Examination reveals an ill-appearing intubated patient.

Significant bruising is noted over the abdomen.

On arrival to the emergency department, his temperature is 98.6°F (37.0°C), pulse is 130/min, blood pressure is 80/50 mmHg, respirations are 22/min, and oxygen saturation is 97%.

Endotracheal tube placement is confirmed with end tidal CO2, and bilateral breath sounds are present.

No external bleeding or wounds are noted on exam.

Pulses are present in all extremities but are weak and rapid.

He was intubated and 2 large bore IVs were placed in the field with administration of 2 liters of lactated ringer's solution while en route.

Infusion of packed red blood cells is initiated.


He has a medical history of obesity and smokes regularly.

The patient states that his symptoms have been worsening over the past week.

He also has experienced abdominal pain and diarrhea.

His temperature is 97.5°F (36.4°C), blood pressure is 142/82 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Physical exam is notable for an erythematous rash with papules and plaques on the patient's face, torso, and extremities.

A fingerstick blood glucose is unable to accurately read his blood glucose and gives a reading of > 500 mg/dL.


His temperature is 98.5°F (36.9°C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air.

He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly.

He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting.

When he wakes up, he is mildly confused but typically returns to baseline within a minute.

However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint.

The patient has a past medical history of diabetes, dyslipidemia, and hypertension.

The patient's neurological exam is unremarkable.


He is otherwise healthy and takes no medications.

He states he has had profuse, watery diarrhea for the past 24 hours.

He notes that eating and drinking make him defecate more, thus he has been refraining from drinking.

His temperature is 97.7°F (36.5°C), blood pressure is 84/64 mmHg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 99% on room air.

Physical exam reveals dry mucous membranes with an otherwise benign exam.

The patient is given 1L of normal saline and drinks 1L of oral fluids.


She has no significant medical history and takes no medications.

Her rash has progressed and the skin on her hands is "peeling."

A diffuse, macular, erythematous rash is noted with desquamation over the patient's hands as shown in Figure A.

The patient's nasal packing is removed revealing copious, foul-smelling, purulent discharge.

Her temperature is 102°F (38.9°C), blood pressure is 84/54 mmHg, pulse is 160/min, respirations are 22/min, and oxygen saturation is 99% on room air.

She had nasal septoplasty performed 1 week prior and has had nasal packing in place since that time.


The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling.


She enjoys a diverse diet and takes levothyroxine.

Her vision has been steadily declining over the past 2 years and she thinks she needs a prescription for glasses.

She further complains that her lips and feet feel numb.

Her blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 12/min.

Her pupils are equal, round, and reactive to light, but appear opacified.

Extraocular movements are intact, albeit slow.

Her visual acuity is decreased bilaterally.

The remainder of her physical exam is unremarkable.

Her basic metabolic panel is shown below: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.9 mEq/L HCO3-: 25 mEq/L BUN: 10 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Thyroid-stimulating hormone: 1.5 µU/mL Ca2+: 7.0 mEq/L Phosphorus: 6.5 mEq/L Albumin: 3.6 mg/dL The patient's ECG is shown in Figure A.


The patient has a medical history of Hashimoto thyroiditis and takes levothyroxine daily.

Her mother has type 1 diabetes mellitus.

She has had only 2 periods in the last year.

She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting.

She has also had more frequent headaches than usual.

Her temperature is 98.5°F (36.9°C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min.

Cardiopulmonary and abdominal exams are unremarkable.

The patient has Tanner 5 breasts and pubic hair.

A pelvic exam reveals a normal cervix, an anteverted uterus without tenderness, and no adnexal masses.


The patient states that when he left for work this morning he was certain that he had closed the door to his pantry.

Upon returning home, he saw that the door to his pantry was wide open.

The patient is certain that his neighbors have been tampering with his food and potentially poisoned him.

He further states that he knows they have been trying to break into his house and steal his things.

He has tried multiple times to get them evicted from the building to no avail.

It is for this reason that he is certain that they are trying to get their revenge upon him.

He storms out of the office angrily, stating that he deserves the best in medical care.

His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.

The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies.

The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms.


According to her boyfriend, the patient has a medical history of bipolar disorder for which she takes lithium, as well as chronic lower back pain for which she sees a pain specialist.

Her temperature is 100.5°F (38.1°C), blood pressure is 102/78 mmHg, pulse is 127/min, respirations are 19/min, and oxygen saturation is 99% on room air.

An ECG is performed as seen in Figure A.

Her boyfriend found her at home next to a suicide note and brought her into the emergency department.


He recently moved to the United States to work in construction.

He drinks alcohol 1-2 times per week and has never smoked.

His temperature is 98.6°F (37°C), blood pressure is 114/72 mmHg, pulse is 82/min, and respirations are 12/min.

He has had the cough for several years but it has been getting worse over the last few months.

He has lost 10 pounds in the last 3 months along with darker stools which he believes is caused by a Western diet.

On physical exam, his lungs are clear to auscultation bilaterally without wheezing.

He has no tenderness to palpation and bowel sounds are present.

He denies any difficulty swallowing or feeling of food getting stuck in his throat.


The patient lives in a foster home and has been admitted many times.

The patient is in the 25th percentile for height and weight which has been constant since birth.

The patient has a history of tricuspid stenosis.

Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus.

Her temperature is 99.5°F (37.5°C), blood pressure is 90/58 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 94% on room air.

Physical exam is notable for bruises along the patient's shins which the guardians state are from playing soccer.

She was recently treated with amoxicillin for an infection.

Her guardians state that the patient has normal bowel movements and has been gaining weight appropriately.

She also recently had magnetic resonance imaging (MRI) of her chest which demonstrated dilation of her airways.

The rest of the exam is deferred because the patient starts crying.


The patient was born at 36 weeks gestation to a 26-year-old primigravid mother via cesarean section for cervical incompetence.

The patient has been exclusively breastfed since birth, and his mother reports that he feeds for 20-30 minutes every 2 hours.

The patient urinates 7 times per day and has begun passing 2-3 stools per day that his mother describes as “grainy” and the color of “mustard.” His birth weight was 3670 g (8 lb 1 oz), and his current weight is 3487 (7 lb 11 oz).

On physical exam, the patient’s anterior fontanelle is soft and flat, and his eyes are moderately icteric.

His temperature is 97.1°F (36.2°C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min.

The patient required no resuscitation at birth and both mother and child were discharged from the hospital at 2 days of life.

The patient has the physical exam finding seen in Figure A.


The patient was diagnosed with gestational diabetes after routine screening in the 2nd trimester and has been started on insulin after unsuccessful attempts at lifestyle management.

She also has migraines and gastroesophageal reflux disorder.

The patient has a 15-pack-year smoking history but quit smoking in her 1st month of pregnancy.

Yesterday she had several episodes of diarrhea and vomited once after attending a company picnic 2 days ago.

She is worried that she is dehydrated but otherwise feels well and has recovered from her gastrointestinal illness.

Her temperature is 98.5°F (36.9°C), blood pressure is 122/82 mmHg, pulse is 84/min, and respirations are 14/min.

She took loperamide with symptomatic relief.

A representative portion of the NST is shown in Figure A.


The patient lives alone and works in a health food store.

He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather.

He has begun taking an assortment of Peruvian herbs to little avail.

When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity.

On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble.

Otherwise, he is not currently taking any medications.

He states that his symptoms have persisted for the past 8 months.


He has a medical history of hypertension, diabetes, and obesity.

On the 2nd day of his hospitalization, the patient has abdominal pain.

He is requesting pain medication for his abdominal pain.

His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air.

An ECG is performed and notable for ST elevation in leads II, III, and aVF.

His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL.

The patient is treated appropriately and transferred to the medical floor.

A physical exam is notable for the finding in Figure A.


He was found lying down at a bus stop unresponsive.

On arrival, the patient has slurred speech and is somnolent.

The patient is easily arousable to voice and sternal rub but falls asleep rapidly.

His temperature is 98.0°F (36.7°C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air.

Physical exam reveals a sleeping man with miotic pupils.

He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam.


The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing.

His symptoms started a few weeks ago but have been worsening.

Sometimes he notes blood on the toilet paper.

He has to strain to have bowel movements and has trouble defecating secondary to pain.

His temperature is 98.1°F (36.7°C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline.

He is generally healthy and does not smoke.


He denies any recent travel or sick contacts and infrequently smokes cigarettes.

For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum.

His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.

A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy.

Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL.

