He has no past medical history and takes no medications.

The patient is unable to offer a history and repetitively asks the nurses what happened.

His temperature is 97.6°F (36.4°C), blood pressure is 122/74 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% of room air.

Physical exam reveals a confused young man.

Cranial nerves 2-12 are intact and the patient has normal strength and sensation.

He drove his car into a pole while speeding at night.

He knows his name and address and is able to remember other information about himself.

Throughout the exam, he continuously asks what happened to him.


He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines.

His medical history is significant for migraines and hypertension.

He has a 20-pack-year smoking history and a history of cocaine use.

He suddenly developed a throbbing, bitemporal headache about 5 hours ago "out of nowhere."

He also endorses nausea and he reports that he vomited once before arrival in the emergency department.

His temperature is 98.6°F (37°C), blood pressure is 147/91 mmHg, pulse is 62/min, and respirations are 12/min.

On physical exam, he appears to be in moderate distress and has pain with neck flexion.

The patient took his prescribed sumatriptan with no relief of his symptoms.

The patient denies any recent trauma to the head.

A head CT is performed and can be seen in Figure A.


The patient’s medications include aspirin and carvedilol.

He reports that he is a smoker with a 50-pack-year history.

When it started, he felt like a “curtain was pulled down” over his right eye but wasn't able to seek care immediately because it was snowing outside and he didn't want to travel in inclement weather.

A review of systems is significant for occasional palpitations and presyncope.

The patient’s temperature is 99°F (37.2°C), blood pressure is 112/72 mmHg, pulse is 84/min, and respirations are 14/min with an oxygen saturation of 97% on room air.

Physical exam reveals 20/800 vision in the right eye.

A fundoscopic exam of the right eye is shown in Figure A.

Physical and fundoscopic examinations of the left eye are unremarkable.


She is otherwise healthy and does not take any medications.

Her breast has not been tender, and she has not noticed any changes to the skin.

Bloody discharge is expressed from the right nipple.

Her temperature is 36.5°C (97.7°F), blood pressure is 110/82 mmHg, pulse is 68/min, respirations are 12/min, and oxygen saturation is 99% on room air.

Exam of the right breast reveals no mass on palpation.


He endorses a history of unprotected sex with multiple partners and intravenous drug use during a recent vacation to Mexico but has no other significant medical history.

He drinks socially and has never smoked.

He also endorses loss of appetite and subjective fever.

He has had vague, mild discomfort in the right upper quadrant since the start of this wrestling season.

His temperature is 98.6°F (37°C), blood pressure is 119/72 mmHg, pulse is 102/min, and respirations are 12/min.

Physical exam demonstrates pain on palpation of the right lower quadrant and mild pain in the right upper quadrant.

A CT of the abdomen confirms appendicitis.

The scan also shows a large liver mass measuring 6 cm as seen in Figure A.

He has significant acne on his face, chest, and back.


He is asymptomatic and has no acute complaints, has no medical problems, and takes no medications.

He was born in the United States but moved to El Salvador at age 11 and has only recently moved back to the United States in the past year.

He was up to date on his vaccinations prior to his move to El Salvador.

The patient’s temperature is 98.2°F (36.8°C), blood pressure is 120/76 mmHg, pulse is 82/min, and respirations are 16/min.

There are no rashes noted on physical exam.

He last received a diphtheria, tetanus, and acellular pertussis (DTaP) vaccine 14 years ago at age 5, the second dose of a meningococcal vaccine 3 years ago, and an influenza vaccine 2 months ago.


The patient's mother reports that the pregnancy was uncomplicated other than an episode of sinusitis in the 3rd trimester, for which she was treated with azithromycin.

Three weeks ago, the patient began vomiting after meals.

The vomitus appears to be normal stomach contents without streaks of red or green.

Despite these adjustments, the vomiting has become more frequent and forceful.

The patient is voiding about 4 times per day and his urine appears dark yellow.

The patient's temperature is 98.7°F (37.1°C), blood pressure is 58/41 mmHg, pulse is 166/min, and respirations are 16/min.

On physical exam, the patient looks small for his age.

His abdomen is soft, non-tender, and non-distended.

His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow’s milk and soy.

He has fallen 1 standard deviation off of the growth curve.


He had a similar episode about 1 month ago which resolved after a few hours.

The pain feels like a stabbing sensation behind his right eye.

He denies any symptoms on the left side.

The last time he had an episode like this, his eye was tearing.

His temperature is 98.2°F (36.8°C), blood pressure is 120/90 mmHg, pulse is 110/min, and respirations are 12/min.

Physical exam reveals a 2 mm pupil on the right and a 5 mm pupil on the left.

Extraocular movements are intact bilaterally.

The remainder of the neurologic exam is unremarkable.


His past medical history is significant for human immunodeficiency virus (HIV) infection, diagnosed 15 years ago.

The patient is intermittently compliant with his antiretroviral therapy (ART).

His temperature is 99.0°F (37.2°C), blood pressure is 130/84 mmHg, pulse is 92/min, and respirations are 11/min.

His most recent lab work showed a cluster of differentiation CD4 count of 150 cells/µL.

He received a dose of the 13-valent pneumococcal vaccine and a dose of the 23-valent pneumococcal vaccine 15 years ago, as well as a second dose of the 23-valent pneumococcal vaccine 10 years ago.


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.

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.

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


While holding her newborn, the mother endorses a headache, blurry vision, and abdominal pain.

Her temperature is 98.0°F (36.7°C), blood pressure is 194/104 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Physical exam reveals an uncomfortable woman.

There is blood in her vagina and her uterus is contracted.

Her cranial nerve exam is unremarkable and she has normal strength and sensation.

She subsequently undergoes an uncomplicated vaginal delivery.

The child is healthy and is heated, suctioned, and stimulated.

Laboratory studies and a urinalysis are pending.


His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation.

He was seen in the emergency department 2 days ago for profuse epistaxis.

A dark, purpuric rash is noted on his torso and extremities.

Upon presentation to the ED today, his temperature is 97.6°F (36.4°C), blood pressure is 64/33 mmHg, pulse is 160/min, respirations are 32/min, and oxygen saturation is 100% on room air.

Physical exam reveals an obtunded man who cannot answer questions.

The patient’s nasal packing is removed with no further bleeding.

The patient is given IV fluids and blood cultures are drawn.

However, his bleeding resolved with pressure and nasal packing.


Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension.

Her current medications include losartan, metformin, insulin, and ibuprofen.

She also recently fell off the treadmill while exercising at the gym.

The pain is present in the morning but is nearly unbearable by the end of the day.

The patient points to the areas that cause her pain stating that it is mostly over the groin.

Her temperature is 98.6°F (37°C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min.

On exam, an obese woman in no distress is noted.

There is pain, decreased range of motion, and crepitus on exam of her right hip.

The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms.


He just switched from being home-schooled to public school and joined the basketball team.

He does not currently take any medications.

He has fainted several times during basketball practices.

He did not sustain any injuries or have any prodromes prior to these episodes.

He is usually unconscious for less than a minute.

He is otherwise healthy and has met all developmental milestones.

His temperature is 97.6°F (36.4°C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Physical exam reveals a well-appearing and playful boy.

An ECG is performed as seen in Figure A.

An echocardiogram is ordered and pending.


Her urinary leaking occurs throughout the day and night, and she often has to get up to use the bathroom while asleep.

Exercising does not affect the loss of urine.

She states that she often cannot make it to the bathroom in time once she senses a need to void.

Her urinalysis is unremarkable, and her postvoid residual volume is 40 mL.

On pelvic examination, there is no dribbling of urine when the patient coughs.

Physical exam is otherwise unremarkable.

Her last menstrual period was 2 weeks ago.


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

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.

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.


Her medical history is significant for mild intermittent asthma for which she uses an albuterol inhaler as needed.

She is sexually active with 1 male partner.

She recently returned from South India following a mission trip for 6 weeks.

These symptoms have been going on for 2 months.

She has lost 6 pounds (2.7 kg) over these 2 months.

Her temperature is 98.6°F (37.0°C), blood pressure is 105/70 mmHg, pulse is 95/min, and respirations are 14/min.

On examination, the patient’s skin is pale.

Labs are obtained and show the following results:

Leukocyte count: 4,500/mm^3
Hemoglobin: 10.5 g/dL
Platelets: 110,000/mm^3
Mean corpuscular volume (MCV): 116 µm^3
Reticulocyte count: 0.5%

A biopsy of the small bowel reveals blunting of villi and a mixed infiltration of lymphocytes, plasma cells, and eosinophils.


She takes no medication other than whey protein supplements, a multivitamin, and fish oil.

