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.

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

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 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.


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.


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.


He states that he lives at home with his parents his entire life and recently was able to get a job at a local factory.

Ever since the patient started working, he has had trouble focusing on his job.

He is unable to stay focused on any task.

His boss often observes him "daydreaming" with a blank stare off into space.

His boss will have to yell at him to startle him back to work.

The patient states that he feels fatigued all the time and sometimes will suddenly fall asleep while operating equipment.

He has tried going to bed early for the past month but is unable to fall asleep until 2 hours prior to his alarm.

His temperature is 98.6°F (37°C), blood pressure is 112/68 mmHg, pulse is 81/min, and respirations are 12/min.

A physical exam is within normal limits.

The patient fears that if this continues he will lose his job.


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.

Her lab values and clinical presentation remain unchanged 24 hours later.


The patient has a medical history of marijuana and IV drug use as well as multiple suicide attempts.

He was brought in by police for shouting on a subway.

The patient claims that little people were trying to kill him and he was acting within his rights to defend himself.

While in the ED, the patient is combative and refuses a physical exam.

Though he is no longer aggressive, he is seen making "armor" out of paper plates and plastic silverware to defend himself.

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

He is given IM haloperidol and diphenhydramine.

The patient is transferred to the inpatient psychiatric unit and is continued on haloperidol throughout the next week.


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

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

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

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

The patient states she is not doing this intentionally.

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

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

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


The patient has a medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures.

The patient has IV drug and alcohol use disorder and has presented to the ED many times for intoxication.

She was at a rehabilitation hospital when her symptoms started.

Physical exam reveals anasarca and asymmetric lower extremity swelling.

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

Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started.

The patient is then transferred to the general medicine floor for continued management.


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

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

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

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


His activity level has been normal and he has been attending school until this morning.

He has no medical history or known allergies, but he has not received any of the recommended vaccines due to parental refusal.

His temperature is 100.3°F (37.9°C), blood pressure is 98/62 mmHg, pulse is 85/min, respirations are 22/min, and oxygen saturation is 98% on room air.

Bilateral conjunctivae are injected, and there is redness on and around the tonsils.

Faint rhonchi are heard at the lung bases bilaterally.


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

She is sexually active and does not use condoms.

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

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

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

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

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

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

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

Intravenous fluids are started and labs are sent.


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.


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.


His medications include hydrochlorothiazide.

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

He reports that he was rocking his grandson to sleep when the symptoms began.

He states the pain is constant and is primarily located on his right side.

When asked to indicate the area of pain, he says that it surrounds his eye and upper forehead.

The patient also reports difficulty seeing out of his right eye, which he attributes to excessive tearing.

The patient’s right eye is shown in Figure A.

Upon physical examination, the right pupil is minimally responsive to light and the globe feels firm.

A right-sided carotid bruit is appreciated.


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 has no significant medical history and takes no medications.

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.


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

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

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

The pain started a year ago and has progressed.

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

He localizes the pain to the front of his groin.

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

A radiograph is obtained as in Figure A.


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.


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.

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.

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

A photograph of his eyes is shown in Figure A.


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.

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


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 hypertension, glaucoma, and osteoarthritis in his left knee that requires him to walk with a cane.

He takes hydrochlorothiazide, timolol eyedrops, and occasional acetaminophen.

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

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

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

The patient is unable to provide a clear history.

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

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

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

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

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


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

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 traveled recently and has no sick contacts.


Her husband tells the physician that he is concerned that the patient has been increasingly obsessed about her weight recently.

She has a history of major depressive disorder for which she takes escitalopram.

She has been experiencing nausea, vomiting, and diarrhea after eating leftovers 2 days ago.

Her temperature is 98.6°F (37.0°C), blood pressure is 110/72 mmHg, pulse is 110/min, and respirations are 11/min.

Physical examination is notable for dry mucous membranes and tachycardia with regular rhythm.