He was appropriately treated and discharged home.

Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible.


His medical history includes type 1 diabetes mellitus and an episode of herpes zoster on his right flank 1 year ago.

He reports that he has headaches at night several times a week.

He first developed these headaches over 1 year ago, but they started up again 3 weeks ago.

The episodes start suddenly and feel like a stabbing, electrical pain over his left eye.

He also reports tearing of the left eye during these episodes.

The headaches self-resolve over the course of 2-3 hours, but the patient complains that he is avoiding going to sleep for fear of waking up in pain.

His temperature is 98.6°F (37°C), blood pressure is 112/69 mmHg, pulse is 61/min, and respirations are 14/min.

On physical exam, his extraocular muscles are intact and his eyes are not injected.

A CT of the head and sinuses shows no acute abnormalities.


He recently went camping and hiking in the woods.

The patient drinks 1-2 beers per day and smokes 1 pack of cigarettes per day.

He is currently sexually active with multiple partners and does not use condoms.

The patient was discharged 1 week ago for pneumonia which was treated with azithromycin; however, he feels that his symptoms may be returning.

His temperature is 99.5°F (37.5°C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air.

He felt itchy recently, then noticed skin lesions that broke out prompting him to come to the emergency department.

Physical exam reveals the findings in Figure A on the patient's arm.

The skin lesions are thick and do not break when pressure is applied.


His medical history is significant for chronic hepatitis C infection, hypertension, type 2 diabetes mellitus, and heart failure.

The patient works as a butcher at a local meat processing shop and is sexually active with several partners.

His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 155/95 mmHg, and respirations are 12/min.

He first noticed the rash 2 weeks prior and he endorses intermittent itchiness from the rash.

On physical exam, his skin has the finding shown in Figure A.

Fine, lace-like white lines are also noted on the patient’s buccal mucosa.


The patient has a medical history of obesity and prediabetes with a hemoglobin A1c of 6.0% last year.

She has started to develop pimples on her face and back over the last several months.

Her last menstrual period was over 3 months ago and her periods have been irregular over the last year.

Her temperature is 98.5°F (36.9°C), pulse is 80/min, blood pressure is 139/88 mmHg, and respirations are 13/min.

Cardiopulmonary exam is unremarkable, and the patient’s abdomen appears slightly distended but exhibits no tenderness to palpation.

The patient’s face has coarse stubble along the jawline and on the upper lip, and there is similar hair along the midline of her lower abdomen.

A pelvic exam reveals mild clitoromegaly, a normal anteverted uterus, and a large left adnexal mass that is mildly tender.

Her laboratory test results are shown below:

Hemoglobin: 13.9 g/dL
Leukocyte count: 8,000 cells/mm^3
Platelet count: 142,000/mm^3

DHEAS: 73 ug/dL (Normal: 145-395 ug/dL)
Testosterone: 256 ng/dL
17-hydroxyprogesterone: 214 ng/dL (Normal: < 200 ng/dL)

Ultrasound findings are shown in Figure A.


Analyzing only those subjects who responded throughout the entire period, it is determined that opioid use disorder only minimally impairs individuals in their daily functioning.

Individuals are surveyed using a validated method and followed up in 6-month intervals for 5 years.

At the end of the study period, 40% of individuals have replied to the survey throughout the entire period.


She was formerly an executive at a software company but had to retire due to frequent memory lapses.

Her medical problems include hypertension and chronic obstructive pulmonary disease for which she takes amlodipine, albuterol, ipratropium, and a fluticasone inhaler.

On occasion, she becomes difficult to understand and her speech becomes disorganized.

She also frequently sees "small people" and animals on the dining room table, which is disturbing to her.

Her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 12/min.

Physical exam is notable for slowed movements and difficulty with balance at rest, which were not present at her wellness visit 1 year ago.


His mother's pregnancy, labor, delivery, and his neonatal course have been unremarkable.

Several times a day, he experiences paroxysmal episodes of crying, bending at the waist, and jerking of the arms and legs.

These episodes last 1-2 seconds, but occur in clusters every 20-30 seconds for several minutes.

He is rolling over less frequently than before, has worse head control, and no longer smiles socially.

His temperature is 98.6°F (37°C), blood pressure is 92/46 mmHg, pulse is 115/min, and respirations are 34/min.

On examination, no dysmorphic features are noted.

A 24-hour electroencephalography (EEG) is performed, during which the patient has one of these spells.

A chaotic pattern of slowing and multifocal epileptiform charges is seen.


The patient’s medical history is significant for depression.

She was recently switched from phenelzine to fluoxetine.

When he said her name or waved his hand in front of her, she did not respond.

When he tried to move her, she would remain in whatever position she was placed.

She resists any attempt to change her position.

The patient remains mute and ignores any external stimuli.

Her temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% on room air.

The patient is lying on the bed with her left arm raised and pointing at the ceiling.


He reports that he is a mailman, and his closed fist was bitten by a dog while he was delivering mail yesterday.

His last tetanus vaccine was 3 years ago.

He has no medical history and takes no medications.

He reports pain but denies fevers, chills, drainage, or any other symptoms.

His temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 125/75 mmHg, and respirations are 16/min.

Examination of the patient's right hand is shown in Figure A.


She works as a mail carrier and is nearing retirement.

She has a medical history of anxiety, depression, irritable bowel syndrome, and dysmenorrhea.

She is not currently taking any medications.

When she goes to bed at night, she has an urge to get up out of bed and walk around.

The patient often wakes her husband when she does this which irritates him.

There is a perpetual uneasiness and feeling of a need to move at night which is relieved by getting up and walking around.

The patient denies symptoms during the day.

Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam reveals 5/5 strength in the upper and lower extremities, 2+ reflexes in the upper and lower extremities, a stable gait pattern, and normal sensation.

Cardiopulmonary and abdominal exams are within normal limits.


He has a history of human immunodeficiency virus (HIV) infection being treated with bictegravir, emtricitabine, and tenofovir.

He does not smoke tobacco and drinks alcohol socially.

He was found by his roommate to be disoriented this morning.

He had complained of a right-sided headache for the past 5 days.

His temperature is 104.2°F (40.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min.

Examination reveals 3/5 strength to right shoulder abduction and elbow flexion/extension and 4/5 strength to right hip flexion/extension.

The remainder of the strength exam on the right and left sides is normal.

Neck flexion does not elicit pain, and there are no tongue lacerations.

During the exam, the patient’s eyes are seen to roll backward with repeated flexion/extension of his extremities and loss of urine.


He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg.

Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema.

His temperature is now 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula.

No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity.

A delta pressure of 25 mmHg is obtained in the left leg.

He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn.


She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving.

She also had an appendectomy at age 15 for appendicitis.

She is a Ph.D. student and her husband is a physician.

She has had nausea and vomiting for about 2 months, tender and swollen breasts, and cravings for foods she typically does not eat.

Her temperature is 98.5°F (36.9°C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min.

A physical exam is notable for abdominal distension but is otherwise unremarkable.

Ultrasound is shown in Figure A, and urine human chorionic gonadotropin is negative in the office.

She took a pregnancy test about 10 weeks ago and was too nervous to read the result immediately.

After 24 hours, she saw that it was positive.

The patient’s affect is normal and she is pleasant and excited about her pregnancy.


He has a history of a distal radius fracture 2 years ago from falling off a ladder.

He drinks 3 alcoholic beverages weekly and denies illicit drug use.

He was working on a home improvement project the day prior to presentation when the pain started.

He describes the pain as "achy and sore."

It is not positional and does not radiate.

He denies fevers, chills, paresthesias, and bowel or bladder incontinence.

The patient’s temperature is 98.4°F (36.9°C), blood pressure is 124/80 mmHg, pulse is 90/min, and respirations are 16/min.

His body mass index (BMI) is 22.4 kg/m^2.

There is tenderness to palpation of his paravertebral lumbar region bilaterally.

Perineal and dermatomal sensation is symmetric and intact.

Strength is 5/5 to knee flexion/extension and ankle dorsiflexion/plantarflexion.

Patellar and Achilles reflexes are 2+ bilaterally.

Raising either leg while the patient is in the supine position does not elicit any pain.


The patient has a history of diabetes and is followed closely by an endocrinologist.

Today, he experienced a headache with blurry vision, thus prompting his presentation.

Otherwise, he has lost 10 pounds over the past month.

His temperature is 100°F (37.8°C), blood pressure is 122/90 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 99% on room air.