She has noticed "twitching" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon.

She has felt more fatigued over the past month.

Her temperature is 98.5°F (36.9°C), blood pressure is 103/71 mmHg, pulse is 105/min, respirations are 11/min, and oxygen saturation is 100% on room air.

Physical exam reveals a thin woman with thinning hair.

She appears pale and her mucous membranes are dry.

Her neurological and cardiac exams are unremarkable.

Laboratory studies are ordered as seen below.

Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 6,100/mm^3 with normal differential Platelet count: 187,500/mm^3 Serum: Na+: 130 mEq/L Cl-: 100 mEq/L K+: 2.3 mEq/L HCO3-: 28 mEq/L BUN: 40 mg/dL Glucose: 79 mg/dL Creatinine: 0.9 mg/dL Ca2+: 8.2 mg/dL Mg2+: 1.8 mg/dL Thyroid stimulating hormone (TSH): 4.0 mIU/L Free T4: 0.4 ng/dL (normal: 0.7-1.53 ng/dL) The patient is given 4 liters of lactated ringer solution and 40 mEq of potassium.

Her repeat whole blood potassium 3 hours later is 2.4 mEq/L, and her repeat BUN is 20 mEq/L.

Another 40 mEq of potassium is administered.

Another repeat whole blood potassium is 2.5 mEq/L.


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

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

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.

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.

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


The child is sleeping at regular 2-hour intervals and feeding and stooling well.

The parents have noticed a “swelling of the belly button.” Cord separation occurred at 7 days of age.

The swelling seems to come and go but is never larger than the size of a blueberry.

They deny any drainage from the swelling.

Her temperature is 98.6°F (37°C), blood pressure is 68/43 mmHg, pulse is 128/min, and respirations are 32/min.

On physical exam, the child is in no acute distress and appears developmentally appropriate for her age.

Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus.

The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain.


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.


He has a history of coronary artery disease and underwent an uncomplicated coronary angioplasty with stent placement 2 years ago.

He routinely travels both domestically and internationally as a senior shipyard worker and has a 30-pack-year smoking history.

He has not smoke or drank alcohol in over 7 years.

Physical exam is notable for right pupillary constriction as well as paresthesias in his right fourth and fifth digits.

His temperature is 99.5°F (37.7°C), blood pressure is 140/60 mmHg, pulse is 97/min, and respirations are 13/min.

There is no pain with active shoulder rotation.


She has a medical history of hypertension for which she takes hydrochlorothiazide.

The patient’s mother had breast cancer at age 68, and her sister has endometriosis.

She states that she feels well and has no complaints.

Her temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min.

A pelvic exam reveals a non-tender, 12-week-size uterus with an irregular contour.

A transvaginal ultrasound is performed and demonstrates two intramural leiomyomas.


The patient lives alone and was found unresponsive by his son.

Generally, the patient manages his own finances, medications, and works part-time.

He has a past medical history of hypothyroidism, depression, and diabetes.

He has not been responding to phone calls for the past 3 days.

The patient is unable to offer a history.

The patient is cold to the touch and moves all extremities to painful stimuli.

His pupils are reactive and sluggish, and he does not follow commands.

His temperature is 88.0°F (31.1°C), blood pressure is 92/62 mmHg, pulse is 35/min, respirations are 9/min, and oxygen saturation is 92% on room air.

There are no signs of trauma or skin infections.

An ECG is performed as seen in Figure A.

The patient is started on IV fluids and hydrocortisone, is externally warmed, and is started on a norepinephrine drip.


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

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

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.


He was born at 39 weeks gestation to a 27-year-old primigravid mother via cesarean section for cervical insufficiency.

The pregnancy was complicated by gestational diabetes and the amniotic fluid was clear.

The patient now is exhibiting increased work of breathing and is progressively more tachypneic.

His chest radiograph can be seen in Figure A.

Upon delivery, the patient had strong respiratory effort and a strong cry.

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

His birth weight is 3,568 g (7 lb 14 oz).

His temperature is 99.0°F (37.2°C), blood pressure is 60/44 mmHg, pulse is 146/min, and respirations are 72/min.

On physical exam, the patient is grunting with nasal flaring and subcostal retractions.

Breath sounds are decreased at the bases bilaterally.


He states that he has been working in a hot, humid attic all day and forgot his water bottle.

The patient has a history of hypertension being managed by his primary care doctor.

He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute.

Physical exam reveals a diaphoretic man.

His temperature is 98.7°F (37.1°C), blood pressure is 149/82 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 99% on room air.

He demonstrates an unremarkable cardiopulmonary exam.

The patient walks with a steady gait and his neurologic exam is non-focal.

The patient is given 2 liters of oral fluids and feels back to his baseline.

He awoke at his neurologic baseline afterwards.


He has a history of type II diabetes mellitus and hypertension.

He takes metformin, insulin, and lisinopril.

This morning, he awoke with purulent, foul-smelling discharge on his pillow.

His temperature is 102.2°F (39.0°C), blood pressure is 130/87 mmHg, pulse is 110/min, and respirations are 16/min.

The patient is toxic in appearance and in mild distress due to pain.

Examination of the external ear reveals findings shown in Figure A. Granulation tissue and purulent drainage are noted in the external auditory canal.


His medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and a prior transient ischemic attack.

His medications include atorvastatin and lisinopril.

The patient lost control of his skis and collided with a tree.

He lost consciousness for about 30 seconds.

When he woke up, he was mildly confused but able to ski down the rest of the mountain.

During the ride, he became gradually more somnolent.

The paramedics report that at the scene the patient had a Glasgow Coma Score (GCS) of 15.

In the emergency department, his temperature is 97.8°F (36.6°C), blood pressure is 141/84 mmHg, pulse is 71/min, and respirations are 16/min.

He is difficult to arouse with a GCS of 7.

A head CT is performed and can be seen in Figure A.

The patient initially denied medical treatment but his wife convinced him to be taken by ambulance to the emergency department for evaluation.


He was born at 37 weeks of gestation to a 38-year-old G3P3 woman.

The pregnancy was uncomplicated and the patient’s mother refused all prenatal testing.

The patient’s 2 older siblings are both healthy.

The vomitus was described as “bright green” without any traces of blood.

The patient has urinated several times since he was born but has not passed any stool.

His abdomen is non-tender, firm, and distended.

His temperature is 98.6°F (37°C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min.

On physical exam, the patient has upslanting palpebral fissures, epicanthal folds, and a single transverse palmar crease.

Digital rectal exam evacuates a small amount of stool and flatulence.

A nasogastric tube is placed to decompress the stomach.

The patient’s abdominal radiograph can be seen in Figure A.


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 had 2 uncomplicated spontaneous vaginal deliveries at full term with her last child born 6 years ago.

She has a history of generalized anxiety disorder, atopic dermatitis, and she is currently on escitalopram.

She has felt nauseous the last several mornings and has been tired for a few weeks.

She is concerned about the risk of Down syndrome in this fetus, as her sister gave birth to an affected child at age 43.

Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 121/67 mmHg, and respirations are 13/min.

The patient appears anxious, but overall comfortable, and cardiopulmonary and abdominal exams are unremarkable.

Pelvic exam reveals normal external genitalia, a closed and soft cervix, a 10-week-sized uterus, and no adnexal masses.


The child was born at 38 weeks of gestation to a 28-year-old G3P3 mother.

The pregnancy was complicated by preeclampsia in the mother which was well-controlled throughout the pregnancy.

The mother went into spontaneous labor but the delivery was complicated by a prolonged 2nd stage of labor.

On physical exam, she appears to be in mild distress and has a 4x5 cm ecchymotic area of swelling over the bilateral parietal bones.

Her temperature is 98.6°F (37°C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min.

Serial assessments of the child’s head circumference over the next 12 hours show no change in the size of the swelling.

A vacuum-assisted vaginal delivery was eventually performed.

The child’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.


At a teaching hospital with residents, the time to tissue plasminogen activator administration is roughly 2 hours.

This has led to many adverse outcomes and increased morbidity at the teaching hospital.


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

He had his Achilles tendon repaired 4 weeks ago and he has been less mobile.

He recently had a cold that kept him home from work for the past week.

Physical exam is notable for dyspnea provoked by walking short distances.

His temperature is 99.2°F (37.3°C), blood pressure is 150/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.

Jugular venous distension is noted on exam.

The patient’s blood pressure is 130/70 mmHg during inspiration.

A bedside echocardiogram demonstrates impaired diastolic filling with normal ventricular contractility.

An ECG is performed as seen in Figure A.


The neonate was delivered at 39 weeks gestation via an uncomplicated vaginal delivery and was discharged home after 2 days.