Laboratory testing shows the following results:

Serum:
Na+: 135 mEq/L
Cl-: 96 mEq/L
K+: 2.9 mEq/L
HCO3-: 36 mEq/L

Venous blood gas shows a pH of 7.52.


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.


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.


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

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

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

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

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

The previous skin lesion appears unchanged.

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

A photograph of the lesion is shown in Figure A.

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


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.


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

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

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

He occasionally misses school due to the pain.

There is blood in his stool during these episodes.

These symptoms have persisted for many years.

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

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

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

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

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

He also has the findings seen in Figure A.


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.


There were no passengers and he was awake but disoriented at the scene.

He is speaking but is confused, opens his eyes to voice commands, and follows simple commands.

His cardiac exam is normal and his lungs are clear to auscultation bilaterally.

Paramedics report that the patient was driving the car and crashed into a tree at roughly 25 miles per hour.

His temperature is 97.9°F (36.6°C), blood pressure is 131/88 mmHg, pulse is 89/min, and respirations are 14/min.

He has multiple lacerations on his face and arms and smells of alcohol and marijuana.

He has bruising over his abdomen without any tenderness to palpation, distension, or rigidity.


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?


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.


He was found lying down at a bus stop unresponsive.

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

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

Physical exam reveals a sleeping man with miotic pupils.

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

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


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

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

There is no family history of malignancy.

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

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

She has no complaints and is asymptomatic.

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.


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.


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

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

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

Physical exam is notable for jugular venous distension.

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

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


The patient has a medical history of alcoholism and has been admitted to the hospital multiple times for withdrawal, abdominal pain, and traumatic injuries from his drinking.

The patient states that his last drink was more than 1 year ago.

His temperature is 99.3°F (37.4°C), blood pressure is 115/78 mmHg, pulse is 78/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam reveals a non-tender, non-distended abdomen.

Laboratory studies are notable for a serum calcium of 7.0 mg/dL.

A computed tomography (CT) scan of the abdomen is performed as seen in Figure A.

A Sudan Black stain of the patient’s stool is positive.


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

He noticed this yesterday as well, but it was much scanter.

He was celebrating his birthday last night and admits having "too much to drink" and vomited profusely overnight.

He currently feels well and is not nauseous.

His temperature is 99.2°F (37.3°C), blood pressure is 110/75 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.

Physical exam reveals a nontender abdomen with normal bowel sounds.

Rectal exam reveals grossly bloody stool.

Laboratory studies are ordered as shown below.


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

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

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

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

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

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

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


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

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

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

Physical exam reveals a thin, ill-appearing man.

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

His chest radiograph is shown in Figure A.


The shaking improves when he reaches for objects but returns when he is not using his hand.

His left hand exhibits a 4-6 Hz tremor when resting on his lap.

The tremor extinguishes with voluntary movement.

In addition, his left upper extremity has increased tone with passive range of motion.

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


His medical history is significant for IV drug use, HIV (CD4: 47/mm^3), hypertension, hyperlipidemia, diabetes mellitus, and seasonal allergies.

His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen.

He has injected conjunctiva and rhinorrhea.

His temperature is 100.8°F (38.2°C), blood pressure is 127/85 mmHg, pulse is 78/min, and respirations are 12/min.

His cranial nerves are intact, and his motor and sensory neurologic exam is normal.

A MRI of the brain is performed and can be seen in Figure A.

His home medications include hydrochlorothiazide, atorvastatin, metformin, cetirizine, darunavir, tenofovir, and emtricitabine.


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.


She was delivered preterm at 35 weeks, and her medical history is significant for several ear infections over the last year.

Her older brother has been diagnosed with attention-deficit hyperactivity disorder (ADHD), but the rest of her family history is otherwise unremarkable.

Otherwise, the patient is energetic and started preschool 3 months ago.

The patient has become more withdrawn lately and has sometimes been ignoring her parents when asked to perform tasks at home.

This seems to have worsened over the last 8 weeks.

She seems distracted during the interview and responds only intermittently to the physician’s directions.