Physical exam is notable for a thin man but is otherwise unremarkable.

His visual acuity is 20/100 in both eyes, though he says that he normally has 20/20 vision.

His gait is mildly ataxic as well, but his neurological exam is otherwise nonfocal.

Laboratory studies are ordered as seen below.


He has no known medical history and takes no medications.

The pain starts in his chest and moves into his back, arms, and abdomen.

His temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure is 210/145 mmHg, respirations are 22/min, and pulse oximetry is 98% on room air.

Exam reveals a diaphoretic, anxious-appearing man.

Pulses are diminished over the left wrist when compared to the right.

A chest radiograph is obtained as shown in Figure A.


Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep.

Today, he reports minimal improvement in his symptoms.

He denies thoughts of suicide or self-harm.

Exam reveals a depressed, tired appearing man.

His temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 120/80 mmHg, respirations are 22/min, and oxygen saturation is 97% on room air.


The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension.

His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide.

The patient leads a sedentary life in which he tends to stay home and watch television.

He does not engage in any physical or strenuous activity.

His temperature is 98.6°F (37°C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min.

He has been having trouble combing his hair and reaching objects that are high on the shelf.

On physical exam, the patient has decreased passive and active range of motion of his shoulder.

The strength of the patient's upper extremity is 4/5 limited by pain.


The patient is otherwise healthy and does not take any medications.

He was punched in the eye and is having pain and blurry vision.

His temperature is 98.1°F (36.7°C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for conjunctival injection of the patient’s left eye as shown in Figure A.

Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left.

His left pupil is sluggish to constrict when compared to the right.

A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye.


Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated.

She is sexually active and does not use condoms.

She admits to drinking at least 5 standard alcoholic drinks a day.

The patient also recently lost a large amount of weight for a fitness show she planned on entering.

The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate.

The pain has been dull and progressive, but became suddenly worse while she was exercising.

On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant.

Her temperature is 99.5°F (37.5°C), blood pressure is 80/40 mmHg, pulse is 110/minute, and respirations are 15/minute with an oxygen saturation of 96% on room air.

On physical exam, you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back.

Intravenous fluids are started and labs are sent.


He has never smoked cigarettes but does have a history of opiate use prior to incarceration.

He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity.

His temperature is 100.8°F (38.2°C), blood pressure is 142/88 mmHg, pulse is 78/min, and respirations are 12/min.

Physical exam reveals a thin, ill-appearing man.

Pulmonary auscultation reveals faint, inspiratory crackles in the right upper lobe.

His chest radiograph is shown in Figure A.


They order the patient’s home medications including clobazam; however, they accidentally order clonazepam.

Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monitoring.


He initially experienced pain which is currently well controlled with acetaminophen.

His temperature is 98.5°F (36.9°C), blood pressure is 123/79 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air.

Physical exam is notable for the finding in Figure A.

A radiograph of the affected digits shows a smooth cortex without disruption of the bone.


The patient has engaged in unprotected intercourse with 12 different partners.

She has a medical history of asthma, IV drug abuse, and depression.

She has 1 to 2 alcoholic drinks per day.

She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex.

The patient presents to the emergency department 3 days later with a complaint of a rash.

She states that every time she has sex a rash has emerged on her skin.

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air.

A physical exam is notable for the finding in Figure A.

The patient is given antibiotics and is advised on safe sex practices.


He smokes 1 pack of cigarettes per day and denies alcohol or illicit drug use.

Today, he reports that he became sunburned this morning within an hour of beginning his workday, despite wearing appropriate sunscreen.

On exam, there is a blistering erythematous rash on the arms and shoulders.

His temperature is 98.6°F (37.0°C), blood pressure is 125/70 mmHg, pulse is 65/min, and respirations are 12/min.

The previous skin lesion appears unchanged.

At that time, he was prescribed treatment for the lesion and instructed to follow up as necessary.

He was seen 4 days ago for a new lesion on his arm that had been present for 1 week prior to that visit.

A photograph of the lesion is shown in Figure A.

He has a medical history significant for type 2 diabetes mellitus that is controlled with metformin.


The patient is otherwise doing well in school and enjoys playing basketball.

His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon.

His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year.

Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school.

His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.

On physical exam, the patient is tall for his age and has long arms.

He has 20 degrees of thoracic scoliosis, which is stable from previous exams.

On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses.


The patient has a medical history of diabetes and hypertension.

His current medications include insulin, metformin, and lisinopril.

For the past month, he has felt abnormally tired and today noticed his vision is blurry.

The patient also endorses increased sweating at night and new-onset headaches.

A neurological exam is notable for decreased sensation in the patient's hands and feet.

He also complains of numbness and tingling pain in his extremities that has been persistent during this time.

His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

A cardiopulmonary exam is within normal limits.

HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy.

Abdominal exam reveals splenomegaly and hepatomegaly.

There are large, non-tender palpable lymph nodes in the patient's inguinal region.

The dermatologic exam is notable for multiple bruises on his upper and lower extremities.


The medical student has had a negative HIV serology from the beginning of medical school 2 years ago.

She is monogamous with one male partner and denies any intravenous drug use.

The source patient was recently diagnosed with HIV and has a CD4 count of 550 cells/µL.

His most recent viral load is 1,800,000 copies/mL, and he was started on HAART 3 days ago.

She was drawing blood from an HIV-positive patient when she stuck herself percutaneously while capping the needle.

She immediately washed the puncture wound with saline.


He has no other significant medical history and does not take any medications.

He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week.

He denies any hemoptysis, facial pain, rhinorrhea, or night sweats.

His temperature is 101.7°F (38.7°C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min.

Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side.

A chest radiograph is ordered and reveals a consolidation in the right middle lobe.

The patient reported similar symptoms 2 months ago.

Chest radiograph performed at the time was notable for a right middle lobe consolidation.

He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms.


His parents report that he is doing well in school and has many friends.

The parents have so far managed the condition using herbal teas and essential oils but have not sought formal medical care.

Their only concern is that he has a “difficult stomach.” Every few months, he complains of intermittent abdominal pain that takes several days to pass.

He occasionally misses school due to the pain.

There is blood in his stool during these episodes.

These symptoms have persisted for many years.

On physical exam, the patient is thin with conjunctival pallor.

His temperature is 98.2°F (36.8°C), blood pressure is 106/61 mmHg, pulse is 88/min, and respirations are 12/min.

He has lost 10 pounds since his annual visit the year before and is the same height.

His sclerae are anicteric and his abdomen is soft and non-tender without hepatosplenomegaly.

He undergoes an abdominal CT that shows disease affecting the terminal ileum.

He also has the findings seen in Figure A.


She had a headache that was present for a few hours before subsiding 2 days ago, and then today she developed a headache that was sudden in onset and at maximal intensity within minutes.

She has never had a headache like this in the past.

Her temperature is 99.0°F (37.2°C), blood pressure is 157/99 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 99% on room air.

On exam, she has pain with passive and active movement of the neck.

No focal neurologic deficits are appreciated.

A non-contrast head CT is obtained as shown in Figure A.


His medical history is notable for a kidney stone 6 months ago.

The patient does not take any medications.

He is a non-smoker and does not drink alcohol or use recreational drugs.

His family history is significant for osteoarthritis in his father who is 78.

His temperature is 98.6°F (37°C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min.

He is otherwise healthy and denies fever, chills, or recent trauma.

Physical examination shows a swollen and tender joint with overlying erythema.

Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils.

Polarized microscopy of the synovial fluid is shown in Figure A.

He underwent a dental procedure to extract an infected wisdom tooth 3 weeks ago.


She was born at 38-weeks gestational age without complications.

Her medications consist of lamotrigine and valproic acid.

Her parents have noticed the patient occasionally stiffens and spreads her arms at home.

She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.

Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.

Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back.


The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations.

A few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones.

The patient has a 50 pack-year smoking history.

His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air.

For the past several months, he has felt progressively weaker and has lost 25 pounds with intermittent abdominal pain.

The patient has a negative Murphy sign and his abdomen is non-tender.

Cardiopulmonary exam is within normal limits.


Her last menstrual period was 7 weeks ago.

She has no other past medical history and takes no medications.

She uses a copper intrauterine device and is in a monogamous relationship.

The pain is most pronounced in the lower abdomen and has gotten worse over the past day.

Her temperature is 99°F (37.2°C), blood pressure is 79/50 mmHg, pulse is 135/min, and respirations are 20/min.

Physical examination is notable for diffuse abdominal tenderness upon palpation.