The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a confirmatory test of cure.

The biological father is no longer involved in the patient's life, but her mother’s boyfriend has been caring for the baby whenever the mother rests.

The neonate’s temperature is 98.5°F (36.9°C), blood pressure is 56/35 mmHg, pulse is 138/min, and respirations are 51/min.

Examination of the genitals reveals no vulvar irritation or skin changes but there is scant pink mucoid discharge at the introitus.

Her daughter has been feeding and voiding well.

She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable.

There are no bruises or marks on her skin.


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.

His Glasgow coma score (GCS) on presentation is 6.

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.

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.


The patient has a past medical history of atrial fibrillation and is currently taking metoprolol and warfarin.

He has never had epistaxis before and has been unable to control it with pressure, head elevation, and ice.

There is not a clear, single bleeding vessel.

His temperature is 98.5°F (36.9°C), blood pressure is 123/81 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 97% on room air.

Physical exam reveals a comfortable man in no distress.

Inspection reveals active bleeding in the anterior nares.


His past medical history is notable for a myocardial infarction 7 years ago, COPD, heart failure with a left ventricular ejection fraction of 22%, obesity, diabetes, and peripheral vascular disease.

He typically has poor exercise tolerance and is only able to walk from his house to his mailbox before becoming dyspneic.

He now has shortness of breath even at rest.

His temperature is 97.7°F (36.5°C), blood pressure is 124/82 mmHg, pulse is 140/min, respirations are 32/min, and oxygen saturation is 78% on room air.

Physical exam reveals an uncomfortable man with increased work of breathing.

He demonstrates bilateral crackles and wheezing on pulmonary exam.

The patient is started on BiPAP, and his oxygen saturation improves to 94%.

He had a cold recently but has no new medical problems.

An ECG is performed, as seen in Figure A, and a chest radiograph is performed, as seen in Figure B.


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.


He recently retired from working the day shift at a cemetery.

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

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

His wife is disappointed that they cannot do any activities in the evening together.

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

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

His temperature is 98.6°F (37°C), blood pressure is 125/83 mmHg, pulse is 87/min, and respirations are 11/min.

The patient’s neurological exam is within normal limits.


She is at 12 weeks gestational age and has not received prior prenatal care.

She has no known medical problems and takes only a prenatal multivitamin.

She has unprotected sexual intercourse with 3 male partners.

She has mild morning sickness but no other symptoms.

Her temperature is 98.6°F (37.0°C), blood pressure is 118/70 mmHg, pulse is 80/min, and respirations are 18/min.

Physical exam reveals a well-appearing woman in no acute distress.

There are no lesions appreciated on skin exam.

An antibody test for human immunodeficiency virus (HIV)-1/2 is positive.

The patient is started on an appropriate treatment regimen.


Her medical history is significant for type 2 diabetes mellitus and hypertension for which she takes metformin and losartan.

She has been having worsening headaches and intermittent nausea over the past 5 months.

The headaches are constant and dull, and they typically worsen when she sneezes or laughs.

Recently, she has become increasingly nauseous and has vomited twice in the past 10 days.

Her temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.

She is noted to have papilledema on fundoscopy, but physical exam is otherwise normal.

Her CT scan findings are presented in Figure A.


The patient works on a farm and does not see a doctor often.

He has a history of hypertension but does not take medications routinely.

He has not had any chest pain, dyspnea, or weakness during this time frame and currently feels at his baseline.

His temperature is 98.1°F (36.7°C), blood pressure is 152/93 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Physical exam is unremarkable and the patient walks with a stable gait and no focal weakness.

An ECG is performed as seen in Figure A.

Laboratory studies are ordered as seen below.


Her home medications include levothyroxine, oral contraceptive pills, and topical trans-retinoin.

She has 2 glasses of wine with dinner several nights a week and has never smoked.

She works as a receptionist at a marketing company.

Every few weeks she has an episode of a right-sided, throbbing headache.

The episodes began several years ago and are accompanied by nausea and bright spots in her vision.

The headache usually subsides if she lies still in a dark, quiet room for several hours.

Her temperature is 98.6°F (37°C), blood pressure is 125/81 mmHg, pulse is 64/min, and respirations are 11/min.

On physical exam, the patient has no focal neurologic deficits.

A CT of the head is performed and shows no acute abnormalities.

The patient denies any weakness, numbness, or tingling during these episodes.


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

He is requesting medications and is crying out in pain.

His temperature is 98.7°F (37.1°C), blood pressure is 149/85 mmHg, pulse is 103/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam reveals swelling over his right leg and knee.

The patient cries out in pain with passive motion of the foot at the ankle.

A radiograph is performed as seen in Figure A.


She was born at 36 weeks gestation to a 37-year-old G2P2 mother.

The pregnancy was complicated by gestational diabetes, and all prenatal testing was unremarkable.

She was feeding well until this morning when she had several episodes of vomiting.

The parents describe the vomitus as “bright green” and the patient has shown little interest in feeding since then.

The patient has not yet regained her birth weight and is in the 46th percentile for height and the 36th percentile for weight.

The patient’s temperature is 99.2°F (37.3°C), blood pressure is 68/46 mmHg, pulse is 132/min, and respirations are 32/min.

On physical exam, the patient is in mild distress.

Her abdomen is distended and firm without guarding.

The patient’s abdominal radiograph can be seen in Figure A and the patient’s upper gastrointestinal series can be seen in Figure B.


The patient is otherwise healthy and takes no medications.

He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house.

His temperature is 98.0°F (36.7°C), blood pressure is 141/90 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Physical exam is notable only for minor pallor but is otherwise unremarkable.

Basic laboratory studies are ordered as seen below.


The patient has a medical history of polycystic ovary syndrome.

She now needs to shave her face every day or else thick hair appears.

She also has worsening acne that started several weeks ago.

Her pregnancy thus far has been complicated by gestational diabetes, which is managed by diet and exercise.

She has a male fetus based on her 20 week anatomy ultrasound.

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

The cardiopulmonary exam is normal, and the patient’s abdomen has a fundal height of 31 cm.

A pelvic exam reveals an unremarkable closed cervix and a right-sided adnexal mass without tenderness.

Transvaginal ultrasound is performed and shown in Figure A.


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.


She has a history of chlamydial infection in her 20's and has had 3 urinary tract infections over the past year.

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

She states that she has had involuntary loss of urine about 4 times each day over the past 3 months.

It is not associated with coughing or sneezing.

The patient has not been sexually active with her husband due to pain with intercourse.

Her temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.

On physical examination, the vulvar skin is pale and atrophic with reduced elasticity and multiple areas of petechiae.

The vaginal mucosa also has a loss of rugae and several areas of friable irritation.

There is minimal clear vaginal discharge.

Urinalysis is normal and fecal occult blood test is negative.

Pelvic ultrasound reveals a small, retroverted uterus.


He recently started playing for his high school basketball team and generally eats healthy food.

He has no significant medical history and takes no medications.

He feels disappointed because his voice has not changed.

He is concerned that he is not as tall as his classmates.

His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.

On physical examination, the patient does not have facial hair or acne.

His height is 60 inches and his arm span is 50 inches.

His visual fields are full and he has no cranial nerve abnormalities.

His strength is 5/5 in bilateral upper and lower extremities.

Chest palpation and abdominal examination are unremarkable.

He has no pubic hair and his testicles are symmetric with a volume of 3 mL.


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.


Her last menstrual period was 8 weeks ago.

The patient has a medical history of type 1 diabetes mellitus since childhood and her home medications include insulin.

The patient’s brother is autistic but her family history is otherwise unremarkable.

Her hemoglobin A1c 2 weeks ago was 13.7%.

At that time, she was also found to have microalbuminuria on routine urinalysis.

Her temperature is 98.6°F (37.0°C), blood pressure is 124/81 mmHg, pulse is 75/min, and respirations are 14/min.

Her primary care provider prescribed lisinopril but the patient has not yet started taking it.


As the infant is resting, vital signs are taken.

His mother notices that his face, chest, and extremities turn dusky blue during nursing.

She also notes that he seems to be snoring loudly and breathing very quickly.

When she removes him from her breast, he begins to cry and his color improves.

The delivery is uncomplicated and the neonate has Apgar scores of 9 and 9 at 1 and 5 minutes respectively.

His temperature is 98.2°F (36.7°C), pulse is 130/min, respirations are 45/min, and oxygen saturation is 97% on room air.

A physical exam demonstrates well-perfused skin but is notable for the facial features shown in Figure A.

After 15 minutes, he attempts to nurse for the 1st time.

The neonate’s prenatal course was unremarkable, and his mother has a medical history of asthma with occasional albuterol inhaler use.


