the patient’s mother had spontaneous rupture of membranes at 35 weeks gestation.

The patient’s three older siblings are all healthy.

In the hospital nursery, the patient’s temperature is 98.2°F (36.8°C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min.

On physical exam, he appears to be in moderate distress.

He has no dysmorphic features, and his abdomen is distended and non-tender.

His mother is breastfeeding and has started to produce milk.

The patient has been feeding well every two hours and is urinating over eight times per day.


Her medical history is significant for Alzheimer’s dementia, coronary artery disease, diabetes mellitus, hypothyroidism, congestive heart failure, osteoarthritis and centrilobular emphysema.

The patient takes memantine, atorvastatin, metformin, levothyroxine, lisinopril, aspirin, albuterol, and ipratropium.

She has no complaints during this visit but her daughter states that she is having difficulty locating objects such as the television remote, car keys, and her purse.

The patient’s vitals are within normal limits today.

Physical exam reveals an elderly female in no acute distress, oriented to person, place and year, but not to month or day of the week.

She has a 3/6 holosystolic murmur at the left sternal border along with an S3 gallop.

There are mild crackles at the lung bases.

A previous urine culture reports growth of > 100,000 CFU of Enterobacter.


She has a history of rheumatoid arthritis and was started on a new medication 4 months ago.

Over the past 2 months, she has had increasing fatigue and difficulties concentrating.

Examination shows pallor of the mucosal membranes and three tender ulcerative lesions in her mouth.

Her hemoglobin concentration is 8.7 g/dL and mean corpuscular volume is 109 μm3.

A blood smear shows hypersegmented neutrophils.


She admits to having unprotected sex with a male partner a month ago while she was traveling in Southeast Asia.

She says that her symptoms began 4 days ago as a painful mass that slowly enlarged, ruptured, and ulcerated.

However, she denies fever, chills, dysuria, or hematuria.

Three weeks prior to her current symptoms she noted a small, painless ulcer on her labium majorum that resolved after a few days.

Temperature is 99°F (37.2°C), blood pressure is 139/84 mmHg, pulse is 76/min, and respirations are 18/min.

Physical examination is significant for left-sided, tender, ulcerative lymph nodes with a dark discoloration.


The patient was on 2 antihypertensive medications and a statin, but she was not receiving any antiplatelet drugs.

Initial examination shows global aphasia, right homonymous hemianopia, and hemisensory loss.

She has a blood pressure of 136/94, heart rate of 84/min, and respiratory rate of 15/min.

An acute ischemic stroke caused by distal left internal carotid artery occlusion with salvageable penumbral tissue is diagnosed based on a non-contrast CT scan, brain MRI, and catheter cerebral angiogram.

Intravenous tissue plasminogen activator is given as treatment within 3 hours of presentation.


If these waste products are not cleared by the liver and kidneys, hyperammonemia can occur, leading to confusion and delirium.

Fortunately, a healthy liver can clear these waste products via the urea cycle.


The patient denies any smoking history, alcohol, or recreational drug use.

He was diagnosed with type 2 diabetes mellitus 1 year ago and has had difficulty controlling his blood glucose levels.

He says the pain is most severe in the proximal parts of his fingers and his wrists, but it has now spread to his elbows, and, occasionally, his knees.

He says the joint involvement is symmetric.

He also complains of morning joint stiffness that improves with activity and reports feeling fatigued during the day.

A review of systems is significant for a weight loss of 3.0 kg (6.6 lb) over the last 3 months despite no change in diet or activity level.

He started taking ibuprofen 2 months ago for the pain which initially subsided, but, over the last few weeks, it has worsened despite the medication.


Current medications include folic acid and a multivitamin.

A rectovaginal swab culture grows bacitracin-resistant colonies of gram-positive cocci with surrounding areas of clear hemolysis.


Her parents note that she was diagnosed with a heart murmur, but it was never treated.

They state that their daughter has recently been more irritable than usual, and she occasionally becomes pale and blue.

She is laying on the examination table with her knees drawn to her chest.

Physical examination reveals a small child in distress.

Cardiac auscultation reveals a harsh, systolic ejection murmur that is best heard at the upper left sternal border.


The patient was an unrestrained passenger in a motor vehicle crash and was ejected from the vehicle after collision.

He is noted to have multiple ecchymoses over his body, as well as petechiae and purpura.

He has a laceration over his clavicle that continues to bleed despite a pressure bandage.

Two large bore IV lines are placed, and the patient oozes from around the sites of venepuncture.

Upon arrival to the trauma bay, the patient has a Glasgow coma scale (GCS) of 6.

He is rapidly intubated, and vitals are a temperature of 99.5°F (37.5°C), pulse of 130 bpm, and blood pressure of 83/64 mmHg.

Radiographs of his lower extremity show multiple long bone fractures.

Labs are notable for a WBC of 20,000/mm^3, Hb of 10.1g/dL, platelets of 48,000/mm^3, and prolongation of the PT and aPTT.


His personal medical history is relevant for frequent visits to the ER for lower gastrointestinal bleeding in the last month with a recent colonoscopy that reported an ulcerative lesion suggestive of colorectal cancer.

He has not been subjected to dental procedures recently, and he denies the use of psychoactive drugs.

His palms and soles show non-tender erythematous lesions.

He is found with a blood pressure of 100/80 mm Hg, a heart rate of 84/min, an elevated respiratory rate, and a holosystolic heart murmur III/VI.

A chest plain film shows clear lungs and mild cardiomegaly, and echocardiography reports the presence of vegetations involving the mitral valve.


His past medical history is only notable for a recent office note from his primary care doctor for treatment of seasonal allergies.

Physical exam is notable for a man who is very irritable and restless.

The patient is answering questions and states he wants to kill himself.

His temperature is 101°F (38.3°C), blood pressure is 173/97 mmHg, pulse is 105/min, respirations are 16/min, and oxygen saturation is 98% on room air.

He is not cooperative with exam or history and becomes combative requiring intramuscular medications and security restraining him.

After this event, the rest of his exam is notable for 7 mm pupils which are equal and reactive to light, spontaneous movement of all limbs, normal sensation, and warm and sweaty skin.


Upon further questioning, it is found that although his sleeping hours are adequate, he does not feel refreshed in the morning.

His wife complains that he snores loudly all night.

After ruling out common medical disorders and possible drug abuse, he is advised an overnight polysomnogram that records 12 episodes of apnea and 30 episodes of hypopnea during a 7-hour sleep.


The patient is a retired welder and has been living with his son since his wife passed away 5 years ago.

He denies any smoking history or current alcohol or drug use.

He feels short of breath even without exertion and states he ‘got winded’ while walking to his bedroom last night.

He describes his cough as non-productive and says he can identify no recognizable triggers.

His vital signs include: pulse rate 72/min, respiratory rate 15/min, blood pressure 134/80 mm Hg, and temperature 36.8°C (98.0°F).

On physical examination, digital clubbing is noted.

Bilateral basilar fine crackles on noted on pulmonary auscultation.

Expiratory flow rates are measured and found to be high when corrected for lung volume.

A chest X-ray is performed and shown in the image below.


She underwent a hysterectomy 9 years ago for leiomyomata uteri.

She has a 5-year history of hypertension treated with lisinopril.

Examination shows a mildly tender abdominal wound without erythema.

Her temperature is 39.5°C (102.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/90 mm Hg.

Cardiac examination shows no abnormalities.

She had a Foley catheter and peripheral line access placed at the time of the procedure.

The patient received cephalexin for antibiotic prophylaxis and one unit of packed red blood cells during the procedure.


He was born at 38 weeks' gestation to a 30-year-old woman, gravida 2, para 1, after an uncomplicated labor and delivery.

The mother did not receive prenatal care.

She takes codeine syrup frequently for dry cough.

Examination shows hyperreflexia, tremors, and an excessive startle response.

Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

The infant's temperature is 37.8°C (100°F), pulse is 165/min, and blood pressure is 83/50 mm Hg.

Complete blood count and serum levels of glucose, bilirubin, and calcium are within normal limits.

The baby is swaddled to prevent excoriations, and fluid resuscitation is initiated.


The patient works in the adult entertainment industry.

She says that she first noticed these blisters shortly after returning from a weekend trip to the beach two weeks prior.

She denies any fevers, joint pains, or other skin rash during this period.

On examination, there are multiple flaccid blisters of the bilateral dorsal hands with hemorrhagic crusts, mild scarring, and hyperpigmentation.

In addition, increased hair growth is noted on the bilateral malar cheeks.

Her temperature is 99.1° F (37.3° C), pulse is 95/min, blood pressure is 130/87 mmHg, respirations are 13/min, and oxygen saturation is 98% on room air.


Past history involves congestive heart failure (CHF).

This has onset over the past 3 weeks, progressively worsening.

Due to concerns of concurrent pneumonia, sputum studies are ordered.

Microscopic examination of his sputum demonstrates heart failure cells (hemosiderin-containing macrophages).


On arrival, she is in acute distress but is fully oriented.