Pelvic examination demonstrates uterine and adnexal tenderness and uterine bleeding.

Laboratory studies are shown below:

Hemoglobin: 9.5 g/dL
Leukocyte count: 6,000/mm^3
Serum beta-human chorionic gonadotropin (hCG): 2,700 IU/L

The patient is started on intravenous fluids.

She denies any recent abdominal or vaginal trauma.


He drinks a glass of wine with dinner every night and took up scuba diving 2 months ago but otherwise does not exercise.

His temperature is 97.5°F (36.4°C), blood pressure is 124/68 mmHg, pulse is 82/min, and respirations are 16/min.

The pain started a year ago and has progressed.

He now has 8/10 pain when climbing stairs or rising from a seated position.

He localizes the pain to the front of his groin.

His body mass index (BMI) is 18.1 kg/m^2.

Physical exam reveals left groin pain at the terminal ranges of hip abduction and internal rotation.

A radiograph is obtained as in Figure A.


Approximately 20 minutes after receiving the medication, he developed pain and stiffness in his neck and eventually was unable to move his neck.

His neck is rotated to the right and is unable to return to midline.

His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 130/80 mmHg, respirations are 16/min, and oxygen saturation is 98% on room air.

Examination reveals an uncomfortable appearing man.

Examination of the patient is shown in Figure A.

He underwent a laparoscopic appendectomy and was treated for post-operative nausea and vomiting with metoclopramide.


His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications.

He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours.

His temperature is 38.5°C (101.3°F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min.

His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation.

His abdomen is distended and tender in all quadrants, with guarding and rebound present.

He also has increased bowel sounds throughout.


She has hypertension for which she takes hydrochlorothiazide and had a recent asthma flare requiring a prednisone taper.

Her pain is 7/10 in severity, non-radiating, and not relieved by rest.

She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence.

Her temperature is 98.6°F (37.0°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min.

Physical exam reveals an uncomfortable middle-aged woman in no acute distress.

There is no tenderness to palpation of the spinous processes.

Flexion of the hip with the knee extended while the patient is supine does not elicit any pain, nor does forced dorsiflexion of the foot at terminal hip extension.

She has 5/5 strength to hip flexion, extension, abduction, and adduction; knee flexion and extension; and ankle dorsiflexion and plantarflexion bilaterally.

Bilateral patellar and Achilles reflexes are 2+.


His mother reports he was eating well until 1 week ago when he began vomiting after breastfeeding.

His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting worse.

The patient now vomits after every feed.

He is now in the 60th percentile for weight and 68th percentile for height.

His temperature is 98.2°F (36.8°C), blood pressure is 58/37 mmHg, pulse is 144/min, and respirations are 34/min.

On physical exam, the patient has dry mucous membranes.

The patient’s mother is exclusively breastfeeding and would prefer not to switch to formula but worries that the patient is not getting the nutrition he needs.

Two weeks ago, the patient was in the 75th percentile for weight and 70th for height.


The patient has a history of coronary artery disease with a drug-eluting stent placed 1 year ago, obesity, hypertension, and dyslipidemia.

He has had severe nausea, vomiting, and diarrhea for the past 3 days.

Today, his wife noticed that he was confused.

He denies chest pain or dyspnea, but complains of diffuse abdominal pain.

His temperature is 99.0°F (37.2°C), blood pressure is 100/60 mmHg, pulse is 105/min, and respirations are 22/min.

Physical exam reveals a confused man with dry mucous membranes.

His abdomen is diffusely tender to palpation.

Laboratory studies are ordered and notable for the following:

Serum:
Na+: 147 mEq/L
Cl-: 112 mEq/L
K+: 3.5 mEq/L
HCO3-: 14 mEq/L
BUN: 80 mg/dL
Glucose: 100 mg/dL
Creatinine: 2.1 mg/dL
Troponin: 0.10 mcg/L (normal < 0.01 mcg/L)

An ECG is ordered and is pending.


Her mother reports that she is eating well at home and sleeping well throughout the night.

She can jump and walk up and down stairs with both feet on each step.

In the doctor’s office, the patient builds a 6-cube tower and imitates a circle.

She seems to have a vocabulary of over 50 words that she uses in 2-word sentences.

The patient enjoys playing near other children and sometimes argues over toys with her older brother.

Her temperature is 98.6°F (37°C), blood pressure is 92/56 mmHg, pulse is 106/min, and respirations are 23/min.

On physical exam, she appears well developed and well nourished, and she is following along her growth curves.

The child is assessed as developmentally normal.


He denies any diarrhea or change in his stools.

He drinks 5-6 beers on the weekend and has a 20 pack-year smoking history.

He says that the pain “comes and goes” throughout the day and usually lasts 20-30 minutes per episode.

He denies any feeling of regurgitation or nighttime cough but endorses nausea.

He used to eat 3 large meals per day but has found that eating smaller meals more frequently improves his pain.

His temperature is 98.6°F (37°C), blood pressure is 117/72 mmHg, pulse is 72/min, and respirations are 13/min.

On physical exam, he is tender to palpation above the umbilicus.

He tried ibuprofen with food and thinks it helped.

The patient undergoes an endoscopy with a biopsy to diagnose his condition.

He has gained 4 pounds since his last appointment 3 months ago.


His medications include aspirin, lisinopril, metformin, and sulfasalazine.

He reports that the dyspnea started 2 months ago after he had the flu.

At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then.

This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table.

His temperature is 97°F (36.1°C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air.

On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted.

A chest radiograph is obtained and the result is shown in Figure A.


She has a medical history of anxiety and is not currently taking any medications.

She has a general aching/pain in her joints that lasts all day.

The pain is constant and is not relieved by rest or activity.

She also has pain in her hands at times and occasionally notices trouble swallowing when she is eating.

Her temperature is 98.6°F (37°C), blood pressure is 115/72 mmHg, pulse is 74/min, and respirations are 11/min.

On physical exam, the patient is a healthy young woman with a sunburn.

Her hands are mildly edematous with the findings in Figure A.


His symptoms started last night and have persisted.

He occasionally has migraine headaches, but he has not had a headache like this in the past.

He reports associated nausea, vomiting, fevers, and neck pain.

His temperature is 100.4°F (38.0°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.

On physical exam, he appears uncomfortable.

Neurologic exam reveals no focal deficits.

There is pain with passive neck flexion.

Lungs are clear to auscultation bilaterally.

Lumbar puncture is performed and CSF results are obtained as shown below.


He has a history of anxiety managed with fluoxetine and lorazepam.

He also has hypertension but does not take any medications.

Today, his symptoms have been persistent despite taking his medications.

He says that he feels lightheaded and can’t walk.

His temperature is 98.7°F (37.1°C), blood pressure is 120/72 mmHg, pulse is 183/min, respirations are 25/min, and oxygen saturation is 99% on room air.

Physical exam reveals a somnolent and uncomfortable man.

An ECG is performed as seen in Figure A.


Her medical history is significant for hypertension treated with lifestyle modification and gastroesophageal reflux disease (GERD).

She noticed the weakness approximately 3 months ago.

It has gotten progressively worse since that time.

She has also noticed increasing difficulty combing her hair, standing from a seated position, and experiences muscle aches.

Her temperature is 98.6°F (37.0°C), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 16/min.

She has 3/5 strength to shoulder abduction and hip flexion bilaterally.

Her strength is 5/5 to wrist extension and ankle plantar flexion.


The patient has an unknown medical history and is currently not on any medications.

She is not sexually active and does not intend to become pregnant in the near future.

The patient's teacher describes her as occasionally "daydreaming" for periods of time during where the patient does not respond or participate in school activities.

The only other concern that the patient's mother has is that, upon awakening, she notices that sometimes the patient's arm will jerk back and forth.

The patient states she is not doing this intentionally.

Her temperature is 98.6°F (37°C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 11/min.

On physical exam, you note a young, healthy girl whose neurological exam is within normal limits.

Nothing has helped the patient change her behavior, including parent-teacher conferences or punishment.


He denies any recent travel or sick contacts and infrequently smokes cigarettes.

Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL.

For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum.

His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.

A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy.

He was appropriately treated and discharged home.


The patient has a medical history of diabetes mellitus that is well-controlled with insulin and metformin.

She has been admitted multiple times for hypoglycemia secondary to missing meals.

She feels fatigued, depressed, and has gained 10 pounds which she attributes to feeling too weak to go to the gym.

She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment.