Her past medical history is unremarkable and she is not currently taking any medications.

She denies drinking alcohol, smoking cigarettes, or using recreational drugs.

She has generally been feeling well, but notes feeling intermittent palpitations over the past few months.

She attributes her palpitations to recently drinking more caffeine, but would like to obtain an electrocardiogram since her symptoms are worrisome and affecting her ability to concentrate on her career as a fitness instructor.

Her temperature is 36.9°C (98.4°F), blood pressure is 116/76 mmHg, pulse is 55/min, respirations are 12/min, and oxygen saturation is 98% on room air.

Her electrocardiogram is shown in Figure A.


The patient’s medical history is significant for hypertension, alcohol use disorder, and chronic obstructive pulmonary disease.

His medications include aspirin, amlodipine, and fluticasone-salmeterol.

He drinks a glass of red wine every night with dinner and smokes a cigar on the weekends.

He is unsure when his symptoms started, but they have been affecting him for “a while.” It began as episodes of “unsteadiness” that progressed to a feeling of “spinning.” He cannot tell if his symptoms change with position but reports that if he does not lie down he will become nauseous.

He also has worsening hearing loss worse on his right side.

His temperature is 98.6°F (37°C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min.

Examination shows delayed horizontal nystagmus.


His medical history is significant for chronic renal failure for which he received a renal transplant 5 years prior, as well as multiple surgeries for skin cancer.

His current medications include aspirin, atorvastatin, prednisone, tacrolimus, and mycophenolate mofetil.

The lesion has grown rapidly over the previous 2 weeks.

He endorses trauma to the area when he accidentally scraped his hand against a window and notes that there was some bleeding.

His temperature is 98.6°F (37°C), blood pressure is 136/91 mmHg, pulse is 82/min, and respirations are 11/min.

Physical exam is notable for a 2 x 2.5 cm nodular lesion of the dorsal hand as seen in Figure A.


He enjoys spending time with his spouse, playing cards with his friends, and taking daily walks around his neighborhood.

His wife has noticed that he has a worsening ability to organize, plan, and exhibit impulse control over the last month.

The patient states that he is able to complete his activities of daily living without assistance, but has some weakness of his left upper and lower extremities that began 3 months prior.

He needs reminders from his wife about daily tasks to complete.

His temperature is 98.2°F (36.8°C), blood pressure is 149/87 mmHg, pulse is 87/min, and respirations are 12/min.

Physical exam reveals an elderly man who is oriented to person, place, and time.

He has 4/5 left-sided weakness of the upper and lower extremities and associated pronator drift of the left upper extremity.

A mini-mental status exam reveals he is able to remember 2 out of 3 words after 4 minutes.

He is able to appropriately draw a clock.

A magnetic resonance imaging study of the brain is shown in Figure A.


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.


He has a history of hypertension, major depressive disorder, Raynaud disease, and chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen at home.

Current medications include lisinopril, inhaled umeclidinium-vilanterol, and as-needed albuterol.

He drinks 4 beers a day and has smoked 1 pack of cigarettes a day for 40 years.

He began feeling the palpitations 3 days ago while eating dinner.

He denies chest pain, shortness of breath, or loss of consciousness.

His temperature is 98.9° F (37.2° C), blood pressure is 130/85 mmHg, pulse is 125/min, and respirations are 16/min.

Physical exam is notable for an irregular pulse and scattered end-expiratory wheezes.

An echocardiogram performed 1 month ago showed a left ventricular ejection fraction of 60-65%.

The patient requires 3 liters of oxygen today.

An ECG is performed as seen in Figure A.


He has a past medical history of diabetes and atrial fibrillation and is currently taking warfarin.

His wife noticed that he was confused, slurring his speech, and had notable weakness that caused him to drop his cup of coffee.

The patient is confused and not able to answer any questions.

Facial drooping of the left lower face is noted, and the patient cannot follow any commands.

The patient is not able to follow any commands for further neurologic evaluation but does not appear to be moving his right upper extremity.

His temperature is 98.0°F (36.7°C), blood pressure is 150/90 mmHg, pulse is 115/min, and respirations are 17/min.


The patient is a long-time runner but states that the pain has been getting worse recently.

The patient has a medical history of surgical repair of his Achilles tendon, ACL, and medial meniscus.

The patient lives with his wife and they both practice a vegan lifestyle.

When running and at rest he has a burning and aching pain along the bottom of his foot that sometimes turns to numbness.

Taking time off from training does not improve his symptoms.

On physical exam, the patient states that he is currently not experiencing any pain in his foot but rather is experiencing numbness/tingling along the plantar surface of his foot.

His temperature is 98.6°F (37°C), blood pressure is 114/72 mmHg, pulse is 81/min, and respirations are 12/min.

Strength is 5/5 and reflexes are 2+ in the lower extremities.


She has also gained about 10 pounds in the last several months, and her periods have become irregular over the last year.

Her last menstrual period was 3 months ago.

Her temperature is 98.6°F (37.0°C), pulse is 72/min, blood pressure is 136/86 mmHg, and respirations are 13/min.

Her skin exam reveals hirsutism along the jawline and acanthosis nigricans in the axillary folds.

Cardiopulmonary and abdominal exams are unremarkable.

A pelvic exam reveals normal external genitalia, a mobile and non-tender 6-week-sized uterus, and no adnexal masses or tenderness.

Transvaginal ultrasound is performed and shown in Figure A.


The patient has no significant medical history, and takes no other medication.

His temperature is 98.6°F (37.0°C), pulse is 130, blood pressure is 85/50, and respirations are 22.

Primary and secondary survey and FAST exam are unremarkable for other associated injuries.

He was not stabbed or otherwise injured elsewhere.

Pressure is removed from the wound, and pulsatile bleeding from the wound is noted.


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 has no significant medical history and takes no medications.

He first felt the pain while lifting boxes at work but thought that he had just strained a muscle.

The pain appears to be worse in the mornings and after rest.

Exercise and physical activity appear to temporarily make the pain better.

His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.

On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally.

He has taken acetaminophen and ibuprofen for the pain.


He was born at 39 weeks gestation to a 38-year-old G3P3 mother.

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

One of the patient’s older siblings has Down syndrome.

The patient is otherwise doing well and feeding every 2 hours.

The patient has had 2 episodes of vomiting that were described as green in color.

The patient's temperature is 98.2°F (36.8°C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min.

On physical exam, the patient is in no acute distress.

His abdomen is firm, non-tender, and distended with hypoactive bowel sounds.

A digital rectal exam fails to relieve the obstruction.

An abdominal radiograph is performed and the result can be seen in Figure A.


He has a medical history of diabetes and hypertension for which he is on metformin and losartan.

He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion.

He also endorses some shortness of breath.

He also believes the pain is worse when leaning back and improved when leaning forward.

His wife noticed he fainted after the pain started but regained consciousness shortly after.

His temperature is 99.2°F (37.3°C), blood pressure is 130/87 mmHg, pulse is 99/min, respirations are 22/min, and oxygen saturation is 100% on room air.

Physical exam reveals an overweight man.

A normal S1 and S2 are auscultated with clear breath sounds.

An ECG is performed as seen in Figure A.


He exercises twice a day, often with heavy weightlifting, and eats a high-protein diet.

He reports occasional alcohol use and remote marijuana use.

He is sexually active with his wife and has no history of sexually transmitted infections.

His temperature is 99.5°F (37.5°C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min.

Physical exam reveals small testes and a receding hairline.

He also has palpable tissue underneath his nipples bilaterally.

His muscle tone is normal in his upper and lower extremities bilaterally.


Pregnancy and delivery were uncomplicated.

Then 1 day ago, the patient developed eyelid edema and eye redness.

This morning, the newborn developed a thick yellow-white eye discharge.

The patient’s rectal temperature is 99°F (37.2°C), blood pressure is 80/50 mmHg, pulse is 134/min, and respirations are 34/min with an oxygen saturation of 98% O2 on room air.

The patient's physical exam is otherwise unrevealing.

The newborn had been sleeping regularly and feeding well.

The mother denies that anyone in the house smokes.

Figure A shows a photograph of one of the patient's eyes.


He states this weekend he had a barbecue.

The patient has a medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament.

His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate.

When he was lifting a heavy object, he suddenly felt pain in his lower back.

He describes the pain as in his buttocks but states that at times it travels down his leg.

He states that it feels electrical and burning in nature.

His temperature is 98.6°F (37°C), blood pressure is 131/82 mmHg, pulse is 82/min, and respirations are 14/min.

On physical exam, he is found to have an intact motor and sensory function in his lower extremities bilaterally.