Her temperature is 98.6°F (37°C), blood pressure is 98/62 mmHg, pulse is 97/min, and respirations are 26/min.

The patient successfully draws a square and can stand on 1 foot.

Her neurological examination is normal, and she is at the 50th percentile for height and weight.

Her language skills are unchanged from her appointment 6 months ago.


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.

She has a past medical history of polycystic ovary syndrome.


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 no medical problems and takes no medications.

He gets along with his 2 brothers, plays turn-taking games with his friends, and completes his chores.

At school, he interrupts class by making barking noises.

His mother notes that he has been making throat-clearing noises daily for the past 2 years.

On exam, he grimaces several times and blinks his eyes rapidly.

His temperature is 98.4°F (36.9°C), blood pressure is 118/72 mmHg, pulse is 72/min, and respirations are 16/min.

He does not appear to be reacting to internal stimuli.


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

He is otherwise healthy and has met all developmental milestones.

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.

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.


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.


The resident suggests performing one on the deceased patient, as the student cannot harm him.

A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation.


For 2 months, she has experienced intermittent palpitations along with menstrual irregularity and hair loss.

At home, the air conditioner is at its coldest setting, but the patient still feels overheated.

Her temperature is 99.5°F (37.5°C), blood pressure is 135/90 mmHg, pulse is 120/min, and respirations are 22/min.

The patient is diaphoretic with tremulous hands, demonstrates thyromegaly, and protrusion of her eyes is noted.

She is given atenolol in the emergency department with improvement of her palpitations and is instructed to follow up with her primary doctor for further management.


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.

Laboratory studies are ordered as seen below.


The patient has no medical conditions and takes no medications.

She typically swims or uses an exercise bike for 45 minutes, 5 days a week, and plays in an office soccer league for 1 hour on 1 day per week.

The first day of her last menstrual period was 7 weeks prior to presentation.

Her temperature is 98.6°F (37.0°C), blood pressure is 110/70 mmHg, pulse is 64/min, and respirations are 17/min.

Physical exam is notable for a nontender abdomen.

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

A urine pregnancy test is positive, and an intrauterine singleton pregnancy measuring approximately 9 weeks gestational age is visualized on transvaginal ultrasound.

The patient asks if she should modify her current exercise regimen due to her pregnancy.


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.


She lives with her mother who has diabetes whose medications include metformin, insulin, lisinopril, amlodipine, and glyburide.

This has happened several times this past month with increasing frequency.

Each time her symptoms improved with eating.

Her temperature is 98.0°F (36.7°C), blood pressure is 132/81 mmHg, pulse is 85/min, respirations are 16/min, and oxygen saturation is 98% on room air.

She is moving all her extremities but follows commands poorly.

Laboratory studies are ordered as seen below.


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.


The patient is not aware of any medical problems and just started seeing a primary care physician last week.

He recently used a friend's prescription for ondansetron for nausea.

He was outside tending to his lawn for several hours in the heat, when he stood up suddenly from pulling weeds and fainted.

He denies any preceding symptoms and returned to baseline within 1 minute.

His temperature is 99.3°F (37.4°C), blood pressure is 142/88 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air.

Physical exam reveals intact cranial nerves, normal strength and sensation, and a stable gait.

An ECG is performed as seen in Figure A.


His other medications include albuterol.

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

Physical exam reveals a depressed affect.

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

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

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


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 gait is ataxic and he exhibits rightward nystagmus.

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.

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


He has a history of heart failure with reduced ejection fraction, obesity, diabetes, hypertension, acute coronary syndrome, atrial fibrillation, and peripheral vascular disease.

He states that his wife made him come in when he fainted today while attempting to stand up.

He otherwise states he has noticed some visual changes, including noting a yellow tint to objects.

His temperature is 98.5°F (36.9°C), blood pressure is 153/91 mmHg, pulse is 40/min, respirations are 15/min, and oxygen saturation is 97% on room air.