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for 2/5 strength in the patient's upper and lower extremities, sparse fine hair on her body, and a rash on her face and arms.

Serum: Na+: 139 mEq/L K+: 3.3 mEq/L Cl-: 100 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 70 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L A muscle biopsy is obtained as seen in Figure A.

Laboratory values are ordered as seen below.


She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia.

She often babbles but sometimes does make identifiable sounds like “dada” and “baba.” They recently started feeding her mushy cereal, which she seems to like but occasionally spits up.

She has started teething and sometimes becomes “fussy.” Vital signs are within normal limits.

The patient’s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A.

She received amoxicillin and had a resolution of her symptoms.

Her father reports that she seems “back to normal.” She can roll over by herself and can sit up without support.


The patient has no significant medical history.

He does have a 33-pack-year smoking history and drinks 4 to 5 alcoholic drinks per day.

The patient has felt steadily more fatigued over the past month and has lost 22 pounds without effort.

Today, he fainted prompting his presentation.

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

The patient is very thin and appears pale.

Stool fecal occult blood testing is positive.

A CT scan of the abdomen is performed demonstrating a mass in the colon with multiple metastatic lesions scattered throughout the abdomen.

The patient is informed of his diagnosis of metastatic colon cancer.

When the patient conveys the information to his family, he focuses his efforts on discussing the current literature in the field and the novel therapies that have been invented.

He demonstrates his likely mortality outcome which he calculated using the results of a large multi-center study.


He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce.

His other medications include albuterol.

Since then, he notes that his symptoms are roughly unchanged.

Physical exam reveals a depressed affect.

His temperature is 99.3°F (37.4°C), blood pressure is 132/88 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air.

A serum thyroid stimulating hormone (TSH) resulted from his last visit and is noted to be 4.8 µU/mL (normal: 0.5-5 µU/mL).


The patient is otherwise healthy and has no other medical problems.

The symptoms began towards the end of running a marathon and persisted after finishing the race.

His temperature is 98.0°F (36.7°C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Physical exam reveals a distended and tender abdomen.

A radiograph is performed as seen in Figure A.


She states that she feels well apart from the discomfort of that sensation.

Her temperature is 97.9°F (36.6°C), blood pressure is 124/84 mmHg, pulse is 180/min, respirations are 22/min, and oxygen saturation is 98% on room air.

After unsuccessful attempts at vagal maneuvers, the emergency physician administers an IV medication.

The effect of the medication wears off in seconds.


The patient works as a farmer and gardens in his spare time.

He has a medical history of poorly managed type 2 diabetes mellitus and irritable bowel syndrome.

His current medications include lisinopril, metformin, insulin, fiber supplements, and a multivitamin.

In addition, he complains of a cut on his scalp that is not seeming to heal.

On physical exam, there is a calm, obese gentleman.

The patient's glucose journal reveals an average blood glucose of 175 mg/dL.

His temperature is 98.8°F (37.1°C), blood pressure is 134/86 mmHg, pulse is 80/min, and respirations are 13/min.

On inspection of the patient's scalp, the finding in Figure B is noted.

The patient is sent home and instructed to keep a blood glucose journal.

Inspection of the patient's scalp reveals the finding shown in Figure A.

Three months later, the patient returns with his glucose journal.


Aside from occasional shin splints, she has a relatively unremarkable medical history.

She takes oral contraceptive pills and a multivitamin daily.

Her periods have been regular, occurring once every 28 to 30 days with normal flow.

She is sexually active with 2 partners, who use condoms routinely.

Her prior pap smear was performed last year and was normal.

Her temperature is 36.7°C (98°F), blood pressure is 115/80 mmHg, pulse is 65/min, respirations are 12/min, and oxygen saturation is 100% on room air.

Her physical exam is within normal limits.

All of her age appropriate immunizations are up to date.

Her mother has diabetes and coronary artery disease, and her father passed away at age 45 after being diagnosed with colon cancer at age 40.

Her grand-aunt underwent bilateral mastectomies after being diagnosed with breast cancer at age 60.


The patient has a medical history of IV drug use, diabetes mellitus, oral cold sores, hypertension, renal failure, and dyslipidemia.

The patient's current medications include lisinopril, atorvastain, insulin, and aspirin.

Prior to the procedure, he was also on dialysis.

His temperature is 98.5°F (36.9°C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min.

The previous day, the patient had a renal transplant from a matched donor.

He is currently recovering and doing well.

The patient successfully recovers over the next few days.


He has a medical history of hypertension, glaucoma, and osteoarthritis in his left knee that requires him to walk with a cane.

He takes hydrochlorothiazide, timolol eyedrops, and occasional acetaminophen.

The patient initially became less talkative than usual before starting to confuse her with her sister.

The patient also could not remember what day of the week it was and he was out of groceries and likely had been for several days when visited.

The patient is unable to provide a clear history.

The patient is lethargic but arousable, oriented only to person, and disheveled.

His temperature is 98.5° F (36.9° C), blood pressure is 122/74 mmHg, pulse is 75/min, and respirations are 14/min.

Neurologic exam reveals intact cranial nerves, 1+ deep tendon reflexes throughout, and 4/5 strength in all extremities.

There is a 3 x 5 cm green-blue area of ecchymosis on the lateral aspect of his left knee.

A CT of the head without contrast is performed and shown in Figure A.

While she was talking to him, he fell asleep and was difficult to rouse.


The patient is a non-smoker and has a history of GERD for which she takes antacids.

She states she has had a cough for the past week.

She also has abdominal pain and trouble focusing that has been worsening and has lost 5 pounds recently.

Her gastroesophageal reflux disease (GERD) has been poorly controlled recently.

Her temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.

A physical exam is within normal limits.


His medical history is significant for gastroesophageal reflux disease for which he takes omeprazole.

He has no family history of neurologic disease.

He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house.

One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker.

The patient expresses frustration that he is no longer able to concentrate enough to enjoy his hobby of solving puzzles.

His temperature is 98.6°F (37.0°C), blood pressure is 120/75 mmHg, pulse is 70/min, and respirations are 16/min.

During the examination, the patient’s cell phone rings unexpectedly causing the patient to suddenly jerk his arms and legs.

Further diagnostic investigation is performed which reveals an elevated 14-3-3 protein on cerebrospinal fluid analysis.


He was the driver in a head-on collision and was not wearing a seatbelt.

The patient is acutely intoxicated and is attempting to attack the nurses.

His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 32/min, and oxygen saturation is 98% on room air.

Physical exam is notable for jugular venous distension.

An electrocardiogram (ECG) is performed as seen in Figure A.

Soon after presentation, he is sedated, paralyzed, and intubated.


The patient had a myocardial infarction 6 months ago, and she now has multiple drug-eluting stents.

Her medical history is otherwise significant for rheumatoid arthritis and migraines.

Her home medications include methotrexate, atorvastatin, clopidogrel, and aspirin.

She often feels lightheaded and like she may “pass out” but never actually loses consciousness.

Her temperature is 98.6°F (37°C), blood pressure is 118/75 mmHg, pulse is 92/min, and respirations are 12/min.

On physical exam, she has an irregular heartbeat with normal cardiac sounds.

Her abdomen is non-distended and she has mild lower extremity edema.

Her ECG upon discharge from that hospitalization was normal.

Her current ECG can be seen in Figure A.


He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago.

The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metformin, and insulin.

The patient has not been filling his prescriptions regularly and can not remember what medications he has been taking.

His temperature is 99.5°F (37.5°C), pulse is 96/min, blood pressure is 180/120 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air.


He has a medical history significant for hypertension that is well-controlled with lisinopril.

He had an uncomplicated appendectomy when he was 23 years old.

He has no family history of gastrointestinal malignancy.

He describes the blood as bright red wisps that float on the surface of the stool.

He has no pain with bowel movements but notes on occasion he may strain.

He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea.

His last colonoscopy was 3 years prior to presentation and was benign.

His temperature is 98.6°F (37.0°C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min.

On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses.

The anus is patent without fissures, hemorrhoids, or skin tags.


Over the past 2 days, the patient’s stools have become looser and streaked with blood.

The patient has also regurgitated several of her feedings in the last few days.

Neither the vomit nor bloody stools have seemed to bother the patient.

The patient is breastfed every 2-3 hours and voids 10-12 times daily.

The patient’s weight continues to trend along the 50th percentile.

The patient’s temperature is 98.4°F (36.9°C), blood pressure is 66/51 mmHg, pulse is 127/min, and respirations are 26/min.