20 hours later, she has several large, tarry black stools and develops hypotension and tachycardia.

Aggressive intravenous fluid resuscitation is begun and the patient is transferred to the intensive care unit of a burn center.

Despite appropriate lifesaving measures, she dies.


His wife divorced him about 6 months ago and took the kids and moved out of state.

Since then he has had difficulty waking up in the morning and getting to work on time.

He takes some comfort in food and has gained about 9.1 kg (20 lb).

He eats out several times a week and sometimes consumes 2 whole meals in one sitting.

Other than this new obsession with eating large quantities of food and excess sleeping he no longer enjoys doing things he liked doing in the past.

Besides eating and sleeping he is always excited to see his children and looks forward to their visits.

Additionally, he does not feel like he has the same drive or focuses at work.

His blood pressure is 119/81 mm Hg, pulse rate is 85/min, respiratory rate is 12/min, and the temperature is 36.8°C (98.2°F).

He says it's the one thing keeping him going.

He reports that he has no interest in hurting himself or others.


His pulse is 124/min and pulse oximetry on room air shows an oxygen saturation of 90%.

A diagnosis of pulmonary embolism is suspected and intravenous heparin is initiated.


He also mentions that his father and brother have lipomas over the extremities.

He noticed the swelling 6 months ago, but he ignored it because it was painless.

However, he is now concerned as the swelling has been increasing in size over the last 6 months.

On physical examination, the swelling is well-circumscribed and non-tender, measuring approximately 4 x 5 cm.

The pathologist reports the tumor to be a liposarcoma rather than a lipoma.

After evaluation, the surgeon performs a surgical resection of the tumor and sends the tissue for histopathological examination.


Her past medical history is significant for asthma.

Her father is not living and had Parkinson disease, and her mother has poorly controlled rheumatoid arthritis.

She is currently sexually active in a monogamous relationship and uses contraception consistently.

She denies cigarette smoking and occasionally drinks wine.

She experimented once with lysergic acid diethylamide 6 years ago.

She says that she has been generally healthy but has noticed difficulty concentrating, becoming increasingly fatigued, and a 15-pound weight increase over the course of a few months.

She also reports mild constipation and joint pain.

Approximately 6-months ago, she experienced palpitations, increased stool frequency, and a hand tremor.

Her temperature is 99°F (37.2°C), blood pressure is 127/98 mmHg, pulse is 55/min, and respirations are 13/min.

On physical exam, the patient has slow speech and movement.

She has tenderness to palpation of her wrist and ankle joints.

She has delayed relaxation of deep tendon reflexes.


The mother has a history of schizophrenia and was treated with lithium until 5 weeks' gestation, when she found out that she was pregnant.

The mother was treated for alcohol abuse disorder 2 years ago.

Apgar scores are 7 and 8, at 1 and 5 minutes, respectively.

Examination shows that the child has micrognathia, a broad nasal bridge, a short philtrum, and small, low-set ears.

Examination of the mouth shows a cleft palate.

A grade 3/6 systolic ejection murmur can be heard over the left sternal border.

Echocardiography shows a single overriding great vessel arising from the heart.


Results from tumor markers and a biopsy are as follows:
AFP 350 ng/mL (normal value < 10 ng/mL)
hCG 0.4 IU/L (normal value < 0.5 IU/L)
Biopsy: Presence of glomeruli-like structures with a central capillary within a mesodermal core, lined by flattened layers of germ cells.


He says he has been hospitalized 3 other times this year for COPD exacerbations.

The medical history is significant for a left main coronary artery myocardial infarction after a coronary artery bypass graft (CABG) 2 months ago, mild cognitive impairment, and type 2 diabetes mellitus.

Current medications are metformin, aspirin, clopidogrel, metoprolol, atorvastatin, galantamine, and enalapril.

He reports a 40-pack-year smoking history but quit 10 years ago.

His temperature is 39.0°C (102.5°F); blood pressure is 100/75 mm Hg; pulse is 122/min; respiratory rate is 20/min, and oxygen saturation is 88% on room air.

He says that symptoms had an acute onset while he was in the ICU for a COPD exacerbation due to a recent upper respiratory infection, which was treated with nebulized albuterol and ipratropium bromide, continuous oxygen, IV methylprednisolone, and levofloxacin.

A foul-smelling discharge is also noted.

Pain seems out of proportion to the exam findings.

The physical examination is significant for the cutaneous finding shown in the picture.

The involved area is severely tender to palpation and there are warmth and crepitus.


She says that the symptoms started after she went on a hike in the woods and foraged from plants along the way.

On presentation, she is found to be somnolent though she is able to be woken by vocal stimuli.

She says that over the last 12 hours, she has been experiencing muscle spasms, blurred vision, dry mouth, and hallucinations.

Her bladder is also found to be completely full though she says she is unable to urinate.

Physical exam reveals dry red skin and enlarged pupils.


However, she has noticed a small whistling noise when she respires through her nose, which you appreciate on physical exam.


She does not smoke or drink alcohol and takes no medications.

A friend of hers who also visited the spa has developed a similar rash.

Her vital signs are within normal limits.

Examination shows multiple erythematous, excoriated papules and pustules over the trunk and upper thighs.

Three days ago, she visited a spa resort with multiple swimming pools and whirlpools.


Examination shows the right upper extremity is externally rotated and slightly abducted.

There is loss of the the normal rounded appearance of the shoulder.

The right humeral head is palpated below the coracoid process.


She is currently complaining of severe abdominal pain but refuses to give any other history.

She has a blood pressure of 135/86, respiratory rate of 18/min, and heart rate of 86/min.

On examination, her abdomen is exquisitely tender with evidence of crepitus in the epigastric region.

Abdominal CT reveals a gastric perforation.

Her mother states that she found a large empty pill bottle next to her.


Upon review, this patient reveals that he has not had care from a physician since he graduated from college.

In the interim he has been largely unemployed and admits that he has recently been homeless.

When asked directly, the patient admits to alcohol and marijuana use but denies illicit drug use.

He appears anxious and agitated and a careful exam reveals dilated pupils and a perforated nasal septum.

His blood pressure is 157/90 mmHg and his his pulse is 116/min.

An EKG reveals ST segment elevation so he is urgently taken for cardiac intervention.


She exercises regularly and eats a well-balanced diet.

She admits that she has been under a lot of stress lately.

She wakes up frequently during the night and gets up earlier than desired.

She experiences discomfort in her legs when lying down at night and feels the urge to move her legs.

The discomfort resolves when she gets up and walks around or moves her legs.

She has tried an over-the-counter sleep aid that contains diphenhydramine, which worsened her symptoms.

Physical examination shows no abnormalities.

A complete blood count and iron studies are within the reference range.


She has hypertension and hyperlipidemia, for which she takes enalapril, furosemide, and simvastatin.

She reports that the pain radiates to her back and is associated with nausea.

Her temperature is 37.5°C (99.5°F), blood pressure is 84/58 mm Hg, and pulse is 115/min.

Examination shows abdominal distention with epigastric tenderness and guarding.

Laboratory studies show:
Hematocrit 48%
Leukocyte count 13,800/mm3
Platelet count 175,000/mm3
Serum
Calcium 8.0 mg/dL
Urea nitrogen 32 mg/dL
Amylase 250 U/L
An ECG shows sinus tachycardia.


Specifically, they have noticed that he has been exhibiting aggressive behavior as well as hyperactivity.

In addition, he has had intellectual disability and is slow to hit developmental milestones.

Physical exam reveals coarse facies, short stature, and joint stiffness.

Eye exam reveals no abnormalities of the cornea or lens.

Based on these findings, the patient is referred to a geneticist for further evaluation.


He is relatively high functioning and currently has no additional significant medical conditions.

He denies any current tobacco use, alcohol use, or illicit drug use.

He feels well and a physical examination shows that he is within normal limits.

His vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 87/min; and respiratory rate, 17/min.


She has no relevant past medical history.

Her vital signs are within normal limits.

On physical exam of the thyroid gland, a solitary nodule is palpated.

It is fixed to the surrounding tissues and nontender.

TSH is normal, and antithyroid antibodies are negative.


His mother complains that he has been sleeping poorly, and she has noticed that he often scratches his perianal area.

A scotch tape test is found to be positive and mebendazole is prescribed.


He has hypertension and takes hydrochlorothiazide.

On questioning, he has had some difficulty speaking for 3 months.

During a conversation, he often has difficulty repeating what his interlocutor has said.

When asked to say the word “kindergarten,” he replies with, “Sintelmarvin… no, that's wrong…kinterflargin, no that isn't it either...kantolargen...no?

His vital signs are within normal limits.

The patient speaks fluently in full sentences and demonstrates normal comprehension.


A representative sample of 100 men shows a normal distribution of hemoglobin concentration with a mean concentration of 17 g/dL and a standard error of 0.1 g/dL.


She uses eyedrops for persistent dryness of the eyes.

She also reports generalized itchiness that started approximately 2 months ago.

Two weeks ago, she noticed yellowing of her eyes.