Physical exam reveals a frail man who is unable to ambulate secondary to lightheadedness.

His neurological exam is otherwise non-focal.


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

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

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

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

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

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

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


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

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


He has experienced similar symptoms before.

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

The patient speaks with a muffled voice.

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

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

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


He is otherwise healthy and takes no medications.

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

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

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

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

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


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 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.


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.


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

He also has hypertension but does not take any medications.

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

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

During the exam, the patient states that he feels lightheaded and appears occasionally somnolent.

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

Physical exam reveals a somnolent and uncomfortable man.

An ECG is performed as seen in Figure A.


He has a medical history of obesity and smokes regularly.

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

He also has experienced abdominal pain and diarrhea.

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

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

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


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.


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.


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

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

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


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.

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.

Physical exam reveals an uncomfortable woman.

Laboratory studies and a urinalysis are pending.


This has happened in the past, but his mother thought he was fabricating his symptoms.

He has had an MRI of the brain with no acute findings in the past.

The child has a history of migraine headaches with aura that resolve with ibuprofen.

He is otherwise healthy and has no medical problems or recent illness and is up to date on his vaccinations.

The mother states this episode lasted about 3 minutes and involved full-body jerking.

After the episode, the child was non-responsive but was breathing on his own.

He initially is unable to move his left upper and lower extremity and has a left facial droop; however, after a few minutes, he has 4/5 strength in the affected side with resolution of his facial weakness.

The mother notes that this is similar to his past episodes.

His temperature is 97.6°F (36.4°C), blood pressure is 100/64 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 99% on room air.

The patient is protecting his airway but is unable to answer questions.

He is able to move the right upper and lower extremity.

She has taken him to a free health clinic to have him seen by a doctor who prescribed medication; however, she has been unable to fill the prescription.


He uses intravenous drugs and is unable to offer a history.

Physical exam reveals an obtunded man covered in vomit, with track marks on his arm and several skin abscesses.

His temperature is 99.0°F (37.2°C), blood pressure is 80/40 mmHg, pulse is 156/min, and respirations are 26/min.

As the fourth liter of fluids is finishing, the patient is noted to have jugular venous distension and an oxygen saturation of 92% on nonrebreather.

The patient is given 4 liters of Ringer lactate and intravenous antibiotics.

The patient is started on norepinephrine, and his blood pressure is subsequently found to be 85/44 mmHg.


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

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

Sometimes he notes blood on the toilet paper.

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

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

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

He is generally healthy and does not smoke.


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.

Physical exam reveals an obtunded man who cannot answer questions.

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.

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

However, his bleeding resolved with pressure and nasal packing.

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


The patient is obese, and her only medication is an oral contraceptive pill.

She otherwise is known to smoke cigarettes on occasion.

She was found to have altered mental status at home, and during transport to the hospital, she became pulseless.

Physical exam is notable for a critically ill patient with chest compressions ongoing.

The monitor shows pulseless electrical activity.

A bedside echocardiograph is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle.

Cardiopulmonary resuscitation is ongoing and 2 intravenous lines are placed.

The patient regains her pulse after several rounds of CPR and epinephrine.

She recently underwent Achilles tendon repair.

Her right lower extremity is in a post-operative splint.


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.


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 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.

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

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.


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.

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

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%.

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


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 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 has dementia at baseline and is minimally interactive.

She was last known to be normal the night before.

This morning, she was found to be obtunded.

Her temperature is 95.0°F (35.0°C), blood pressure is 84/54 mmHg, pulse is 50/min, respirations are 9/min, and oxygen saturation is 98% on room air.

Physical exam reveals an obtunded woman who only withdraws her extremities to pain.

Her skin is cool and pale, and her hair is thin.

Laboratory values are notable for a whole blood sodium of 120 mEq/L.

The patient is given several intravenous boluses of fluids and her blood pressure improves to 100/60 mmHg.

No further history was provided from the nursing home, and the patient is unable to provide any history.