On physical exam, the patient appears well nourished and is cooing.

Physical exam reveals the finding seen in Figure A.

The patient previously had several soft stools per day that ranged in color from mustard yellow to dark green.


He has experienced similar symptoms before.

Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue.

The patient speaks with a muffled voice.

His temperature is 98.1°F (36.7°C), blood pressure is 120/83 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Physical exam reveals swollen lips and a protruding, enlarged tongue.

He demonstrates no rash and his abdomen is soft and nontender.


She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured.


The patient was born at 39 weeks and met all her developmental milestones.

She is currently up to date on her vaccinations and did not have infections during early childhood.

Her parents are divorced and her father has noted she does not seem to get sick when he takes care of her.

Her mother says that last night her daughter felt ill, and her condition has been worsening.

Her daughter experienced a severe headache and had a stiff neck.

This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine.

Her temperature is 99.5°F (37.5°C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air.

The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics.

She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection.

She also was treated for a urinary tract infection 10 weeks ago.


She was born at 38-weeks gestational age without complications.

Her medications consist of lamotrigine and valproic acid.

Her parents have noticed the patient occasionally stiffens and spreads her arms at home.

She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.

Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.

Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back.


He has a diet high in refined carbohydrates and has gained 20 pounds since starting high school.

The patient has had lesions on his face that have persisted since he was 13 years of age.

Physical exam is notable for the findings in Figure A.

The patient is started on benzoyl peroxide and topical retinoids.


Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission.

The headache started suddenly while she was eating dinner and she says it feels like the “worst headache of my life.” An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding.

On hospital day 3, she is found to be disoriented to person, place, and time.

Her temperature is 99.6°F (37.6°C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min.

Physical examination shows poor skin turgor.

Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L.

The patient undergoes surgical management of her condition.


The patient was born at 39 weeks via vaginal delivery to a G1P1 29-year-old woman.

The patient has been breastfeeding and producing 5 stools/day.

His temperature is 99.5°F (37.5°C), blood pressure is 60/38 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 98% on room air.

A cardiopulmonary exam is notable for a benign flow murmur.

A musculoskeletal exam reveals the findings shown in Figure A.


The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence.

The child had a runny nose and cough for a few days last week.

The patient’s mother endorses decreased appetite during the aforementioned illness which has now returned to baseline.

On physical exam, the patient has scleral icterus and dark urine staining her diaper.

The patient’s family history is significant for an older brother with glucose-6-phosphate dehydrogenase (G6PD) deficiency and a maternal uncle with cirrhosis secondary to chronic hepatitis B.


The patient was born at 39 weeks of gestation to a 30-year-old primigravid via vaginal delivery.

The patient’s mother received routine prenatal care and the pregnancy was uncomplicated.

The patient’s anatomy ultrasound at 20 weeks of gestation was unremarkable.

The patient’s mother denies any family history of genetic diseases.

The patient’s APGAR scores were notable for poor muscle tone at both 1 and 5 minutes of life.

The patient’s birth weight is 2.6 kg (5 lb 11 oz), which is at the 5th percentile.

His height and head circumference are in the 15th and 3rd percentile, respectively.

His temperature is 97.1°F (36.2°C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min.

On physical exam, the patient has a wide nasal bridge, down slanting palpebral fissures, and widely spaced eyes.

He has good respiratory effort with a high-pitched cry.


The patient has a medical history of diabetes.

He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25.

The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea.

He has lost 17 pounds since he last came to the emergency department 1 month ago.

The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam.

His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm.

Symptoms are not changed with changes in head and neck position.


The patient has a medical history of obesity, diabetes, diabetic nephropathy, hypertension, and a 40-pack-year smoking history.

His current medications include atorvastatin, lisinopril, insulin, metformin, and nicotine gum.

He was riding the train home from a business conference when his symptoms began.

The patient's right lower extremity appears mildly inflamed, and palpation of the calf elicits pain.

His temperature is 99.5°F (37.5°C), blood pressure is 130/87 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 93% on room air.

A chest radiograph is ordered as seen in Figure B.

Laboratory values are ordered as seen below: Serum: Na+: 137 mEq/L Cl-: 105 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 22 mg/dL Glucose: 129 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.1 mg/dL AST: 11 U/L ALT: 12 U/L On physical exam, the patient appears to be in distress.

His cardiac exam is notable for tachycardia.

Pulmonary exam reveals bilateral air movement without any wheezes or crackles.


He has a family history of skin cancer, colon cancer, and ovarian cancer.

The patient has a medical history of asthma and seasonal allergies.

He is concerned about a rash that does not seem to be improving.

He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated.

His temperature is 98.6°F (37.0°C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air.

Physical exam reveals the finding in Figure A.


His medical problems include hypertension, hyperlipidemia, hypothyroidism, and chronic neck pain for which he takes amlodipine, hydrochlorothiazide, atorvastatin, levothyroxine, and duloxetine.

Surgical history consists of posterior lumbar fusion and elective left total hip arthroplasty.

He has a 90-pack-year smoking history and quit 10 years ago.

He reports these symptoms started intermittently in the middle finger after returning from a golfing trip but has progressed to being nearly constant.

The thenar eminence, thumb, and other digits are spared.

The patient’s temperature is 99.6°F (37.6°C), blood pressure is 134/80 mmHg, pulse is 90/min, and respirations are 16/min.

Physical exam reveals 4/5 strength in elbow extension and wrist flexion on the right.

He has 5/5 strength in the remainder of the motor exam on the right upper extremity and on the left upper extremity.

The triceps reflex is 1+ on the right compared to 2+ on the left.

His neck pain, which radiates down his right arm, is reproduced with axial loading during neck extension with simultaneous rightward rotation and lateral bending.


Her temperature is 99.6°F (37.6°C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min.

Physical examination shows poor skin turgor.

Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L.


His medical problems include hypertension, diabetes, and hyperlipidemia for which he takes lisinopril, metformin, and atorvastatin.

He has 3-5 drinks of scotch per night before working on his car.

His wife has noticed a tremor while he is working on his car and knows that his father died of Parkinson disease.

He says that the tremor is nothing to worry about and only occurs during a few activities such as pouring drinks, pointing the remote at the television, or fixing his car.

On physical exam, the tremor is replicated during finger to nose testing.

The patient states his wife is just overreacting.


She was found on the floor of her apartment after her neighbor called 911.

She is confused and is unable to provide any history, but complains of generalized pain.

Her temperature is 99.2°F (37.3°C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Physical exam reveals, a confused, ill-appearing woman.

Lungs are clear to auscultation bilaterally.

An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine.


The patient works as a farmer and has no concerns about his health.

He has a medical history of hypertension and obesity.

His current medications include lisinopril and metoprolol.

His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for a murmur after S2 over the left sternal border.

The patient demonstrates a stable gait and 5/5 strength in his upper and lower extremities.


His temperature is 98.6°F (37.0°C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air.

Physical exam reveals the finding in Figure A.

He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated.

He has a family history of skin cancer, colon cancer, and ovarian cancer.


The patient’s older sister had her first period at age 14.

The mother had her first period at age 13.

The patient reports she is doing well in school and is on the varsity basketball team.

Her medical history is significant for asthma and atopic dermatitis.

Her medications include albuterol and topical triamcinolone.

Her temperature is 98°F (36.7°C), blood pressure is 111/72 mmHg, pulse is 65/min, and respirations are 14/min with an oxygen saturation of 99% on room air.

Physical exam shows absent breast development and external genitalia at Tanner stage 1.

Serum follicle-stimulating hormone (FSH) level is measured to be 38 mIU/mL.


The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery.

He has felt a mass in his eye that has persisted for the past month.

His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid.


He has a medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for 1 week.

His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate.

In general, he has been in good health; however, he recently has experienced weight loss, abdominal pain, and general fatigue.

His temperature is 99.5°F (37.5°C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air.

A mild systolic murmur is heard in the left upper sternal region.

The rest of the physical exam is within normal limits.

Laboratory values are ordered as seen below.


His medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia.

His current medications include metformin, atorvastatin, and lisinopril.

He was having dinner at home with his wife when he suddenly noticed he had difficulty eating and speaking.

He also noticed a new-onset weakness on his left side.

His temperature is 98.6°F (37°C), blood pressure is 130/80 mmHg, pulse is 70/min, and respirations are 15/min.

On examination, strength is 5/5 in the right upper and lower extremities and 3/5 in the left upper and lower extremities.