Physical examination shows jaundice of the conjunctivae and skin.

The mucous membranes of the mouth are dry.

The liver edge is palpable 3 cm below the right costal margin.

There are generalized skin excoriations.

Laboratory studies show:
Hemoglobin 15 g/dL
Leukocyte count 7,700/mm3
Platelet count 332,000/mm3
Serum
Glucose 122 mg/dL
Total bilirubin 3.1 mg/dL
Direct 2.5 mg/dL
Alkaline phosphatase 452 U/L
AST 155 U/L
ALT 168 U/L
Hepatitis B surface antigen negative
Hepatitis B core IgM antibody negative
Hepatitis B surface antibody positive
Hepatitis C antibody negative
Ultrasonography of the abdomen shows mildly increased echogenicity of the liver.


Currently, she is at her 29th week of gestation and has received the tetanus vaccination as part of the antenatal care program she received since she immigrated at the end of her first trimester from Romania.

She has a runny nose, mild headache, and feels achy.

She has a mild fever and diffuse rash over her body.

She is concerned about the health of her baby and wants to know if there are any medications that will make her feel better in a short time.


Some of the animals exposed to these bacteria develop symptoms of infection.

Animals exposed to the noninfectious isolate do not develop symptoms of infection.

The investigator cultivates the noninfectious isolate in a culture with lysed bacteria from the infectious isolate.


Her current medications include hydrochlorothiazide, levothyroxine, albuterol, oral contraceptives, and a multivitamin.

She has tried several different statins, all of which have resulted in bothersome side effects.

Her physical examination is unremarkable.

Her blood pressure is 116/82 mm Hg and her heart rate is 82/min.

You decide to initiate colesevelam (Welchol).


This novel drug has the property where its clearance is relatively predictable based on patient demographics and can easily be extrapolated from other data.

Its metabolism and volume of distribution also do not change dramatically from patient to patient.

The investigator wants to make sure that the plasma concentration of the drug in this patient is 15 mg/L and he knows the following drug characteristics.


His parents are recent immigrants to the United States.

He was born in a traditional home birth and has never seen a medical provider.

Mom had no prenatal care, has no medical issues, and is unvaccinated.

The baby had been breastfeeding well until 24 hours ago when mom noticed he started having trouble latching.

In the last 12 hours, he has completely refused to feed.

He has had a decreased number of wet diapers and has stooled twice in the last 24 hours.

His temperature is 98.6°F (37.0°C), pulse is 180/min, respirations are 52/min, and blood pressure is 70/50 mmHg.

On exam, the infant has increased tone, a clenched jaw, no head lag, and clenched hands.


She denies any history of smoking, alcohol use, or recreational drug use.

The patient was on a trip to Thailand 2 years ago with her family but denies any recent travel.

Her blood pressure is 120/88 mm Hg, pulse is 78/min, temperature is 37.2°C (99.0°F), and respiratory rate is 16/min.

Laboratory findings are unremarkable, except for a potassium level of 3.3 mmol/L and serum calcium of 11 mg/dL.

The attending physician suspects that this might be a case of a genetic mutation in the menin 1 gene on chromosome 11 and orders a genetic analysis.


The patient was helping his son move this past weekend, and he noticed after the move that he had pain and weakness in his right shoulder.

The patient has a past medical history of diabetes, obesity, and asthma.

His current medications include albuterol, lisinopril, metformin, and glipizide.

The patient thought that this pain was just him being in poor shape so he started going to the gym and lifting weights which made his symptoms significantly worse.

On physical exam you note an obese gentleman who seems to be in pain.

You note prominent weakness of external rotation of his right upper extremity.

When you ask the patient to slowly lower his right arm to his side when he holds it overhead, you note that he suddenly drops his arm and appears to be in pain.

The patient's strength is 1/5 for abduction of the right arm.


Upon examination, the patient exhibits painless subcutaneous nodules on the back of the wrist, the outside elbow, and the front of the knees, as well as inflammation in the joints of the lower extremities.


The patient was diagnosed with schizophrenia 4 years ago and has since tried several antipsychotic medications, none of which have been able to treat his negative symptoms.

He has changed to clozapine 2 weeks ago and says that he does feel better.

His physical exam is unremarkable, and he is responding appropriately to questioning.


Auscultation of the lungs shows coarse crackles at the right upper posterior field.

An x-ray of the chest shows an opacity in the right upper lobe.

Sputum analysis shows acid-fast bacilli.

Examination of the injected area 48 hours later shows no induration or erythema.

A small amount of tuberculin fluid is injected into the subcutaneous tissue on the left forearm.


He does not have any significant past medical history.

The patient’s mother says that he has had a “running nose” for the past few days However, he did not receive any treatment for it, and his condition rapidly worsened today.

There is a petechial rash present on his chest, and he has some neck rigidity.

His temperature is 38.2°C (100.7°F), blood pressure is 90/50 mm Hg, heart rate is 120/min, and respiratory rate is 22/min.

On physical examination, the patient is unresponsive.

Empiric intravenous antibiotics are started, and a lumbar puncture is performed.


Following the operation, the man is started on a patient controlled analgesia (PCA) thought to be dosed adequately to control his pain in the face of his opioid tolerance.

He reports intense pain 6 hours after the conclusion of the surgery.


Within the first 24 hours after birth, the newborn develops fever and a yellow discoloration of skin and sclerae.

Examination shows loss of flexion in the extremities, splenomegaly, and cyanosis.

Laboratory studies show decreased haptoglobin levels and increased LDH levels.

A photomicrograph of a peripheral blood smear is shown.


She is currently on methimazole, which she last took approximately 1 week ago.

She is accompanied by her sister who says that her symptoms developed acutely and is unsure about what caused it.

Approximately 5 days ago she developed an upper respiratory infection managed with bed rest and ibuprofen.

Her temperature is 105°F (40.6°C), blood pressure is 95/68 mmHg, pulse is 145/min, and respirations are 23/min.

On physical examination, the patient has altered mentation and is agitated and diaphoretic.

The patient also has a goiter, exophthalmos, warm skin, and a hand tremor.


His parents said that he has had a fever and cough for several days prior to presentation and was given an over the counter medication.

On presentation, he is found to be confused and very lethargic.

Physical exam of this patient reveals mild hepatomegaly and dry mucous membranes.


She says she is postmenopausal, and her last menstrual period was 5 years ago.

A detailed workup is performed, and several premalignant lesions are found in her uterus.

The surgical team decides to use an anesthesia protocol consisting of nitrous oxide, desflurane, and atracurium.


Past medical history is noncontributory.

The symptoms usually resolve in 2 to 3 days.

She has had these swelling events her whole life; however, they have become more debilitating recently.

Last week she had an event that restricted her ability to eat and swallow.

Today, her physical exam is within normal limits.

C1-inhibitor levels are ordered and found to be extremely low.

The treating physician has a strong suspicion of an inherited disorder.

Her father is alive and well with no significant medical history.

Her mother and her maternal aunt have a similar condition.

She brought a picture of her swollen hand as seen in the picture.


Her earlier pregnancy was uncomplicated.

She had an ultrasound scan 2 weeks ago that showed a live intrauterine pregnancy consistent with a 22-week gestation with no anomalies.

Pelvic examination shows a uterus consistent in size with a 24-week gestation.


He is currently visiting the United States as a tourist from Turkey, where he works at a factory that processes sheep wool and hide.

An x-ray of the chest shows widening of the mediastinum.

A sputum culture grows gram-positive rods in gray colonies that have irregular margins with wavy projections on microscopy.


The pregnancy was complicated by gestational diabetes and fetal weight is estimated to be at the 90th percentile for gestational age.

Postpartum examination shows a third-degree laceration in the vagina extending into the perineum at the 6 o'clock position.

During delivery, there is an arrest in the second stage of labor, and a vacuum-assisted delivery is performed.


His medications include pravastatin, lisinopril, and hydrochlorothiazide.

He reports a slow and steady weight gain of 6 pounds over the past 6 months, despite attempts to control his diet and increase his level of exercise.

He is obese (BMI 32), and his waist circumference is 43 inches.

His physician is concerned about an abnormal fasting blood glucose and dyslipidemia.

On further work-up with oral glucose tolerance test, the patient is diagnosed with diabetes.


It has rapidly increased in size during this period.

Examination shows large dense breasts; a 5-cm, nontender, multinodular mass is palpated in the right outer quadrant of the right breast.

There are no changes in the skin or nipple.

There is no palpable cervical or axillary adenopathy.

Mammography shows a smooth polylobulated mass.

Biopsy of the mass shows papillary projections of epithelial-lined stroma with hyperplasia and atypia.


He has no history of serious illness and takes no medication.

His mother said that when he tried to get out of bed that he was unable to stand without support.

He also complained of prickling in his hands and feet.

Three weeks ago, he had a fever, dry cough, and a sore throat.

The fever and sore throat subsided a week after they began, but the cough is persisting.

His vital signs are within normal limits.

There is severe weakness in both lower extremities and mild sensory loss of the hands and feet.