No clonus or Babinski sign is appreciated.

An exam of the cranial nerves is intact bilaterally.


Over the past several weeks, the child has been more fatigued and his parents state that “he always seems to be sick.” They state that sometimes he complains about his bones hurting and they note that he is less playful.

His temperature is 102°F (38.9°C), blood pressure is 92/60 mmHg, pulse is 115/min, respirations are 23/min, and oxygen saturation is 99% on room air.

Physical exam is notable for diffuse non-tender lymphadenopathy.

Abdominal exam reveals hepatosplenomegaly.


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.


She returned from a recent missionary trip to South America 12 months prior where she endorsed eating a local delicacy as well as a period of fevers and eyelid swelling during her stay.

She endorses decreased exercise tolerance as well as intermittent palpitations.

Her temperature is 99.1°F (37.3°C), pulse is 95/min, blood pressure is 130/85 mmHg, respirations are 15/min, and oxygen saturation is 97% on room air.

Physical exam is notable for a laterally displaced point of maximal impulse as well as a 2/6 diastolic murmur radiating to the axilla.


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 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.


The patient has never been pregnant and previously used a copper intrauterine device (IUD) for contraception, but she had the IUD removed 1 year ago because it worsened her menorrhagia.

She has now been using combined oral contraceptive pills (OCPs) for nearly 1 year.

The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain.

Her medical history is otherwise unremarkable.

She reports that for the last several years, she has had chronic pain that is worse just before her menstrual period.

Over the past 2 months, she has also had worsening pain during intercourse.

She denies dysuria, vaginal discharge, or vaginal pruritus.

Her temperature is 98.0°F (36.7°C), blood pressure is 124/73 mmHg, pulse is 68/min, and respirations are 12/min.

The patient has pain with lateral displacement of the cervix on pelvic exam.

A pelvic ultrasound shows no abnormalities, and a urine pregnancy test is negative.


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.

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


Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools.

Her temperature is 37.2°C (98.9°F), blood pressure is 100/72 mmHg, pulse is 72/min, respirations are 12/min, and oxygen saturation is 100% on room air.

Her abdomen is soft, mildly diffusely tender to deep palpation, and non-distended.

She is found to have the finding on colonoscopy in Figure A. Serum perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are positive.

She has a family history notable for a father with coronary artery disease and a mother with primary sclerosing cholangitis.


She denies pain, but reports her right eye “feels funny.” The patient’s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis.

Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate.

She was in her usual state of health until waking up this morning unable to see out of her right eye.

Her temperature is 98°F (36.7°C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air.

The patient's pupils are symmetric in size and equally reactive to light with accommodation.

A fundoscopic exam of the right eye is shown in Figure A.


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.


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

His medications include amlodipine, atorvastatin, and metformin.

For the past few months, he has pain in his chest with physical activity.

The pain goes away after he takes a break.

He reports no chest pain while he is resting, and the pain is not worsening.

His temperature is 36.5°C (97.7°F), blood pressure is 132/80 mmHg, pulse is 74/min, respirations are 14/min, and oxygen saturation is 98% on room air.

He has a regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, or gallops.

His anterior, lateral, and posterior chest are non-tender to palpation.

His electrocardiogram is shown in Figure A. Troponin I level is < 0.017 ng/mL.


He has a medical history significant for high blood pressure, hyperlipidemia, and seasonal allergies with no prior surgical history.

He moved from India 7 years prior to presentation.

He currently lives in Oregon and has not left the west coast since moving.

His temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 76/min, and respirations are 16/min.

He has had a chronic cough and a 20 pound unintentional weight loss over the past 6 months.

His physical exam is significant for hyperpigmentation of the oral mucosa and temporal muscle wasting.

Radiography of the abdomen demonstrates bilateral adrenal calcifications.


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.


Since then, he has been on valproic acid but the seizure activity remains unchanged.

He was recently enrolled in daycare because she could no longer care for him full-time.

She reports that occasionally he “suddenly drops” when running around the house.

Since then, the seizure activity has increased and the daycare facility also noted concerns over his lack of response to voice commands.

A physical exam is significant for lack of response to auditory stimulation.

The patient is then startled when a door is closed quickly and he suddenly loses consciousness.

His temperature is 98.6°F (37°C), blood pressure is 105/52 mmHg, pulse is 110/min, and respirations are 25/min.

An EEG is performed, which is unrevealing.

An ECG is quickly performed and is shown in Figure B.

She says that his first seizure occurred 1 year ago.

Family history is significant for a cousin who died suddenly at a young age.


His past medical history is significant for previous myocardial infarction, a 30-pack-year smoking history, gastroesophageal reflux disease, and poorly controlled hypertension.

The patient’s only home medication is omeprazole.

His temperature is 98.6°F (37°C), blood pressure is 140/90 mmHg, pulse is 90/min, respirations are 30/min, and oxygen saturation is 88% on room air.

Physical exam is significant for a jugular venous pressure of 15 cm, an S3 heart sound, bibasilar crackles, and 2+ pitting edema to the knees bilaterally.

His neurological exam is nonfocal and he walks with a steady gait.


He is brought in by his home care nurse, who reports that the patient has a history of myasthenia gravis and frequent urinary tract infections.

His temperature is 99.0°F (37.2°C), blood pressure is 128/78 mmHg, pulse is 92/min, and respirations are 28/min with an oxygen saturation of 86% O2 on room air.

The patient was in his normal state of health until 5 days ago when he developed a urinary tract infection.

This morning, he experienced poor grip strength and progressive difficulty breathing.

The patient has gray-blue skin, hypophonia, weak upper extremities, and normal leg strength.

An arterial blood gas is drawn with results as shown below:

PO2: 55 mmHg
PCO2: 60 mmHg
pH: 7.30

The patient is intubated.

He was receiving gentamicin infusions for his infections.


Her mother is concerned that the patient is a picky eater and refuses to eat vegetables.

She drinks milk with meals and has juice sparingly.

She goes to sleep easily at night and usually sleeps for 11-12 hours.

The patient has trouble falling asleep for naps but does nap for 1-2 hours a few times per week.

She is doing well in daycare and enjoys parallel play with the other children.

Her mother reports that she can walk downstairs with both feet on each step.

She has a vocabulary of 10-25 words that she uses in the form of 1 word commands.

She is in the 42nd percentile for height and 48th percentile for weight, which is consistent with her growth curves.

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 nourished.


He has a history of obesity, hypertension, type 2 diabetes mellitus, and depression.

His current medications include metformin, aspirin, rosuvastatin, lisinopril, and fluoxetine.

He has a 25-pack-year smoking history and drinks 1 glass of wine a day.

His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.

On physical exam, he has a 1.2 x 1.7 cm ulcer on the plantar surface of his left metatarsal head.


He has a history of diabetes, obesity, and hypertension but does not see a physician for his underlying conditions.

His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free.

The patient denies any preceding symptoms.

His temperature is 99.2°F (37.3°C), blood pressure is 140/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.

Physical exam reveals normal vision, strength, and sensation with a stable gait.

Finger-nose testing and tandem gait are unremarkable.

A CT scan of the head is performed and is unremarkable.


The patient was born at 29 weeks gestation to a G1P1 mother.

Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS).

Since discharge from the hospital, her mother reports that the patient has been doing well without health problems.

She has been gaining weight appropriately.

Her temperature is 98.6°F (37.0°C), blood pressure is 80/50 mmHg, pulse is 120/min, and respirations are 25/min.

The patient's mother asks the pediatrician about potentially delaying the 2-month vaccine doses due to the baby's medical history.

Which of the following is the correct vaccination plan for this infant in terms of the vaccinations below?


The patient's medical history is notable for diabetes which was managed during her pregnancy with insulin.

The patient is fatigued but states that she is doing well.

Currently, she is complaining that her vagina hurts.

The next morning, the patient experiences chills and a light red voluminous discharge from her vagina.

She states that she feels pain and cramps in her abdomen.

Her temperature is 99.5°F (37.5°C), blood pressure is 107/68 mmHg, pulse is 97/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Laboratory values are obtained and shown below.


Her medical history includes type 2 diabetes mellitus which is well-controlled with metformin.

Initially, she attributed her mother's forgetfulness and word-finding difficulties to normal aging, but over the past few years, her mother's memory has worsened, her mood has grown more irritable, and her mother has been found wandering the neighborhood unsure of how to get home.

On exam, her temperature is 98.2°F (36.8°C), blood pressure is 115/82 mmHg, pulse is 73/min, respirations are 12/min, and oxygen saturation is 99% on room air.

Cardiopulmonary exam reveals normal S1 and S2, no murmurs, and clear lungs bilaterally.