There are no signs of trauma noted on exam.


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.

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.

There is not a clear, single bleeding vessel.


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

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

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

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

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

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

The patient's neurological exam is unremarkable.


He 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.


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

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

He has no family history of gastrointestinal malignancy.

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

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

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

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

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

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

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


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.


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

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

Today, his wife noticed that he was confused.

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

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

Physical exam reveals a confused man with dry mucous membranes.

His abdomen is diffusely tender to palpation.

Laboratory studies are ordered and notable for the following:

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

An ECG is ordered and is pending.


Her 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.


He has a history of alcohol use disorder and has vomited small streaks of blood in the past, but has never undergone formal medical workup for it.

His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total.

On exam, he has bright red blood in his mouth and pharynx, and also displays a distended abdomen with a fluid wave, jaundice, scattered spider angiomas, and multiple ecchymoses.

His temperature is 98.4°F (36.9°C), blood pressure is 98/68 mmHg, pulse is 125/min, and respirations are 22/min.

A rapid point-of-care hemoglobin and platelet count is 8.8 g/dL and 80,000/mm^3, respectively.

The patient is given 1L of normal saline.


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.


One month prior to his ED visit, he had been treated with oral antibiotics when he presented to an urgent care center with left-sided otorrhea, otalgia, and hearing loss.

In the ED, he denied headaches, fever, otalgia, otorrhea, or hearing loss.

Magnetic resonance imaging of the brain with contrast showed diffuse enhancement and possible coalescence in the left mastoid process with adjacent dural enhancement and sigmoid sinus occlusion.

There was no periauricular swelling or erythema.

Otoscopic examination showed no inflammation of the external auditory canals, and the tympanic membranes were translucent without evidence of retraction or effusion.

Computed tomographic venogram confirmed occlusion of the left transverse and sigmoid sinuses, and computed tomography of the temporal bone showed coalescence of mastoid air cells with erosion into the sigmoid sinus.

Histologic findings from the specimens demonstrated cells with oval nuclei and abundant cytoplasm arranged in syncytial clusters with occasional whorls, pseudoinclusions, and psammomatous calcifications (Figure, A).

Immunohistochemical stains were positive for epithelial membrane antigen (EMA) and vimentin (Figure, B).Hematoxylin-eosin stain (A) and immunohistochemical stain (B) after mastoidectomy for biopsy and culture specimens.

He received intravenous vancomycin and cefepime and was started on a heparin drip before being transferred to our facility.

Mastoidectomy was performed for biopsy and culture specimens.

On presentation at our facility, the patient appeared well with normal vital signs.


Additional treatment with fluconazole, augmentin, doxycycline, omeprazole, prednisone, and bactrim failed to improve symptoms.Further exploration of the patient’s history revealed that 5 years earlier, he had traveled to Guyana in South America.

After that trip, he sought medical care for multiple neck subcutaneous nodules as well as for a 4-cm focus of neck cellulitis.

B, Physical examination showed recurrent skin lesions at incision site and in the surrounding skin.Empirical treatment with augmentin and nystatin oral suspension for possible bacterial or fungal pharyngitis was unsuccessful, with symptoms worsening during the subsequent 2 weeks.

A physical examination, including flexible laryngoscopy, revealed cobbling, adherent, thick yellow mucus and ulceration of the uvula (Figure 1A).A, Nasopharyngoscopic imaging revealed infected nasal surface of uvula.

Results of laboratory testing for group A Streptococcus, COVID-19, and mononucleosis were negative.

A tissue biopsy was performed, and results of pathology revealed epithelial hyperplasia with suppurative granulomatous inflammation without evidence of dysplasia or malignancy.

There was no evidence of fungal or acid-fast organisms.

Tissue culture revealed only normal respiratory flora.

Findings of pathologic testing revealed dense granulomatous inflammation.

After failed treatment with empirical antibiotics, the largest lesion was excised.

However, results of stains for bacteria, fungus, and acid-fast bacillus were negative (Figure 1B).