Knee and ankle jerk reflexes are absent.

The remainder of the examination shows no abnormalities.

Laboratory studies show:
Hemoglobin 12.0 g/dL
Leukocyte count 6000/mm3
Segmented neutrophils 64%
Eosinophils 2%
Lymphocytes 26%
Monocytes 7%
Platelet count 160,000/mm3
Erythrocyte sedimentation rate 27 mm/h
Serum
Na+ 138 mEq/L
Cl- 101 mEq/L
K+ 4.9 mEq/L
HCO3- 26 mEq/L
Ca2+ 9.7 mg/dL
Creatine kinase 93 U/L
A lumbar puncture is performed; cerebrospinal fluid analysis shows a leukocyte count of 2/mm3, a glucose concentration of 60 mg/dL, and a protein concentration of 91 mg/dL.


He has recently been fired from his job because he is always late and lost his fiancee as she could not deal with his habits anymore.

He explains that he has this fear that something terrible will happen to his house if he does not check every appliance, outlet, window and door lock, faucet, and light fixture before he leaves.

He states that he must check everything 7 times in a specific order and if he goes out of order he must start from the beginning and perform it all over.

The physician explained that cognitive-behavioral therapy may be of assistance and also prescribed clomipramine.


During the physical exam, the physician finds that the patient is hypertensive.

The physician suspects a pituitary adenoma.


He denies smoking, drinking alcohol, and using illicit drugs.

He complains of anxiety, nausea, abdominal cramping, vomiting, and diarrhea for three days.

His temperature is 37°C (98.6°F), pulse is 110/min, and blood pressure is 150/86 mm Hg.

Physical examination shows dilated pupils, diaphoresis, and piloerection.

His abdominal exam shows diffuse mild tenderness.

There is no rebound tenderness or guarding.

His hemoglobin concentration is 14.5 g/dL, leukocyte count is 8,000/mm, and platelet count is 250,000/mm3; serum studies and urinalysis show no abnormalities.


He has smoked one pack of cigarettes daily for 35 years.

He has noticed that it is easier for him to climb the stairs after he has exercised.

He has also had a 4.6-kg (10.1-lb) weight loss over the past 6 months.

The pupils are equal and react sluggishly to light.

Muscle strength in the proximal lower extremity is initially 3/5 but increases to 5/5 after repeated muscle tapping.


CT demonstrates a mass in the head of the pancreas, and biopsy is planned for the following day.

Endoscopic ultrasound-guided biopsy the next morning confirms the diagnosis of pancreatic adenocarcinoma.

The patient's daughter approaches you outside the room to request that the results of the biopsy not be shared with the patient.

She asks that the results instead be shared with her and her brother, who is the patient's documented health care proxy.

She explains that she and her brother have discussed the situation and decided that it is best to not inform the patient that she has cancer.


He has been seen in the emergency room 5 times in the past 2 years for acute alcohol intoxication.

His past medical history is notable for diabetes mellitus and gout.

He takes metformin, glyburide, and allopurinol.

The dorsal surface of the tongue is depapillated, and there are erythematous swollen patches at the oral commissures.

His temperature is 98.6°F (37°C), blood pressure is 130/85 mmHg, pulse is 86/min, and respirations are 16/min.


The ECG monitor shows a tachycardic irregular rhythm with erratic undulations, but no discernible P waves or QRS complexes.

After another attempt at defibrillation, the patient remains pulseless and his blood pressure is 60/35 mm Hg.

During immediate advanced cardiac life support, two attempts at defibrillation are made, after which the patient is given 1 mg of IV epinephrine.


He has a past medical history of type-2 diabetes mellitus, hypertension, hypercholesterolemia, and ischemic heart disease.

In addition, he had an ischemic stroke 9 years ago, from which he recovered completely with physiotherapy and rehabilitation.

He has a history of a 56-pack-year cigarette smoking habit.

His medications include aspirin, atorvastatin, glimepiride, metformin, metoprolol, and ramipril.

The diplopia is more prominent on his left-side lateral gaze.

He denies having fever, headache, ocular pain, lacrimation, changes in color vision, or limb weakness.

The mental status examination is unremarkable.

His muscle strength is normal in all 4 limbs.

His sensations are decreased on his left side, including his face.

The examination of extraocular movements is shown in the image.


The mother did not receive any prenatal care.

Physical examination shows sunken fontanelles, tightly clenched fists, and erythema around the umbilical cord stump.


She recently retired after working for 28 years as a typist at a data entry firm.

The stiffness is worse at the end of the day.

Physical examination shows swelling, joint-line tenderness, and decreased range of motion of the first metacarpophalangeal joint and the distal interphalangeal joints of the right hand.

Discrete, hard, mildly tender nodules are palpated over the 2nd and 4th distal interphalangeal joints of the right hand.

An x-ray of her right hand shows narrowing of the interphalangeal joint spaces with subchondral sclerosis and osteophytes.


He also complains that the nurse practitioner at the facility started him on 4 new medications, in addition to his existing prescriptions.

On physical examination, tense axillary bullae are noted that do not rupture with light, gloved touch.

On direct immunofluorescence, linear C3 and IgG deposits are seen along the basement membrane.


He recently started basic infantry training and has been running several kilometers daily.

Initially, the pain only occurred while running, but now it is also present at rest.

The pain is located diffusely over the right forefoot.

Examination shows mild swelling over the distal right forefoot.

Pressing the metatarsal of the third right toe results in pain.

The remainder of the examination shows no abnormalities.

An x-ray of the right foot shows a slight loss of cortical density and callus formation at the third metatarsal shaft.


She was born at 38 weeks' gestation and required bag-mask resuscitation immediately after delivery.

Her mother has noticed the bluish lip discoloration worsen when she fed and improve when she cried.

The patient's pulse is 163/min, respirations are 62/min, and blood pressure is 60/30 mm Hg.

The crying infant's lungs are clear to auscultation.


The symptoms began 5 minutes after she ate a peanut butter sandwich.

There is stridor on auscultation of the chest.

Her respirations are 36/min and blood pressure is 84/50 mm Hg.

She is intubated and mechanical ventilation is begun.

Intravenous fluid resuscitation and the appropriate pharmacotherapy are begun.


He was born to a 33-year-old woman at 31 weeks gestation via cesarean section.

Vital signs are significant for systemic hypotension, bradycardia, and hypoventilation.

On physical exam, the patient has an altered level of consciousness with decreased spontaneous and elicited movements.

The patient is hypotonic on motor testing, has bulging anterior fontanelle, and appears cyanotic.


He says that he has felt increasing shortness of breath while exercising over the past 6 months.

He is a well-built man in mild distress.

The vital signs include heart rate 98/min, respiratory rate 18/min, temperature 36.5°C (97.7°F), and blood pressure 135/90 mm Hg.

The cardiac examination is significant for a harsh systolic ejection murmur at the left lower sternal border which is accentuated by forceful expiration against a closed airway.

Palpation of the carotid artery shows 2 closely spaced pulses which occur during systole.


Her only complaints are fatigability and a depressed mood for the past 2 weeks.

Her vital signs are as follows: blood pressure, 125/80 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉).

The physical examination is unremarkable and the gynecologic examination is consistent with 18 weeks gestation.


The patient states that he has been having trouble chewing his food, but is not experiencing any pain.

On examination, the patient has an obvious distortion of the facial features on the right without erythema or lymphadenopathy.

A neurological exam reveals no deficits.

His blood pressure is 115/80 mm Hg, heart rate is 65/min, and the temperature is 37.2°C (98.9°F).

The patient is up to date on all of his immunizations.


She is worried he may be going through some sort of “problem.” He is currently in 9th grade; his mother says that he is the captain of his high school wrestling team and does reasonably well in school.

His mother reports multiple instances over the past month when she walked into his room while he was masturbating.

On examination, he seems embarrassed and avoids making eye contact.

Physical examination shows no abnormalities.


He has had hypertension for the last 20 years and is on antihypertensive medications.

He also mentions that he occasionally has bouts of cough at night after about 2–3 hours of sleep which is relieved when he sits upright.

He denies shortness of breath at rest, palpitations, and loss of consciousness.

On physical examination, his temperature is 36.9°C (98.4°F), pulse is 104/min, blood pressure is 122/82 mm Hg, and respirations are 18/min.

Chest auscultation reveals crackles over the lung bases bilaterally.

Examination of his abdomen reveals mildly tender hepatomegaly.

Laboratory investigation results include a hemoglobin of 14.8 g/dL (9.18 mmol/L) and an elevated serum B-type natriuretic peptide.

His two-dimensional echocardiogram reveals an enlarged left atrium and an ejection fraction of 55%.


The patient states that he recently retired from working the day shift at a cemetery.

The patient has a past medical history of irritable bowel syndrome which is managed with fiber supplements.

When the patient retired, his goal was to finally be able to go out with his wife; however, he finds that he is unable to stay awake past 6 pm in the evening.

His inability to stay awake has been straining his marriage as his wife is disappointed that they cannot do any activities in the evening together.