She scores 16/30 on the Montreal Cognitive Assessment (MoCA) test.


She is sexually active and uses condoms.

She states that it started 1 day ago and has not improved with hygiene products.

She does not complain of any abdominal or pelvic pain but states she has some mild burning when urinating.

Her temperature is 97.6°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 98% on room air.

Physical exam is notable for thick, white discharge from the cervix.

There is no cervical motion or adnexal tenderness or masses.

Some whitish discharge is noted from the urethra.


Her medical history is significant for type 2 diabetes mellitus, hypertension, and osteoporosis for which she takes metformin, enalapril, and alendronate.

She was found to have a deep vein thrombosis of her left leg 3 months prior to presentation.

She noticed her symptoms while in the bathtub at home.

She has never had symptoms like this before.

Over the previous several months she has had episodes of joint swelling and pain in her hands as well as redness, burning pain, and swelling of her hands and feet.

Her temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 135/85 mmHg, and respirations are 13/min.

Physical exam is notable for a woman in discomfort with excoriations over the skin on her forearms.


Her mother fears that her daughter may have caught measles.

The patient has had headaches in the past but this is the worst headache of her life.

Her symptoms started yesterday and have been getting progressively worse.

The patient states that the pain is mostly on the left side of her head.

Her temperature is 98.6°F (37°C), blood pressure is 123/74 mmHg, pulse is 85/min, and respirations are 13/min.

On exam, the patient is an obese girl who is clutching her head with the light in the room turned off.

Her neurological exam is within normal limits.

Fundoscopic exam reveals mild bilateral papilledema.

An MRI of the head is obtained and reveals cerebral edema.

A lumbar puncture reveals an increased opening pressure with a normal glucose level.

There has been a recent outbreak of measles at the patient’s school and the patient’s mother has been trying to give her daughter medicine to prevent her from getting sick.


She has been compliant with her medications, which include albuterol, metformin, glyburide, and atorvastatin.

She thinks that her husband is having sex with other women because they have not had sex over the past year.

She feels that her co-workers also disrespect her for her weight and constant sweat stains around her armpits and chest.

She has noticed that the sweat stains get itchy and induce a burning sensation unless she showers or changes her shirt.

Her temperature is 98.6°F (37°C), blood pressure is 128/85 mmHg, pulse is 91/min, and respirations are 11/min.

On physical exam, the patient has a flat affect, with moist oral mucosa and nasal polyps.

Her neck is thick with a posterior cervical fat pad.

During cardiac auscultation, the finding in Figure A is noted below her breasts.


The child was born at 39 weeks gestation to a 34-year-old G2P2 mother by vacuum-assisted vaginal delivery after prolonged labor.

The mother was diagnosed during this pregnancy with gestational diabetes mellitus and received prenatal care throughout.

All prenatal screening was normal and the 20-week anatomy ultrasound was unremarkable.

She denies that the lump was present at birth and is concerned about an infection.

His birth weight was 3.8 kg (8.4 lb) and his length and head circumference are at the 40th and 60th percentiles, respectively.

His temperature is 98.6°F (37°C), blood pressure is 65/42 mmHg, pulse is 131/min, and respirations are 36/min.

On physical exam, the child is in no acute distress.

He has a 3x3 cm fluctuant swelling over the right parietal bone that does not cross the midline.

There is no discoloration of the overlying scalp.


She has no significant medical history, is up to date on all vaccinations, and her last tetanus shot was 3 years ago.

On arrival, her temperature is 36.7°C (98°F), blood pressure is 82/63 mmHg, pulse is 120/min, respirations are 20/min, and oxygen saturation is 97% on 2L oxygen nasal cannula.

On physical exam, there are extensive ecchymoses and abrasions along her left posterior ribs and left flank.

A CT scan of the abdomen is obtained, which is shown in Figure A.


The patient has a medical history of asthma and his only medication is albuterol.

His temperature is 98.0°F (36.6°C), blood pressure is 120/70 mmHg, pulse is 105/min, and respirations are 17/min.

Exam was significant for pulsatile bleeding from a clean-cut wound on his right second finger.

Radiography of the hand revealed a complete amputation of the right finger from the distal interphalangeal joint.

The teacher applied dressings and pressure to the patient's injured digit and immediately transported the patient to the emergency department.

The wound was cleaned, compression applied, analgesics administered, and the hand surgeons were notified.

He arrived within 20 minutes of the accident.

The teacher states that he left the amputated finger in the classroom, but the principal would be transporting it to the hospital.


His past medical history is notable for hypertension and atrial fibrillation treated with metoprolol, apixaban, and lisinopril.

At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking.

When his wife noted this she brought him into the hospital.

On arrival to the emergency department, the patient is not responding to verbal stimuli and only withdraws his left upper extremity and lower extremity to pain.

The patient has a seizure and subsequently demonstrates agonal breathing.

He no longer responds to painful stimuli.

His temperature is 99.0°F (37.2°C), blood pressure is 170/100 mmHg, pulse is 95/min, and respirations are 16/min.

A fingerstick blood glucose is 122 mg/dL.


The patient has a medical history of type 2 diabetes mellitus, depression, anxiety, and irritable bowel syndrome.

Her current medications include metformin, glyburide, escitalopram, and psyllium husks.

The pain was initially a 4/10 in severity but has increased recently to a 6/10 prompting her to come in.

On exam, the patient is an obese woman with pain upon palpation of the right upper quadrant.

Her temperature is 99.2°F (37.3°C), pulse of 95/min, blood pressure of 135/90 mmHg, respirations of 15/min with 98% oxygen saturation on room air.

Initial labs are are below:

Na+: 140 mEq/L
K+: 4.0 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
AST: 100 U/L
ALT: 110 U/L
Amylase: 30 U/L
Alkaline phosphatase: 125 U/L

Bilirubin
Total: 2.5 mg/dL
Direct: 1.8 mg/dL

The patient is sent for a right upper quadrant ultrasound demonstrating an absence of stones, no pericholecystic fluid, a normal gallbladder contour and no abnormalities noted in the common bile duct.

MRCP with secretin infusion is performed demonstrating patent biliary and pancreatic ductal systems.


The patient has a history of depression and multiple suicide attempts.

He takes fluoxetine as well as over-the-counter pain medications for a recent muscle strain.

He exercises regularly and recently has started making his own beer at home.

He has become gradually more confused over the past several days.

His wife also notes he has had diarrhea, nausea and vomiting, and abdominal pain for the past week.

His temperature is 98.3°F (36.8°C), blood pressure is 107/75 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 99% on room air.

Physical exam reveals a confused man with a garlic odor on his breath and the finding in Figure A. Cardiopulmonary exam reveals a rapid heart rate with no murmurs and clear breath sounds.

He works in a large industrial compound that manufactures semiconductors.


The father’s brother died of sickle cell anemia at an early age.

Parental studies reveal that both mother and father are carriers of the sickle cell gene.

The patient's temperature is 98.6°F (37.0°C), blood pressure is 80/45 mmHg, pulse is 130/min, and respirations are 25/min.

The physician decides to repeat testing for the patient and his 3-year-old sister.

The physician begins counseling the family.


Since he retired, he has been working on projects at home and taking time to exercise every day.

He eats a balanced diet and has been spending time with his wife every evening.

His medical history is significant for hypertension and diabetes for which he takes lisinopril and metformin.

Despite this, the patient claims that he feels less well-rested when he wakes up in the morning.

The patient states that he used to sleep 9 hours a night in his youth and felt excellent.

Now he sleeps 7 hours a night and doesn’t feel as well rested as he used to.

His temperature is 98.6°F (37°C), blood pressure is 131/85 mmHg, pulse is 71/min, and respirations are 12/min.

His neurological exam is within normal limits.

The patient is muscular and has a healthy weight with a pleasant demeanor.

The patient’s wife states that he seems to sleep peacefully.

He denies feeling fatigued or tired currently.


He has no past medical history and takes no medications.

He states he has a constant sensation that the room is spinning.

He is now having trouble walking and has been vomiting intermittently.

His dizziness is constant and unchanged with performance of the Dix-Hallpike maneuver.

His temperature is 98.0°F (36.7°C), blood pressure is 122/84 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Physical exam reveals a young man who is vomiting.

His gait is ataxic and he exhibits rightward nystagmus.

The head impulse test reveals a corrective saccade and there is no skew deviation.


Pregnancy and delivery were uncomplicated but the mother had limited prenatal care during the third trimester.

The mother reports that the patient has developed a cough and nasal discharge.

Upon visual examination of the eyes, mucoid ocular discharge and eyelid swelling are noted.