Review of systems was notable for fatigue.

Examination of the mouth revealed multiple coalescing painless nonpruritic black macules and patches on the tongue, roof of the mouth, and buccal mucosa.

Examination of the skin was notable for erythematous and hyperpigmented patches covering 90% of the body surface area, consistent with her known mycosis fungoides.

Other notable findings on examination were 1- to 2-cm lymphadenopathy in the bilateral inguinal folds and axillae.

The patient had previously received 5 cycles of romidepsin with progression of disease, followed by 4 doses of pegylated liposomal doxorubicin hydrochloride, which was followed by partial response.Black macules and patches on the tongue, roof of the mouth, and buccal mucosa.


He had immigrated from Nigeria 10 years prior, had not returned since, and was working as a traveling nurse.

Ophthalmology was consulted to evaluate for a conjunctival foreign body of the left eye.

At the time of the examination, his symptoms had resolved; however, he had a photograph from a cellular phone taken during the episode (Figure 1).

He reported a similar sensation of movement in his left eye that occurred for 1 night about 5 years ago for which he visited an urgent care center where he was diagnosed with allergic conjunctivitis.

He also reported recent swelling of the left side of his face with associated numbness and occasional swelling of his left hand, all of which resolved after a few days.

The photograph shows an irregular, serpiginous extension from beneath the plica semilunaris toward the corneal limbus with localized conjunctival hyperemia.

A slitlamp examination did not reveal any conjunctival hyperemia, foreign bodies, or other abnormalities like those shown in the photograph.

His uncorrected visual acuity was 20/20, extraocular movements were full and without pain or abnormal sensation, and intraocular pressure was normal.

His dilated fundus examination was unremarkable.


On examination, his best-corrected visual acuity was 20/20 OU, and intraocular pressures were normal in both eyes.

Results of slitlamp examination of the right eye were unremarkable.

Slitlamp examination of the left eye revealed a round, pigmented lesion measuring 3 × 3 mm in basal dimension and with gravitational shifting within the anterior chamber fluid with patient head tilt (Video).

Anterior segment optical coherence tomography depicted the lesion in the anterior chamber angle abutting the corneal endothelium and resting on the iris stroma with no internal fluid level and no solid component.

Ultrasound biomicroscopy confirmed the lesion to be cystic with a thickness of 1.6 mm.

Dilated fundus examination revealed normal findings in both eyes.


Her medical history was notable for morbid obesity, hypertension, diabetes, and stroke.

She reported no fever, fatigue, weight changes, gastrointestinal symptoms, difficulty concentrating, anxiety, or hyperhidrosis.

Physical examination results revealed multiple firm skin-colored papules and nodules coalescing to form a large plaque on the anterior aspect of the left lower leg, whereas the right lower leg had diffuse induration and hyperpigmentation (Figure 1).

Laboratory analysis revealed normal complete blood cell count, thyroid function, serum protein electrophoresis, and serum immunofixation.

A biopsy of a left leg nodule was performed.Multiple firm skin-colored papules and nodules coalesce to form a large plaque on the anterior aspect of the left lower leg.

The patient had previously been diagnosed with elephantiasis nostras verrucosa, and she was advised to elevate and compress the leg but was unavailable for follow-up.


The patient used a wheelchair due to a right-sided hemiparesis and hemianopsia caused by an intracranial hemorrhage.

Clinical examination also demonstrated a lipolymphedema of the lower legs that had been attributed to a functional venous insufficiency with insufficient venous pump activity.

The patient had been wearing compression stockings for years.

The family history was positive for cerebral venous malformations involving the patient’s father and aunt, the father having died of an intracranial hemorrhage in his early 70s.A, Clinical picture.

Since the age of 24 years, the lesions had been growing very slowly in number and size and had been bleeding occasionally after a trauma.

B and C, Hematoxylin-eosin stain.Sonography of the skin lesions demonstrated intradermal slow-flow vascular malformations with a maximum diameter of 1.2 cm.