The patient has tried drinking caffeine but finds that it does not help.

The patient’s neurological exam is within normal limits.

The patient’s wife claims that the patient seems to sleep peacefully, and the patient states he feels rested when he awakes.


Six months ago, she was vaccinated against influenza.

Her father died of a myocardial infarction at the age of 50 years.

She has smoked one-half pack of cigarettes daily for the last 18 years.

She goes ballroom dancing twice each week.

Her medications include enalapril and low-dose aspirin.

Her last mammography 1 year ago showed no abnormalities.

Two years ago, a pap smear and colonoscopy were normal.

She is 165 cm (5 ft 5 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2.

Cardiopulmonary examination shows a soft S4 gallop.

The remainder of the examination shows no abnormalities.


Lab studies show:

Serum Na+: 140 mmol/L
Serum K+: 3.5 mmol/L
Serum albumin: 1.9 g/dL
Total serum bilirubin: 1.0 mg/dL
Serum creatinine: 1.2 mg/dL

Urinalysis shows 4+ proteinuria and fatty casts.


He has had a weight loss of 41 kgs (90 lbs) in the past year.

Physical examination shows a soft bulge inferior and lateral to the navel on the left.

A CT scan of the abdomen of a patient with the same condition is shown.


Her mother reports that the patient recently received a pair of fashionable silver earrings from her older sister as a birthday present.

Physical examination is only significant for erythema and tenderness over the lobules of the ears bilaterally.

Her vital signs show a blood pressure of 121/73 mm Hg, heart rate of 72/min, and a respiratory rate of 21/min.


He has bowel movements 10–12 times daily; the stool contains blood and mucus.

His vital signs are within normal limits.

Examination of the abdomen shows diffuse tenderness to palpation.

Serum concentration of C-reactive protein is 20 mg/L (N<10).

Colonoscopy shows a bleeding, ulcerated rectal mucosa with several pseudopolyps.


The last menstrual period was 4 months ago.

She also reports having a mild headache for 1 month.

There has been a grape-like mass protruding from her vagina for the last 15 days.

On examination, the fundus of the uterus is at the level of the umbilicus and no fetal heart sounds are heard.

The vital signs are as follows: blood pressure 160/100 mm Hg, pulse rate 108/min.

On USG examination, no fetal parts are seen.


She recently moved from New Jersey, and her medical records show a total colectomy.


He was born at home and had unreliable prenatal care because his parents have been experiencing housing instability.

About a day after birth, he started to become lethargic and was feeding poorly.

His parents thought that he might just be tired so they put him to bed; however, by the next morning he started to vomit and act extremely irritable.

On presentation, he is found to have nuchal rigidity and bulging fontanelles.

Based on this presentation, appropriate cultures are obtained and he is placed on empiric antibiotics.


When asked about his diet, he says, “Being overweight runs in my family.

He is 180 cm (5 ft 11 in) tall and weighs 103 kg (227 lb); BMI is 32 kg/m2.


He is a foreign exchange student and is concerned he will fail out of his academic program.

The patient is a first year college student, drinks alcohol regularly, smokes marijuana, and has unprotected sex with multiple partners.

The patient states that for the past several weeks he has felt oddly fatigued and has struggled to complete his work.

He has experienced some occasional nausea and vomiting which has caused him to lose weight.

His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Total bilirubin: 2.0 mg/dL
AST: 85 U/L
ALT: 92 U/L

Urine
Color: Amber/brown
Marijuana: Positive
Amphetamines: Positive
Cocaine: Positive

The patient refuses an examination of his genitals.

Laboratory values are ordered as seen below.


Examination of the lower extremities shows bilateral pitting pedal and ankle edema.

Cardiac examination shows a widely split S2 that varies with respiration.


Past medical history is significant for gastroesophageal reflux disease, and recent appendicitis, status post laparoscopic appendectomy complicated by delirium tremens.

He denies fever, weight loss, pain, pruritus or urinary symptoms.

His vitals are a temperature of 37.0°C (98.6°F), blood pressure of 130/80 mm Hg, pulse of 78/min, and respiratory rate of 12/min.

Physical examination reveals a distended abdomen with shifting dullness on percussion.

In addition, multiple purple spider web-like lesions are present on the chest and arms, which blanch when pressure is applied.

On anoscopy, a non-tender, dilated vascular protrusion is noted superior to the pectinate line.


For the past 2 years, she has been urinating a considerable volume every time she goes to the bathroom.

Her heart rate is 86/min, respiratory rate is 15/min, temperature is 37.4°C (99.3°F), and blood pressure is 111/79 mm Hg.

Laboratory studies are significant for the following:
Calcium 13.8 mg/dL
PTH 230 pg/mL
Her complete metabolic panel is otherwise within normal limits.

Imaging studies show subperiosteal resorption and osteoporosis.

Scintigraphy reveals the most common pathologic condition associated with the patient’s diagnosis.


Her past medical history is notable for obesity, type I diabetes mellitus, and rheumatoid arthritis.

She is on insulin and takes methotrexate.

She reports that for the past 3 years, she has experienced several periods of depressed mood.

The episodes do not coincide with any specific life events and seem to resolve after 4-6 weeks.

During these episodes, she experiences a depressed mood, sleep disturbances, and a poor appetite, but she at times is able to enjoy spending time with her children and husband but other times she is distressed and cannot enjoy time with them.

Upon further questioning, she also reports experiencing occasional episodes of elevated mood over the past ten years.

During these episodes, she is very productive at her work as a lawyer and requires less sleep than usual.

Her temperature is 99.2°F (37.3°C), blood pressure is 124/80 mmHg, pulse is 78/min, and respirations are 17/min.

On exam, she is quiet with a flattened affect, but is cooperative and answers questions thoroughly.


She has a history of hypertension well controlled with diet and exercise.

She has no history of smoking or illicit drug use.

Her pulse is 68/min, respirations are 16/min, and blood pressure is 119/76 mm Hg.

Physical examination shows no abnormalities.


Paramedics arrive quickly, and he is taken to the hospital where several stable lumbar fractures and a shattered right calcaneus are found.

He undergoes surgery and his calcaneus is repaired with 11 screws.


He has allergic asthma treated with inhaled salbutamol.

He immigrated to the USA from Thailand 9 years ago.

He lives by himself and works as a waiter in a restaurant.

He has had 6 lifetime male sexual partners and uses condoms inconsistently.

On mental status examination, the patient is somnolent and has short-term memory deficits.

His temperature is 38.2°C (100.8°F), pulse is 88/min, and blood pressure is 128/76 mm Hg.

Examination of the mouth shows several white patches on the tongue and oral mucosa that can be easily scraped off with a tongue blade.

The remainder of the examination shows no abnormalities.

Laboratory studies show:
Hemoglobin 13.6 g/dL
Leukocyte count 9,600/mm3
Segmented neutrophils 80%
Eosinophils 1%
Lymphocytes 17%
Monocytes 2%
CD4+ T-lymphocytes 80/mm3 (Normal ≥ 500)
Platelet count 328,000/mm3
Serum
pH 7.36
Na+ 135 mEq/L
Cl- 101 mEq/L
K+ 4.8 mEq/L
HCO3- 22 mEq/L
Glucose 95 mg/dL
Creatinine 0.9 mg/dL
BUN 16 mg/dL
Bilirubin, total 0.7 mg/dL
AST 13 U/L
ALT 15 U/L
Erythrocyte sedimentation rate 10 mm/hour
HIV test positive
A lumbar puncture is performed and an opening pressure of 150 mm H2O is noted.

Cerebrospinal fluid analysis shows a leukocyte count of 25/mm3 (60% lymphocytes), protein concentration of 52 mg/dL, and a glucose concentration of 37 mg/dL.

India ink stain shows organisms with prominent capsules.


His mother had a myocardial infarction at 54 years.

There is tenderness above the left posterior calcaneus and a firm, 3-cm, skin-colored nodule that moves with the left Achilles tendon.

A photomicrograph from a biopsy of the nodule is shown.


The patient was exclusively breastfed up to the age of 7 months.

Supplementary feeding was started with non-starchy vegetable followed by starchy vegetables, meat, fish, eggs, and bread.

Bread and cookies were the last product to be introduced at the age of 12 months.

The patient’s mother tried to withdraw dairy products from the patient’s diet because she heard that lactose can cause such symptoms, but it did not help.

His mother says that these symptoms developed approximately 2 years ago.

There are a few aphthous ulcers in the oral cavity.

The patient’s vital signs include: blood pressure 90/55 mm Hg, heart rate 101/min, respiratory rate 19/min, and temperature 36.3℃ (97.3℉).

His weight is 11 kg (24.2 lb, -2 SD) and height is 90 cm (2 ft 11 in, -1 SD).

On physical examination, the patient’s skin is pale with a papulovesicular rash on his abdomen and back.

The abdomen is distended but no tenderness to palpation.

An immunological assay is performed and shows positive anti-transglutaminase and anti-endomysial antibodies.