Immediately after delivery, the baby was given silver nitrate drops and vitamin K. His temperature is 99°F (37.2°C), blood pressure is 81/52 mmHg, pulse is 135/min, and respirations are 36/min with an oxygen saturation of 98% O2 on room air.

On lung exam, scattered crackles are appreciated.

A chest radiograph is performed that shows hyperinflation with bilateral infiltrates.


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.


Menarche was at age 12 and she had regular periods up until 2 years ago.

She is otherwise healthy, participates in multiple school sports teams, and has been training rigorously for upcoming competitions.

She denies alcohol use, smoking, and recreational drugs.

She is not sexually active and does not take oral contraceptives.

At that time, her periods became less regular until around 7 months ago when they ceased altogether.

Her temperature is 36.7°C (98°F), blood pressure is 121/80 mmHg, pulse is 62/min, respirations are 11/min, oxygen saturation is 100% on room air, and BMI is 20 kg/m^2.

Her pelvic exam reveals an anteverted uterus, no adnexal masses, a normal-appearing cervix with no cervical motion tenderness, and normal vaginal anatomy.


Physical exam reveals sparse hair that is falling out throughout the patient’s body.

He has a rash by the corners of his mouth.

The patient has multiple loose bowel movements and on day 6 the patient’s surgical wound does not appear to be healing.

The patient is intoxicated and is unable to offer further history.

His temperature is 97.5°F (36.4°C), blood pressure is 92/52 mmHg, pulse is 145/min, respirations are 33/min, and oxygen saturation is 90% on room air.

He is intubated to protect his airway, given 2 units of packed red blood cells, and sent to the operating room for an exploratory laparotomy.

The patient is subsequently admitted to the intensive care unit.

He is extubated the next day and appears well.

It is held together only by the sutures with minimal underlying healing.


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.


He was born at 37 weeks gestation to a 39-year-old G3P3 mother.

The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress.

The mother declined all prenatal screening tests during this pregnancy.

His temperature is 98.6°F (37°C), blood pressure is 63/41 mmHg, pulse is 133/min, and respirations are 39/min.

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

His weight is 3.0 kg (6.6 lb), and his height and his head circumference are in the 30th and 40th percentiles, respectively.

On physical exam, he is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of the bowel.

The abdominal defect is immediately covered in sterile saline dressings and an orogastric tube and 2 peripheral intravenous lines are placed.

The infant was eventually delivered via Caesarean section.


His parents report that he is feeding and stooling well and they have just started experimenting with solid foods.

The patient was noted to be developmentally appropriate for his age at his last visit 2 months ago.

His parents are concerned because a few weeks ago he started rolling from back to front in addition to front to back, but he now struggles when placed on his back.

In the examination room, he is able to roll from front to back but cannot roll from back to front.

He is not able to sit without support and makes no attempt at bouncing when supported in a standing position.

On physical exam, the patient seems well-nourished and has no dysmorphic features.

His temperature is 98.6°F (37°C), blood pressure is 77/49 mmHg, pulse is 112/min, and respirations are 24/min.

The patient’s abdomen is non-tender and soft without hepatosplenomegaly.

His patellar reflexes are 4+ bilaterally.


His medical and surgical history is significant for the reconstruction of a torn anterior cruciate ligament in his right knee.

His family history is significant for a mother with “thyroid problems” and a father with coronary artery disease.

The patient is an information technology specialist at a local company.

His temperature is 98.6°F (37.0°C), blood pressure is 124/82 mmHg, pulse is 71/min, and respirations are 12/min.

On physical exam, the patient is tall and slender with a BMI of 21 kg/m2.

A single nodule can be palpated on the patient’s thyroid.

He has palpable cervical lymphadenopathy.

On cardiac exam, he has a normal S1/S2 with no murmurs, rubs, or gallops, and his lungs are clear bilaterally.

His abdomen is soft and non-tender without hepatosplenomegaly.

A physical exam of the perioral region can be seen in Figure A.


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.


Her family history is notable for hypothyroidism in her mother.

She does not smoke cigarettes, stopped drinking alcohol prior to pregnancy, and does not use drugs.

She first presented 4 weeks ago with bilateral hand tremors.

She reports mild improvement in her symptoms but continues to experience sweating and palpitations.

At that time, she was found to have a thyroid-stimulating hormone (TSH) concentration <0.01 mU/L and an elevated free T4.

Her temperature is 97.6°F (36.4°C), blood pressure is 113/70 mmHg, pulse is 126/min, and respirations are 18/min.

On physical exam, she appears anxious, mildly diaphoretic and has a non-tender prominence on her neck which is shown in Figure A.

She was started on propranolol and propylthiouracil.

The dosage of both medications has been titrated to the maximum dose.


His medical history is pertinent for intravenous drug use.

The pain is localized to 1 spot in his lower back and is worse with physical activity.

His temperature is 36.8°C (98.2°F), blood pressure is 118/90 mmHg, pulse is 92/min, respirations are 13/min, and oxygen saturation is 99% on room air.

On physical exam, he has midline back tenderness to palpation at L2-L3.

Laboratory workup reveals an erythrocyte sedimentation rate of 112 mm/h and C-reactive protein of 10 mg/dL.


She has a history of hypertension, hyperlipidemia, and diabetes.

Her medications are lisinopril, amlodipine, atorvastatin, and metformin.

She is a non-smoker and drinks 3-4 standard drinks per week.

She has no complaints and is asymptomatic.

Her temperature is 98.2°F (36.8°C), blood pressure is 142/84 mmHg, pulse is 82/min, and respirations are 16/min.

On physical exam, a solid, immobile neck mass is palpated inferior to the cricoid cartilage to the left of midline.

An ultrasound is obtained and shows a 1.2 cm hypoechoic mass with microcalcifications.

Serum thyroid-stimulating hormone (TSH) concentration is 7.2 µU/mL.

There is no family history of malignancy.


He has a history of depression which is well managed with fluoxetine.

He has a past medical history of diabetes and notes that his home blood glucose readings have been higher lately.

He states that since starting the medication, his sexual drive has increased, yet he is unable to achieve orgasm.

As a result, he refuses to take the medication anymore.

His temperature is 98.3°F (36.8°C), blood pressure is 127/82 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.

Physical exam reveals an obese man in no acute distress with a normal affect and non-focal neurologic exam.

The physician agrees to change the patient’s antidepressant.


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

He is currently not taking any medications and has not filled his prescriptions for over 1 year.

He has been taking his medications and resting.

The patient states he feels better since the incident.

An ECG is obtained and is seen in Figure A.

At this visit, his temperature is 99.5°F (37.5°C), blood pressure is 130/87 mmHg, pulse is 80/min, respirations are 11/min, and oxygen saturation is 96% on room air.

The patient is managed appropriately and is discharged on atorvastatin, metoprolol, aspirin, clopidogrel, and sodium docusate.

The patient visits his primary care physician 4 weeks later and claims to be doing better.


His medical history is otherwise significant for hypertension and diabetes mellitus, for which he takes metformin and lisinopril.

His dyspnea began 1 hour ago while he was sitting in a chair watching television.

He also endorses lightheadedness and fatigue but denies chest pain.

His temperature is 98.8°F (37.1°C), blood pressure is 85/54 mmHg, pulse is 48/min, and respirations are 22/min.

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

He has normal cardiac sounds with an irregular rhythm.

His lungs are clear to auscultation bilaterally, and his electrocardiogram can be seen in Figure A.

The patient is given an initial dose of atropine but this has no effect.

Two weeks ago, he had a mitral valve repair for mitral insufficiency secondary to myxomatous degeneration.


The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day.

He was born at 35 weeks gestation to a 27-year-old G4P4 mother.

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

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

The patient’s 3 older siblings are all healthy.

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

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

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


He admits to occasional cocaine and marijuana use.

Otherwise, the patient has no significant medical history and is not taking any medications.

During this past week, he has been unable to properly study and prepare for final exams because he is exhausted.

He has been going to bed early but is unable to get a good night’s sleep.

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 a tired and anxious appearing young man.

His neurological exam is within normal limits.

The patient states that he fears he will fail his courses if he does not come up with a solution.


He has a history of hypertension, hyperlipidemia, and depression.

He currently takes amlodipine and atorvastatin and is compliant with his medications.

He has a 45-pack-year smoking history, but he does not drink alcohol or use any illicit drugs.

He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite.

He denies any diarrhea or hematochezia and says the pain is not affected by movement.

During evaluation, the patient becomes diaphoretic and pale and reports that he feels fatigued.

His temperature is 98.6°F (37°C), his blood pressure is 110/64 mmHg, pulse is 97/min, and respirations are 15/min.