On cranial nerve examination, his tongue deviates to the right side.

There is also decreased sensation to light touch and vibration on the left side of his body.


He is back to playing basketball for his school team without any difficulty.

The patient denies any abdominal pain, fevers, chills, nausea, vomiting, diarrhea, or constipation.

His urine appears more amber than usual but he suspects dehydration.

His temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 76/min, and respirations are 15/min.

The laparoscopic incision sites are all clean without erythema.

Urine: Epithelial cells: Scant Glucose: Negative Protein: 3+ WBC: 3/hpf Bacteria: None Leukocyte esterase: Negative Nitrites: Negative The patient is told to return in 3 days for a follow-up appointment; however, his urinalysis at that time is similar.

He eats solids and drinks liquids without difficulty.

The pediatrician orders a urinalysis, which is notable for the following.


The patient has a medical history of a suicide attempt and alcohol abuse.

He is not currently taking any medications.

The patient admits to using heroin and cocaine and drinking 5-8 alcoholic drinks per day.

His temperature is 103°F (39.4°C), blood pressure is 92/59 mmHg, pulse is 110/min, respirations are 20/min, and oxygen saturation is 96% on room air.

The patient has felt unwell for the past week and has felt subjectively febrile.

Cardiopulmonary exam is notable for a systolic murmur heard best along the left sternal border.

Dermatologic exam reveals scarring in the antecubital fossa.

IV fluids are administered and the blood pressure is subsequently 120/70 mmHg.


He has no health concerns and has not seen a physician in years.

The patient has a medical history of depression treated with fluoxetine and lithium.

His temperature is 99.5°F (37.5°C), blood pressure is 122/78 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Physical exam is notable for the finding in Figure A.


His symptoms started last night and have persisted.

He occasionally has migraine headaches, but he has not had a headache like this in the past.

He reports associated nausea, vomiting, fevers, and neck pain.

His temperature is 100.4°F (38.0°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.

On physical exam, he appears uncomfortable.

Neurologic exam reveals no focal deficits.

There is pain with passive neck flexion.

Lungs are clear to auscultation bilaterally.


She has felt tired and unwilling to engage in any activities lately.

She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort.

She no longer finds any happiness in activities that she previously enjoyed.

She struggles to sleep and at times can't sleep for several days.

She returns 1 week later stating that her symptoms have not improved.

She is requesting help as her performance at work and school is suffering.

Her temperature is 99.5°F (37.5°C), blood pressure is 115/72 mmHg, pulse is 60/min, respirations are 13/min, and oxygen saturation is 98% on room air.

The patient is started on appropriate first-line therapy and sent home.


He has a medical history of obesity and anxiety and is not currently taking any medications.

His temperature is 104°F (40°C), blood pressure is 147/88 mmHg, pulse is 200/min, respirations are 33/min, and oxygen saturation is 99% on room air.

Physical exam reveals dry mucous membranes, hot flushed skin, and inappropriate responses to the physician's questions.

Laboratory values are ordered as seen below.


She was found on the floor of her apartment after her neighbor called 911.

She is confused and is unable to provide any history, but complains of generalized pain.

Her temperature is 99.2°F (37.3°C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Physical exam reveals, a confused, ill-appearing woman.

An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine.


His medical history is otherwise notable for hypertension and hyperlipidemia.

His only home medication is pravastatin.

The patient smokes half a pack per day of cigarettes and drinks 2-3 beers throughout the day.

His family history is significant for Parkinson disease in his father.

For the last several years he has noticed this "shaking" when he brushes his teeth and prepares a cup of coffee in the morning.

The shaking then gradually improves over the course of the day.

On physical exam, his temperature is 98.6°F (37.0°C), blood pressure is 159/84, pulse is 74/min, and respirations are 12/min.

He has a high-frequency bilateral hand tremor elicited on finger-to-nose testing.


She denies any recent travel, new sexual partners, or antibiotic use.

Physical examination reveals multiple clustered vesicles and shallow ulcers in the vulvar region.

A Tzanck smear shows multinucleated giant cells.


He has no significant medical history and takes no medications.

He has had headache and fever for the last 2 days, and this morning he was confused and had difficulty answering questions.

His temperature is 104°F (40°C), pulse is 120/min, blood pressure is 105/60 mmHg, and respirations are 22/min.

On exam, flexion of the neck causes flexion of the hips and knees.

Fundoscopic exam reveals no papilledema.

Examination of the patient's rash is shown in Figure A.


The patient lives alone and drinks 7 alcoholic beverages per day and smokes 1-2 packs of cigarettes per day for the past 40 years.

He has felt very weak every morning with his symptoms persisting throughout the day.

He notes minor improvement when he rides his bike but otherwise has not noticed any change in his symptoms with rest or ibuprofen use.

The patient has lost 12 pounds recently and has had a chronic cough.

His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 93/min, respirations are 17/min, and oxygen saturation is 92% on room air.

A chest radiograph is ordered as seen in Figure A.


The patient lives in a foster home and has been admitted many times.

The patient is in the 25th percentile for height and weight which has been constant since birth.

The patient has a history of tricuspid stenosis.

Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus.

Her temperature is 99.5°F (37.5°C), blood pressure is 90/58 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 94% on room air.

Physical exam is notable for bruises along the patient's shins which the guardians state are from playing soccer.

She was recently treated with amoxicillin for an infection.

Her guardians state that the patient has normal bowel movements and has been gaining weight appropriately.

The rest of the exam is deferred because the patient starts crying.


He has a medical history of hypertension, diabetes, and obesity.

On the 2nd day of his hospitalization, the patient has abdominal pain.

He is requesting pain medication for his abdominal pain.

His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air.

An ECG is performed and notable for ST elevation in leads II, III, and aVF.

His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL.

A physical exam is notable for the finding in Figure A.

The patient is treated appropriately and transferred to the medical floor.


He denies any recent travel or sick contacts and infrequently smokes cigarettes.

Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL.

For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum.

His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.

A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy.

He was appropriately treated and discharged home.


A physical exam is notable for the finding in Figure A.


The patient’s medical history is significant for depression.

She was recently switched from phenelzine to fluoxetine.

When he said her name or waved his hand in front of her, she did not respond.

When he tried to move her, she would remain in whatever position she was placed.

She resists any attempt to change her position.

The patient remains mute and ignores any external stimuli.

Her temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% on room air.

The patient is lying on the bed with her left arm raised and pointing at the ceiling.


She works as a mail carrier and is nearing retirement.

She has a medical history of anxiety, depression, irritable bowel syndrome, and dysmenorrhea.

She is not currently taking any medications.

When she goes to bed at night, she has an urge to get up out of bed and walk around.

The patient often wakes her husband when she does this which irritates him.

There is a perpetual uneasiness and feeling of a need to move at night which is relieved by getting up and walking around.

The patient denies symptoms during the day.

Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam reveals 5/5 strength in the upper and lower extremities, 2+ reflexes in the upper and lower extremities, a stable gait pattern, and normal sensation.

Cardiopulmonary and abdominal exams are within normal limits.


He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg.

Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema.

His temperature is now 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula.

No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity.

A delta pressure of 25 mmHg is obtained in the left leg.

He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn.


He has no known medical history and takes no medications.

The pain starts in his chest and moves into his back, arms, and abdomen.

His temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure is 210/145 mmHg, respirations are 22/min, and pulse oximetry is 98% on room air.

Exam reveals a diaphoretic, anxious-appearing man.

Pulses are diminished over the left wrist when compared to the right.

A chest radiograph is obtained as shown in Figure A.


She had a headache that was present for a few hours before subsiding 2 days ago, and then today she developed a headache that was sudden in onset and at maximal intensity within minutes.

She has never had a headache like this in the past.

Her temperature is 99.0°F (37.2°C), blood pressure is 157/99 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 99% on room air.

On exam, she has pain with passive and active movement of the neck.

No focal neurologic deficits are appreciated.

A non-contrast head CT is obtained as shown in Figure A.


She was born at 38-weeks gestational age without complications.

Her medications consist of lamotrigine and valproic acid.

Her parents have noticed the patient occasionally stiffens and spreads her arms at home.

She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.

Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.

Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back.


The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations.

A few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones.

The patient has a 50 pack-year smoking history.

His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air.

For the past several months, he has felt progressively weaker and has lost 25 pounds with intermittent abdominal pain.

The patient has a negative Murphy sign and his abdomen is non-tender.

Cardiopulmonary exam is within normal limits.