Her height and weight are appropriate for her age, and she is up to date on all her vaccinations and has no medical complaints.

She is doing well in school and has a part-time job stocking shelves at a clothing store.

She was offered a higher-paying job as a cashier at the store, but she declined.

She is very shy and withdrawn with the physician.

Afterwards, her mother asks to speak to the physician alone and expresses concern that her daughter is very socially isolated and feels lonely.

She is also worried that her daughter is extremely sensitive to criticism, even from family.

The daughter is interested in art and music, but hasn’t participated in any extracurriculars because she says that she is untalented and thinks nobody wants to hang out with her.


She is sexually active with 2 male partners and uses condoms inconsistently.

Pelvic examination shows multiple hyperkeratotic exophytic papules over the vulva.

The lesions turn white on application of 3% acetic acid.


Two weeks ago, while visiting Guatemala, she had an emergency appendectomy under general inhalational anesthesia.

Her temperature is 38.3°C (100.9°F) and blood pressure is 138/76 mm Hg.

Examination shows jaundice and tender hepatomegaly.

Serum studies show:
Alkaline phosphatase 102 U/L
Aspartate aminotransferase 760 U/L
Bilirubin
Total 3.8 mg/dL
Direct 3.1 mg/dL
Anti-HAV IgG positive
Anti-HAV IgM negative
Anti-HBs positive
HBsAg negative
Anti-HCV antibodies negative
Abdominal ultrasonography shows an enlarged liver.

A biopsy of the liver shows massive centrilobular necrosis.

During the surgery, she received a transfusion of 1 unit of packed red blood cells.


The patient’s past medical history is significant for a few episodes of acute pain crisis and a need for splenectomy 3 years ago.

Shortly after the transfusion has begun, the patient experiences fevers, chills, a burning sensation at the intravenous (IV) site, and sudden hypotension.

The vital signs upon arrival include: temperature 36.7°C (98.0°F), blood pressure 106/74 mm Hg, heart rate 111/min and regular, and respiratory rate 17/min.

On physical examination, her pulses are bounding and fingernails are pale, but breath sounds remain clear.

Oxygen saturation was initially 91% on room air and electrocardiogram (ECG) shows sinus tachycardia.

Her mother denies any previous history of blood clots in her past, but she says that her mother has also had to be treated for pulmonary embolism in the recent past.


Her medications include propranolol and sumatriptan.

The pain varies in location and intensity.

She also has joint stiffness in the morning and reports fatigue throughout the day that she attributes to not sleeping well.

She reports a tingling sensation in her lower limbs.

Her bowel habits are unchanged but she often feels bloated.

Examination shows symmetric muscular tenderness at the base of the neck, over the shoulders, and in the lumbosacral area.

Strength and deep tendon reflexes are normal.

Laboratory studies show:
Hemoglobin 14.3 g/dL
Leukocyte count 9300/mm3
Platelet count 230,000/mm3
Mean corpuscular volume 85 μm3
Erythrocyte sedimentation rate 12 mm/h
Serum
Glucose 92 mg/dL
Creatinine 0.6 mg/dL
TSH 3.1 μU/mL
Urinalysis is within normal limits.


He reports a 20-pack-year smoking history.

Upon asking about other symptoms, he mentions that he had a cough for the last 4 months which he attributes to his smoking.

He says he had frequent nasal stuffiness and headaches over the last 3 months, for which he takes over-the-counter cold medications and analgesics.

Over the last 2 months, he often felt that his face was mildly swollen, especially in the morning hours, but he did not consider it to be anything serious.

His temperature is 36.8°C (98.4°F), pulse is 96/min, blood pressure is 108/78 mm Hg, and the respiratory rate is 24/min.

On physical examination, auscultation of the chest reveals rhonchi and crepitus over the right lung.

A chest radiograph reveals a mass in the middle lobe of the right lung.

The remainder of the exam is unremarkable.


He denies any inciting trauma or similar prior episodes.

On examination, the right first toe is grossly erythematous and edematous, with range of motion limited due to pain.


She describes the pain as affecting the inside part of the knee as well as the front of her knee, below the kneecap.

She denies any inciting injury or trauma to the knee but reports that the pain is worse when she is climbing up stairs or rising from a chair.

Physical examination is significant for localized tenderness to palpation over the left anteromedial proximal tibia, 6 cm inferior to the joint line.

Valgus stress testing is negative for any pain or instability of the knee joint.

Radiographs of the left knee are obtained and reveal only mild arthritis, without evidence of any fractures or bony lesions.


She and her boyfriend had intercourse for the first time a few weeks ago.

She is tearful about the pregnancy and is very concerned.

She took several over the counter pregnancy tests that confirmed her pregnancy.

After extensive conversations with her physician and counseling, she decides she wants to medically abort her 6-week pregnancy.

Two weeks ago she missed her menstrual period.


She has myopia and has been wearing corrective lenses for 10 years.

Her vital signs are within normal limits.

Her symptoms occur only when looking sideways.

Ten days ago, she lost her balance and fell off her bike, for which she went to a hospital.

A CT scan of the head at that time showed no abnormalities and she was released without further treatment.

The pupils are equal and reactive to light.

Her best corrected visual acuity is 20/40 in each eye.

She has an adduction deficit in the right eye and nystagmus in the left eye when looking left; she has an adduction deficit in the left eye and nystagmus in the right eye when looking right.

Fundoscopy reveals bilateral disc hyperemia.

Her only medication is an oral contraceptive.


The patient has had a history of diabetes mellitus for the past 2 years which is well controlled.

His current medications are insulin and aspirin.

Family history is significant for coronary artery disease.

He has an 80 pack-year history of smoking and currently smokes.

He consumes 4 drinks per day of alcohol.

On physical examination, his blood pressure is 144/89 mm Hg, the heart rate is 80/min and regular, the breathing rate is 25/min, and the pulse oximetry is 96%.

Normal cardiac and lung sounds were heard on auscultation.

A percutaneous coronary intervention was performed in 2014.


Physical examination shows pallor, tenderness to palpation over the temples, and inward deviation of the left eye.

Laboratory studies show an erythrocyte sedimentation rate of 65 mm/h.

Temporal artery biopsy shows transmural granulomatous inflammation and fragmentation of the internal elastic lamina.

Treatment with high-dose intravenous corticosteroids is begun.


She has been sexually active with multiple male partners over the past year and uses condoms inconsistently; she has been taking an oral contraceptive for the past 2 years.

She has no previous history of serious illness or sexually transmitted diseases.

Her temperature is 37°C (98.6°F), pulse is 75/min, respirations are 12/min, and blood pressure is 122/82 mm Hg.

Pelvic examination shows erythema of the vulva and vagina and foul-smelling, frothy, yellow-green vaginal discharge.

Three weeks ago, she had an episode of acute bacterial rhinosinusitis that was treated with a 10-day course of amoxicillin.


The patient had normal development throughout childhood, is on the soccer team at school, and is not sexually active.

Her father has hypertension and her mother has endometriosis and heavy periods.

The patient underwent menarche at age 11, and her periods were irregular every 2-3 months for two years.

After that, her cycles became roughly regular every 28-35 days, but she has had extremely painful cramps and often has to miss school.

The cramps are intermittent and feel like a dull ache in the center of her abdomen, and there is usually accompanying back pain.

She reports some periods being “really heavy” and requires a superabsorbent pad every 6 hours for 2 days each cycle, but this does not limit her activities.

On exam, the patient is 5 feet 5 inches and weighs 158 pounds (BMI 26.3 kg/m^2).

She is well appearing and has no abdominal tenderness.

She has Tanner IV breasts and Tanner IV pubic hair, and external genitalia are normal.

The patient has been using heating pads with limited relief.

She denies any bowel or bladder changes.


On arrival, she has a cervical collar in place and is unresponsive.

Her pupils are dilated and not reactive to light.

Her temperature is 36.7°C (98°F), pulse is 70/min, and blood pressure is 131/76 mm Hg.

Serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

A CT scan of the head without contrast shows a massive intracranial bleed and a cervical spine injury at the level of C3.

She is intubated, and mechanical ventilation is begun.


Physical examination shows nuchal rigidity and photophobia.

Blood cultures are obtained and a lumbar puncture is performed.

A Gram stain of cerebrospinal fluid shows gram-negative cocci in pairs.


He had 2 myocardial infarctions at the age of 66 and 69 years and suffers from chronic heart failure.

At the time of presentation, his vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 108/min, respiratory rate 29/min, and temperature 35.5°C (95.9°F).

On physical examination, the patient sits upright.

Lung auscultation reveals widespread bilateral fine rales.

Cardiac examination is significant for S3, accentuation of the pulmonic component of S2, and a systolic murmur heard best at the apex of the heart.


Methods:
In this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA.

Patients who were immunocompromised or had a history of recurrent infections were excluded.

After collecting data on changes in plaque volume, LDL-C levels, FEV1/FVC ratio, and ACQ scores from baseline to 12-month follow-up, he is curious if the changes in the aforementioned measurements are statistically significant.

Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms.