Physical exam is notable for diffuse abdominal tenderness without rigidity or guarding.

Repeat blood pressure is 87/50 and pulse is 127.

Intravenous fluid boluses are administered.


The patient was born at 39 weeks of gestation via spontaneous vaginal delivery.

He is up to date with routine vaccinations.

His mother is concerned about his vision, as she noticed him squinting while watching television.

When focusing on the pediatrician's penlight, the patient's left eye wanders.

He is able to walk alone, speak 3 words, and scribble with a crayon.

His temperature is 98.6°F (37.0°C), blood pressure is 80/55 mmHg, pulse is 105/min, and respirations are 25/min.

On exam, his pupils are round and reactive to light.

However, when the right eye is covered, the left eye refocuses on the light.

The rest of his neurological exam, including extraocular movements, is within normal limits.

A photograph of his eyes is shown in Figure A.


Her mother reports that the patient began having “explosive” diarrhea 6 hours ago.

The patient has little interest in feeding since leaving the hospital after her birth and has not yet regained her birth weight.

The patient passed meconium on the 3rd day of life.

Her temperature is 101.8°F (38.8°C), blood pressure is 58/37 mmHg, pulse is 148/min, and respirations are 38/min.

On physical exam, the patient appears to be in moderate distress.

She has no dysmorphic features and she has a normal S1/S2 without any murmurs, rubs, or gallops.

A digital rectal exam reveals a tight anal sphincter and precipitates a release of gas and liquid stool.

Her immediate postnatal period was otherwise significant for 2 episodes of bilious vomiting that resolved with the temporary use of a nasogastric tube and expulsion of stool during a digital rectal exam.

Her abdominal radiograph can be seen in Figure A.


She has a medical history of generalized anxiety disorder and hypothyroidism for which she takes escitalopram and levothyroxine.

She had a Roux-en-Y gastric bypass 5 years ago.

She has been in a monogamous relationship with her husband for the last 15 years and uses a copper intrauterine device.

She feels more irritable with her husband and children and does not find pleasure in creating art anymore.

Over the last 2 weeks, she has been sleeping approximately 5 hours a night and had a fall while walking in her home with the lights off.

Physical examination is notable for a depressed affect.

Pupils are equal, round, and reactive to light and accommodation.

She has 4/5 strength in the bilateral lower extremities and brisk patellar reflexes.

She denies any head trauma or loss of consciousness associated with the fall.


The patient was found on a mountain trail non-responsive.

Dark bullae are noted on the patient's extremities.

His temperature is 91°F (32.8°C), blood pressure is 103/61 mmHg, pulse is 60/min, respirations are 11/min, and oxygen saturation is 97% on room air.

An ECG is performed as seen in Figure A.

The patient is placed under a warm air circulator, and his extremities are bathed in warm water.

His mental status rapidly improves with warming.

Laboratory studies are ordered and are pending.


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.


His past medical history is notable for diabetes and obesity.

He has smoked 1 pack of cigarettes per day for the past 30 years.

His symptoms started at work when he was lifting boxes.

He states that he currently feels crushing pressure over his chest.

He is given nitroglycerin, with minimal improvement in his symptoms.

His temperature is 97.9°F (36.6°C), blood pressure is 155/99 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 98% on room air.

Physical exam reveals an uncomfortable, diaphoretic man.

His heart and breath sounds are unremarkable.

The patient’s chest pain is worse when the ECG in the emergency department is taken, compared to the one taken in triage.

He is given aspirin and an ECG is performed in triage, as seen in Figure A.

A repeat ECG in the emergency department is performed, also seen in Figure A.


She has a history of obesity, hypertension, and depression for which she takes losartan and sertraline.

She has smoked 1 pack of cigarettes per day for 30 years.

Her temperature is 99.5°F (37.5°C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min.

Physical exam is unremarkable, including no costovertebral or suprapubic tenderness to palpation.


The patient has a past medical history of obesity, poorly controlled diabetes, hypertension, and peripheral vascular disease.

He states that ever since his wife died 4 months ago, he has been eating and sleeping more and no longer engages in any activities he once enjoyed such as hiking or fishing.

He feels guilty for not spending more time with his wife before she died.

He was recently fired for making several major bookkeeping mistakes at work as an accountant as he had trouble focusing.

The patient is requesting oxycodone at this appointment as he states he has burning pain in his legs that feels worse now than it has in years past.

His temperature is 98.7°F (37.1°C), blood pressure is 129/82 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam reveals a stable gait and reduced sensation symmetrically over the lower extremities.

He complains of electric pain when touching his lower extremities.


Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin.

She traveled recently and has no sick contacts.

On exam, her abdomen is soft, non-distended, and non-tender to palpation; however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding.

Her temperature is 37.0°C (98.6°F), blood pressure is 118/82 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air.

She recently completed a course of clindamycin 2 weeks ago for a tooth infection.


She experienced menarche at age 12 and has regular periods.

She states that she has had recurrent bouts of mood swings, bloating, and abdominal pain that occur together approximately every 4 weeks.

She states that when these symptoms occur, she gets into frequent arguments at work, is unable to concentrate, and sleeps longer than usual.

Furthermore, she has episodes of extreme anxiety during these periods, leading her to take off time from work.

She notes that these symptoms are causing distress in her interpersonal relationships as well.

Her temperature is 98.2°F (36.8°C), blood pressure is 100/70 mmHg, pulse is 75/min, and respirations are 12/min.

Physical exam reveals a nontender abdomen.

Pelvic exam reveals a closed cervix with no cervical motion or adnexal tenderness.

Her cardiopulmonary and neurological exams are unremarkable.

She has no past medical history and takes no medications.


She has had regular menses since menarche, and her last menstrual period ended 8 days ago.

Her temperature is 98.6°F (37°C), blood pressure is 114/71 mmHg, pulse is 81/min, and respirations are 12/min.

She had unprotected sexual intercourse earlier that morning and requests emergency contraception.

The patient asks for an emergency contraceptive pill and would prefer that her parents not be notified about her visit.


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.


He was running a marathon but became confused halfway through the race.

He arrives unable to coherently answer questions and is not sure where he is.

His temperature is 105°F (40.6°C), blood pressure is 116/68 mmHg, pulse is 167/min, respirations are 29/min, and oxygen saturation is 99% on room air.

Physical exam reveals a confused man who is moving all 4 extremities and is protecting his airway.

During the exam, he develops a tonic-clonic seizure, which lasts 1 minute and then terminates on its own.

A urine dipstick is positive for red blood cells.

The patient is given intravenous fluids, and basic laboratory studies are drawn and pending.


He was noted to have surpassed his birth weight at his last office visit 1 week ago.

His parents report that he suddenly started vomiting this morning and has shown no interest in feeding since then.

They describe the vomitus as green and without any traces of blood.

His temperature is 97.6°F (36.4°C), blood pressure is 78/56 mmHg, pulse is 148/min, and respirations are 44/min.

On physical exam, the patient is in mild distress.

He has no dysmorphic features, and his mucous membranes are dry.

An abdominal radiograph is performed as in Figure A.


He has no medical problems and takes no medications.

He was riding his bicycle when he fell onto his outstretched right hand.

He immediately clutched his right elbow in pain and began crying.

His temperature is 98.4°F (36.9°C), blood pressure is 108/64 mmHg, pulse is 100/min, and respirations are 20/min.

On exam, the boy is holding his right wrist with his left hand and cries upon palpation of a region that is 2 cm proximal to his elbow.

The radial head is palpated just distal to the lateral epicondyle.

He is unable to make a pincer with his right thumb and index finger.

When asked to hold a pen between his right thumb and index fingers, he drops it.

The radial pulse is diminished on the right.


He was walking in the park about 45 minutes prior to arrival when the patient stumbled and fell.

He had sudden weakness in his left leg and was unable to grasp a handrail with his left hand.

His temperature is 98.0°F (36.6°C), blood pressure is 128/89 mmHg, pulse is 130/min, and respirations are 18/min.

On exam, he has 3/5 strength in the left upper and lower extremities and a left-sided facial droop.

A non-contrast CT scan of the head is performed, which suggests parenchymal ischemia in the distribution of the right middle cerebral artery.

He is given intravenous alteplase with rapid improvement in his strength deficits and facial asymmetry.

An ECG is performed, as shown in Figure A.


He was in class when he suddenly fainted and became unresponsive.

An autopsy is performed and is notable for no clear abnormalities.

The patient’s laboratory studies were unremarkable from a visit to the pediatrician 3 weeks ago.

His teacher began chest compressions and he has received epinephrine and defibrillation from paramedics while in transport.

On arrival, the patient remains pulseless and is pronounced dead.


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.