His symptoms started last night and have persisted.

He occasionally has migraine headaches, but he has not had a headache like this in the past.

He reports associated nausea, vomiting, fevers, and neck pain.

His temperature is 100.4°F (38.0°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.

On physical exam, he appears uncomfortable.

Neurologic exam reveals no focal deficits.

There is pain with passive neck flexion.

Lungs are clear to auscultation bilaterally.

Lumbar puncture is performed and CSF results are obtained as shown below.


For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum.

His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.

A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy.

He was appropriately treated and discharged home.

Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible.


The patient has a medical history of diabetes mellitus that is well-controlled with insulin and metformin.

She has been admitted multiple times for hypoglycemia secondary to missing meals.

She feels fatigued, depressed, and has gained 10 pounds which she attributes to feeling too weak to go to the gym.

She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment.

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for 2/5 strength in the patient's upper and lower extremities, sparse fine hair on her body, and a rash on her face and arms.

Serum: Na+: 139 mEq/L K+: 3.3 mEq/L Cl-: 100 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 70 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L A muscle biopsy is obtained as seen in Figure A.

Laboratory values are ordered as seen below.


She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia.

Her father reports that she seems “back to normal.” She can roll over by herself and can sit up without support.

She often babbles but sometimes does make identifiable sounds like “dada” and “baba.” They recently started feeding her mushy cereal, which she seems to like but occasionally spits up.

She has started teething and sometimes becomes “fussy.” Vital signs are within normal limits.

The patient’s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A.

She received amoxicillin and had a resolution of her symptoms.


The patient is otherwise healthy and has no other medical problems.

The symptoms began towards the end of running a marathon and persisted after finishing the race.

Physical exam reveals a distended and tender abdomen.

His temperature is 98.0°F (36.7°C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air.

A radiograph is performed as seen in Figure A.


His medical history is significant for gastroesophageal reflux disease for which he takes omeprazole.

He has no family history of neurologic disease.

He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house.

One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker.

The patient expresses frustration that he is no longer able to concentrate enough to enjoy his hobby of solving puzzles.

His temperature is 98.6°F (37.0°C), blood pressure is 120/75 mmHg, pulse is 70/min, and respirations are 16/min.

During the examination, the patient’s cell phone rings unexpectedly causing the patient to suddenly jerk his arms and legs.

Further diagnostic investigation is performed which reveals an elevated 14-3-3 protein on cerebrospinal fluid analysis.


The patient has a medical history of poorly managed diabetes, constipation, anxiety, dyslipidemia, and hypertension.

He decided to come in when his symptoms worsened.

He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol.

His temperature is 99.5°F (37.5°C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 95% on room air.

Physical exam reveals a systolic murmur heard loudest along the left upper sternal border.

Abdominal exam reveals an obese, tympanitic and distended abdomen with a 3 cm scar in the right lower quadrant.

Vascular exam reveals weak pulses in the lower extremities.

His wife recently returned from a cruise with symptoms of vomiting and diarrhea.


The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery.

He has felt a mass in his eye that has persisted for the past month.

His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid.


His medical history is significant for hyperlipidemia and poorly controlled hypertension.

His current medications include atorvastatin and amlodipine.

On cranial nerve exam, his left pupil is 6 mm in diameter compared to 3 mm on the right.

His left eye is displaced laterally and downward and he also has left-sided ptosis.

Strength is 2/5 in the right upper and right lower extremities and 5/5 in the left upper and left lower extremities.

He has marked right-sided dysdiadochokinesia.

His temperature is 98.6°F (37.0°C), blood pressure is 175/95 mmHg, pulse is 90/min, respirations are 16/min.


The patient has engaged in unprotected intercourse with 12 different partners.

She has a medical history of asthma, IV drug abuse, and depression.

She has 1 to 2 alcoholic drinks per day.

She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex.

She states that every time she has sex a rash has emerged on her skin.

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air.

A physical exam is notable for the finding in Figure A.

The patient is given antibiotics and is advised on safe sex practices.

The patient presents to the emergency department 3 days later with a complaint of a rash.


The patient is a Swedish foreign exchange student and does not speak any English.

Her medical history and current medications are unknown.

She was hiking when she suddenly felt unable to breathe and had to take slow deep breaths to improve her symptoms.

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 90% on room air.

Physical exam is notable for poor air movement bilaterally and tachycardia.


He attributes this to intravenous drug use in prison.

He has felt very fatigued and has had a cough.

He has lost roughly 15 pounds over the past 3 weeks.

His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.

The patient is started on appropriate treatment.


The patient has a medical history of a suicide attempt in college, constipation, anxiety, depression, and a sunburn associated with surfing which was treated with aloe vera gel.

The pain has lasted for several months but seems to have worsened recently.

Any activity such as opening jars, walking, or brushing her teeth is painful.

Her temperature is 99.5°F (37.5°C), blood pressure is 137/78 mmHg, pulse is 92/min, respirations are 14/min, and oxygen saturation is 98% on room air.

Laboratory values are obtained and shown below.


His mother's pregnancy, labor, delivery, and his neonatal course have been unremarkable.

Several times a day, he experiences paroxysmal episodes of crying, bending at the waist, and jerking of the arms and legs.

He is rolling over less frequently than before, has worse head control, and no longer smiles socially.

His temperature is 98.6°F (37°C), blood pressure is 92/46 mmHg, pulse is 115/min, and respirations are 34/min.

On examination, no dysmorphic features are noted.

A 24-hour electroencephalography (EEG) is performed, during which the patient has one of these spells.

A chaotic pattern of slowing and multifocal epileptiform charges is seen.


His medical history is notable for a kidney stone 6 months ago.

The patient does not take any medications.

He is a non-smoker and does not drink alcohol or use recreational drugs.

His family history is significant for osteoarthritis in his father who is 78.

His temperature is 98.6°F (37°C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min.

He is otherwise healthy and denies fever, chills, or recent trauma.

Physical examination shows a swollen and tender joint with overlying erythema.

Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils.

Polarized microscopy of the synovial fluid is shown in Figure A.


The patient has no significant medical history.

For the past 3 months, the patient has been coughing when he drinks liquids.

His speech also sounds different according to his wife.

His temperature is 98.6°F (37.0°C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min.

On physical exam, he is unable to fully extend his tongue, and there are fasciculations on his tongue.

When tapping the mandible at the chin while the mouth is held open, there is pronounced upward movement of the lower jaw.


He was driving under the influence of alcohol when he sustained a crash against a pole.

His medical history is significant for hypertension but he does not take any medications.

One week later, the patient’s GCS score is now 3.

His temperature is 98.6°F (37.0°C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min on a ventilator.

His Glasgow coma score (GCS) on presentation is 6.

Laboratory studies do not show significant electrolyte, acid-base, or endocrine disturbances.

The patient is admitted to the intensive care unit and appropriate care is initiated.

Sedative and paralytic agents are withdrawn.


He has no medical history and takes no medications.

He recently started experimenting with alcohol and marijuana that one of his friends has been stealing from their parents.

He says that the spasms usually occur after he wakes up as he is getting ready for school, and consist of disorganized jerking motions that stop after a few minutes.

He has also noticed that they occur when he stays up late to cram last minute for exams.

His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.


His only medical problem is hypertension for which he takes amlodipine.

The patient is a non-smoker, uses alcohol infrequently, and has never used illicit drugs.

The pain started 6 hours ago when he was gardening and carrying a heavy bag.

The pain is rated as 10/10 in severity and radiates down the posterior aspect of the right thigh.

His temperature is 99.6°F (37.6°C), blood pressure is 140/70 mmHg, pulse is 90/min, and respirations are 20/min.

Physical examination reveals 3/5 strength to hip extension, knee flexion and extension, and plantar flexion bilaterally.

Sensation to pinprick is diminished over the posterolateral legs and lateral aspects of both feet.

Ankle and knee reflexes are absent bilaterally.

The patient’s underwear is wet and a bladder scan reveals 800 mL of urine.


She has not had time for regular check-ups.

She exercises 3-4 times a week and consumes red meat sparingly.

She drank and smoked cigarettes socially with coworkers but never at home or on vacation.

Her family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.

She last had a colonoscopy 5 years ago that revealed no abnormal findings.

She wakes up with achy wrists and elbows that she suspects is from years of using a computer keyboard.

Her temperature is 99°F (37.2°C), blood pressure is 125/83 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 99% on room air.

Her physical exam is grossly unremarkable.