Plaque volume was determined by ultrasound.

Analyses were performed from baseline to month 12.

Results:
At baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all).

Patients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants.

Which of the following is the most appropriate statistical method to compare the groups?"

"Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma
Introduction:
Active asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors.

It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease.

This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression.

All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence.

A total of 215 participants (18%) were lost to follow-up.

At 12-month follow-up, the groups contained the following numbers of participants:
Pulmharkimab 75 mg/d: 388 participants
Pulmharkimab 150 mg/d: 202 participants
Placebo: 395 participants
Table 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes.

Models were adjusted for sociodemographic variables and medical comorbidities.

All outcome variables were approximately normally distributed.


She drinks one to two glasses of wine on the weekends.

The palpitations are accompanied by chest pain that is sharp and localized to the left 3rd intercostal space.

Her pulse is 110/min and irregularly irregular, and blood pressure is 135/85 mmHg.

Examination shows a fine tremor on both hands and digital swelling.

There is retraction of the left upper eyelid.

A systolic ejection murmur is heard along the right upper sternal border.

The extremities are warm, and pulses are 2+ bilaterally.


The patient lives with his daughter and was chatting with her when suddenly his speech became distorted with random and disconnected words that made no sense.

He seems to be physically frustrated that no one understands him.

Physical examination demonstrates weakness of the right arm.


Currently, she takes aspirin (81 mg once daily), rosuvastatin (10 mg once daily), lisinopril (20 mg once daily), and isosorbide mononitrate (60 mg once daily).

She has been menopausal for the last 15 years.

The vital signs are as follows: blood pressure 135/80 mm Hg, heart rate 76/min, respiratory rate 14/min, and temperature 36.5℃ (97.7℉).

The pain is bilateral, “band-like,” and extends to the neck.

The patient rates the 4 points out of 10 on a visual scale.

The headache is not accompanied by nausea, vomiting, photophobia, or phonophobia, and is not aggravated by movements, but gets worse when the patient coughs or laughs.

The headache has persisted throughout the day and is usually worse in the morning an hour after she has breakfast and taken her medications.

The physical examination reveals S2 accentuation that is best heard in the second intercostal space at the right sternal border.

Palpation of the paranasal sinuses is painless.

The neurologic exam shows no focal symptoms, no pain on palpation of the trigeminal points, and no meningeal symptoms.

The patient was diagnosed with stage 1 arterial hypertension 2 years ago and stable angina pectoris 3 weeks ago.


He states that he received all of his recommended vaccinations prior to beginning college, but has not had any vaccines in the past 13 years.

His medical history is significant for intermittent, exercise-induced asthma.

He has been sexually active in the past with multiple female partners.


She says that she punctured her foot with a rusty nail while she was playing tennis and that the puncture wound has since progressed to a non-healing ulcer.

Over the last 2 days, she has also been experiencing a fever and drainage from the wound.

On presentation, she is found to have a slightly fruity smelling red ulcer with purulent drainage.

Probing the ulcer goes all the way down to bone.


He recently returned from a trip to Belize.

Physical examination shows scleral icterus and tender hepatomegaly.

Serum studies show markedly elevated transaminases and anti-hepatitis A virus antibodies.

In this patient, infected cells express more MHC class I molecules on their surfaces.


His only medication is ibuprofen for joint pain.

He has been unable to practice with his recreational soccer team and has had to rest frequently when walking to work.

There is tenderness to palpation and stiffness of the metacarpophalangeal joints of both hands.

Pulmonary examination shows coarse crackles in both lung fields.

The liver is palpated 4 cm below the right costal margin.


Her personal history is relevant for allergic rhinitis.

Physical examination shows grouped, erythematous papulovesicular lesions on her arms, torso, and abdomen.


The patient is light-skinned and has a history of occasional sunburns when she does not apply sunscreen.

Current medications include demeclocycline for malignancy-associated hyponatremia and amoxicillin for sinusitis.

Physical examination shows prominent erythema and a papular eruption on her forehead, cheeks, neck, and the dorsum of both hands.

She wore a long-sleeved shirt and was exposed to direct sunlight for about 10 minutes.


His previous medical history is significant for a previous car crash in which the patient required internal fixation of a femur fracture and a corneal transplant for corneal degeneration.

Otherwise he had no neurologic deficits prior to 6 weeks ago.

On presentation, he is conscious but does not know where he is nor how he got there.

His wife is contacted and says that he has been getting increasingly confused over the past 6 weeks.

This progressed from misplacing objects to getting lost in places that he knew how to navigate previously.

Most worryingly, he has recently started forgetting the names of their children.

In addition to these memory changes, she says that he now has rapid jerky movements of his extremities as well as coordination and balance problems.

Finally, he has become extremely paranoid about government surveillance and has had hallucinations about secret agents in their house.

Physical exam reveals myoclonus and ataxia.


The patient's past medical history reveals recurrent upper respiratory infections but no skin or soft tissue infections.

The child had cardiac surgery as an infant but has otherwise been healthy.

He was in his usual state of health until 3 days ago when he began to complain of a sore throat as well as general malaise.

On presentation, his temperature is 100°F (37.8 °C), blood pressure is 115/72 mmHg, pulse is 65/min, and respirations are 22/min.

Physical exam shows white plaques on the tongue and mouth.

A scraping of this material reveals a characteristic morphology after being treated with KOH.

Serum protein electrophoresis shows a normal distribution of bands from this patient.


She has a 6-year-old daughter who was born at term after an uncomplicated pregnancy.

She has no history of severe illness and tries to stay healthy by going to the gym an hour per day.

Her menses occur at regular 28-day intervals and last 5 to 6 days; her last menstrual period started 2 days ago.

She says she is worried because she and her husband have been trying to conceive for more than a year with no success.

Analysis of her husband's semen has shown normal sperm counts and morphology.

Physical examination shows no abnormalities.

Conception by in vitro fertilization was attempted once 3 months ago but was unsuccessful.


The patient's past medical history is notable for anxiety, obesity, hypertension, and polycystic ovarian syndrome.

She is currently not on any medications other than an exercise program with which she is non-compliant.

They found her somnolent next to her computer and scattered pill bottles over two hours ago.

A physical exam is performed and is within normal limits.

Her temperature is 99.5°F (37.5°C), pulse is 82/min, blood pressure is 125/85 mmHg, respirations are 11/min, and oxygen saturation is 97% on room air.

The family cannot recall the types of pill bottles that they found and did not bring them to the ED.

The patient begins communicating with the physician and states that she did take acetaminophen but it was only a few pills.


The patient and his wife are asymptomatic and have no history of serious illness.

Genetic testing in the patient's family shows that his mother is not a carrier of the mutation that is responsible for the disease in his relatives.

The patient's older brother died at age 13 from heart failure and his 6-year-old nephew currently has severe muscle weakness.

A pedigree chart of the patient's family is shown.


The patient has recently gained weight and can't seem to exercise like she used to.

She also notes that her thinking seems slow.

Physical examination shows thickened, dry skin.

Serum analysis confirms the physician's suspicions.


Physical examination shows dense breasts and a 2.5-cm rubbery, mobile mass that is nontender in the upper outer quadrant of the right breast.

A biopsy of the mass shows rounded contour with overgrowth of fibrous and glandular tissue.


His wife arrives within minutes to the hospital exclaiming that under no circumstance should he receive any blood transfusions during surgery.

After reviewing his medical chart, you see also see an annotation indicating no blood transfusions for religious reasons.


The patient has developed an upper respiratory infection while at school.

His temperature is 37.8° C (100.2° F) and vital signs are within normal limits.


The breast tissue in pregnant women contained an increased number of acinar glands with epithelial proliferation compared to the non-pregnant women.


He has been healthy apart from an upper respiratory tract infection 6 months ago.

He was delivered at 38 weeks' gestation.

He is at the 40th percentile for height and 50th percentile for weight.

His mother noticed deformities in both of his legs since he started walking independently.

The mother is concerned that he has a growth disorder.

Examination shows closed anterior and posterior fontanelles.

The knees do not stay together when both the feet and ankles are placed together.

His 6-year-old sister was treated for developmental dysplasia of the hip.

He can kick a ball and say a 2-word phrase.

He plays well with other children at his day care.


She is current with her Pap smears, all of which have been normal.

She denies any recent travel or a history of trauma.

The patient has not been sexually active for the past 2 months.

She smokes 1 pack of cigarettes per day and drinks alcohol occasionally, but has never used illicit drugs.

The pelvic examination reveals a small, firm, non-tender, immobile cystic mass at the edge of the exocervical os with a yellow hue.

The remainder of the physical examination is unremarkable.

The patient appears well and has no specific complaints.

Her menstrual periods are regular and usually last 3–4 days.

The patient is otherwise asymptomatic and has no other complaints.


Pregnancy was complicated by polyhydramnios.

Apgar scores are 7 and 7 at 1 and 5 minutes, respectively.

He is at the 2nd percentile for head circumference and 15th percentile for length.

Examination shows a prominent posterior part of the head.

The ears are low-set and the jaw is small and retracted.

The fists are clenched, with overlapping second and third fingers.

The calcaneal bones are prominent and the plantar surface of the foot shows a convex deformity.

Abdominal examination shows an omphalocele.


He has had sexual intercourse with multiple men and women over the past year and does not use barrier protection.

His last screen for sexually transmitted diseases was 10 years ago and was normal.

His past medical history is notable for well-controlled asthma.

He was involved in a motorcycle accident 2 years ago and suffered multiple fractured bones in his upper and lower extremities, all of which have healed.

He has a distant history of cocaine abuse.

On examination, he appears cachectic but is pleasant and appropriately interactive.

His temperature is 100.8°F (38.2°C), blood pressure is 130/75 mmHg, pulse is 85/min, and respirations are 20/min.

An HIV differentiation assay and follow-up Western blot are performed and are positive.

The patient is started on tenofovir, abacavir, and efavirenz.

However, the patient develops a hypersensitivity reaction to abacavir, so the decision is made to replace this medication with ritonavir.


His past medical history is insignificant.

His symptoms are progressively getting worse over the past few months despite adequate rest and trial of over the counter analgesics.

His back pain is constant and non-radiating in nature.

On examination, there is mild tenderness over the lumbar region in the midline with an absence of paraspinal muscle tenderness.

Complete blood count
RBC 4.9 million cells/µL
Hemoglobin 9.8 g/dL
Hematocrit 41%
Total leukocyte count 6,800 cells/µL
Neutrophils 70%
Lymphocyte 26%
Monocytes 3%
Eosinophil 1%
Basophils 0%
Platelets 230,000 cells/µL
Basic Metabolic Panel
Sodium 136 mEq/L
Potassium 5.1 mEq/L
Chloride 101 mEq/L
Bicarbonate 24 mEq/L
Albumin 3.6 mg/ dL
Urea nitrogen 31 mg/dL
Creatinine 2.7 mg/dL
Uric Acid 6.7 mg/dL
Calcium 12.1 mg/dL
Glucose 105 mg/dL
Urinalysis shows proteinuria without any RBCs or pus cells.


She says that her mother had osteoporosis and she is concerned that she may develop it as well.

She takes calcium and vitamin D supplements daily.

The patient states that she has mild joint pain, which she attributes to osteoarthritis, but she notes no recent fractures.

After review of her DEXA scan, her physician states that she has osteopenia.


The bacteria are found to be able to grow in a specialized culture that contains sheep blood, cystine, and potassium tellurite; the colonies are black and have a shining surface.


He was delivered at term to a 32-year-old woman.

He is not able to sit upright on his own.

He is at the 75th percentile for height and 25th percentile for weight.

His temperature is 37.7°C (99.8°F), blood pressure is 110/68 mm Hg, pulse is 150/min, and respirations are 50/min.

The liver is palpated 2 cm below the right costal margin.

Neurologic examination shows profound weakness in proximal and distal muscles of the upper and lower extremities.


Two weeks after the conditioning regimen is started, he develops a temperature of 38.5°C (101.3°F).


The patient has a past medical history of depression, anxiety, and obesity.

The patient has a known history of medication non-compliance.

She seemed to be responding to internal stimuli when being initially interviewed.

On physical exam the patient is poorly kempt and has an odd body odor.

Cardiac exam is unrevealing with the exception of a friction rub.

Her temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air.

Inspection of her oropharynx reveals multiple ulcers.

Since the incident, the patient has calmed down and is currently resting.

The patient refused to explain her behavior to the police.

She is no longer responding to internal stimuli and is more cooperative.


The complete blood count showed leukocytosis.

Anaerobic culture of the peritoneal fluid needle aspirate showed a gram-negative pathogen.

His appendix was removed for an abscess 3 days ago.


She reports that herer father has a similar condition.

Her right knee has also been stiff and slightly swollen for the past 6 weeks.

She is overall fatigued and has difficulty moving around but has not sought medical attention until now.

On physical examination, the distal interphalangeal joints are swollen, warm, and painful; her nails are pitted and cracked.

There are also rough, erythematous skin patches seen over her elbows which have been present for the last few months.

They both use hydrating creams and topical glucocorticoids with moderate benefit.


She recently returned from a year of traveling abroad, but has otherwise been healthy.

She presented to the physician because she discovered blood in her sputum after coughing.

Two weeks later, she returns with a skin rash, diarrhea, and confusion, and is given a factor to take in addition to the medications previously prescribed.

Based on clinical suspicion, an acid fast stain is performed showing the causative organism, and she is started on appropriate therapy.


On examination, she is found to have rebound tenderness in the lower right quadrant of her abdomen.

Further workup suggests ovarian cancer, which is confirmed later in the week to be stage 4 with confirmed distant metastases in the lungs and brain.


His stools are bulky, foul-smelling, and difficult to flush.

Over the past 6 months, he has had recurrent dull epigastric pain that is triggered by meals and lasts for a few days.

Abdominal examination shows mild epigastric tenderness with no rebound or guarding.


He is known to be hypertensive, but noncompliant with medications for the last 20 years.

Physical examination reveals dry skin, ecchymoses, and conjunctival pallor.

His blood pressure is 180/99 mm Hg, heart rate is 89/min, and respiratory rate is 17/min.

The initial laboratory results are remarkable for hemoglobin of 10 g/dL, mean corpuscular volume of 90 μm3, platelet count of 200,000/mm3, blood urea nitrogen of 29 mg/dL, and creatinine of 2.1 mg/dL.


He was born at 29 weeks via spontaneous vaginal delivery.

He is meeting all of his milestones and is up to date with all vaccines.

He presents to the pediatric ward with fever, dyspnea, and cough, which he developed 3 days ago.

His mother also reports he had poor weight gain despite a good appetite during the past 2 months as well as frequent stools with an unpleasant smell.

His blood pressure is 80/50 mm Hg, the heart rate is 109/min, the respiratory rate is 29/min, and the temperature is 39.1°C (102.4°F).

The patient’s weight is between the 5th and 10th percentile.

His length is between the 50th and 75th percentile.

The patient is sluggish and reacts torpidly to examination.

His skin is pale and dry with decreased turgor and elasticity.

On auscultation, there are diminished vesicular sounds and disseminated moist rales at the bases of both lungs.

The abdomen is distended without palpable masses.

The patient’s blood analysis shows the following findings:
Complete blood count
 Erythrocytes  3.3 x 106/mm3
 Hb  12 g/dL
 Total leukocyte count  17,500/mm3
 Neutrophils
 59%
 Lymphocytes
 32%
 Eosinophils
 3%
 Monocytes
 6%
 Basophils
 0
Platelet count
232,000/mm3
Sputum culture grows Pseudomonas aeruginosa.

A sweat test shows chloride concentration of 85 mEq/L (elevated).


Since she started high school one year ago, her academic performance has decreased.

She also has had difficulty finding friends at the new school.

She is afraid that her classmates will make fun of her and think that she is “stupid.” One month ago, when she had to give a presentation, she could not stop wondering how her classmates were going to react if she said something wrong.

During the presentation, her heart started racing and she became flushed.

Since this event, she avoids saying anything in class.

She spends her breaks in the restroom because she is worried that nobody will talk to her.

Physical and neurologic examinations show no abnormalities.

On mental status examination, the girl avoids eye contact and appears uncomfortable and anxious.


He also ‘can’t catch his breath’ at times.

The mother also reports that he seems to be slightly shorter than other children his age.

His temperature is 36.6°C (97.9°F), blood pressure is 110/70 mm Hg, and respiratory rate is 14/min.

On auscultation, a localized harsh pansystolic murmur is heard over the left sternal border at the level of the 2nd–3rd intercostal space.

The murmur becomes louder when the patient is asked to squat.


She tested positive for both Kernig and Brudzinski's signs and shows signs of confusion, dyspnea, and hypotension.

The blood culture results confirmed the presence of Neisseria meningitidis, and a complete blood count (CBC) revealed leukocytosis.


His past medical history is also significant for asthma and eczema.

He takes no medications except for omeprazole.

He feels solid food getting stuck in his chest behind the sternum when he eats.

Drinking does not cause any difficulty swallowing.

He has no coughing or nasal regurgitation.

He has had heartburn for 2 years with no response to high-dose omeprazole.

His vital signs are within normal limits.

Physical examination shows no abnormal findings.


The patient recently underwent anesthesia for an appendectomy several months ago.

He also has a past medical history of schizophrenia well controlled with haloperidol and is currently taking phenytoin for epilepsy.

He is also currently taking propranolol for anxiety and hyperthyroidism.

He was at work as a construction worker when his coworkers found him down at the work site.

He has minimal muscle tone and is incoherent when answering questions.

The patient is covered in sweat and dirt.

His temperature is 106°F (41.1°C), blood pressure is 109/62 mmHg, pulse is 170/min, respirations are 23/min, and oxygen saturation is 95% on room air.

Physical exam is notable for an altered man with a Glasgow Coma Scale of 10.