A biopsy of a lower-extremity papule was performed (Figure, B and C).

At the age of 4 years, recurrent seizures had led to the diagnosis of cerebral venous malformations.

Mutational analysis resulted in the detection of a heterozygous pathogenic KRIT1 variant.


She disclosed a history of macular degeneration in both eyes and retinal detachment in the left eye that was treated 35 years previously.

Medical history revealed cutaneous basal cell carcinoma and squamous cell carcinoma, both treated surgically.On examination, visual acuity was 20/50 OD and 20/400 OS.

External examination showed posterior-chamber intraocular lenses in both eyes and conjunctival scarring in the left eye from circumferential scleral buckle surgery with no visible extraocular tumor.

Fundus evaluation showed macular drusen in the right eye and a pale optic disc with geographic macular atrophy in the left eye, explaining her visual acuity of 20/400 OS.

In addition, a shallow circumferential buckle effect and an inferotemporal mass measuring 15.0 × 10.0 mm in basal dimension and 9.1 mm in thickness (Figure, A) were seen in the left eye.

The mass appeared elevated, amelanotic with overlying retinal vasculature, and with chorioretinal atrophy.

No retinal detachment or breaks were seen.

By ultrasonography the mass was echolucent (Figure, A inset).

Magnetic resonance imaging (MRI) revealed a T1, T2-hypointense shallow circumferential band in the left eye.

In addition, there was an inferotemporal nodular mass in the left eye showing T1 (gadolinium) hypointense, T2-hyperintense features, underlying the encircling buckle, and with adjacent subtle delineation.

There was no enhancement with gadolinium (Figure, B).Fundus photograph and magnetic resonance imaging of the left eye.

A, Fundus photograph of left eye showed a pale optic disc, geographic macular atrophy, and an inferotemporal amelanotic mass (white arrowhead); inset shows ultrasonography revealing an echolucent mass (white arrowhead).

B, Magnetic resonance imaging (MRI) (T2-weighted axial orientation) revealed a shallow hypointense circumferential band in the left eye (pink arrowheads), inferotemporal hyperintense nodular mass (asterisk), and inward compressed sclera (white arrowhead); inset (T1-weighted coronal orientation with gadolinium) shows hypointense encircling band (pink arrowhead), subtle scleral indentation (white arrowhead), and no gadolinium enhancement of mass (asterisk).

She was referred to the Ocular Oncology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, for suspected choroidal melanoma.


On close inspection, milia and a few erosions with partially detached epidermis were identified.

No extracutaneous involvement was observed.A, Multiple pruritic erythematous to violaceous lichenified papules and plaques on the left shin.

There were no abnormalities of the mucous membranes, nails, hair, or teeth.

B, Close-up of the skin lesions showing an erosion with partially detached epidermis and multiple milia.

C, Histopathologic examination revealed dermoepidermal separation (hematoxylin-eosin stain).

D, Histopathologic examination revealed several milia (hematoxylin-eosin stain).


Her medical history was positive for relapsing urinary tract infections since early infancy without adequate follow-up.

Three weeks prior, she had presented with mild fever and flulike symptoms, associated with a severe frontal headache that was mildly relieved by analgesics.

Findings of an ophthalmological examination 1 year prior were reported as normal.At initial examination, she was conscious but somewhat lethargic.

Her best-corrected visual acuity was 20/20 OD and 20/80 OS.

Pupillary light responses, extrinsic ocular motility, anterior segment biomicroscopy, and intraocular pressure were normal in both eyes.

Dilated fundus examination revealed a bilateral sectorial macular star that was more extended in the left eye, with retinal veins slightly dilated and tortuous, attenuated arterioles, some juxta and peripapillary nerve fiber layer infarcts, and optic disc edema with marked papillary telangiectasia; in addition, some faint, small, tan-yellow dots were observed at the level of the retinal pigment epithelium in the posterior pole, some of them already grayish and with a hypopigmented halo (Figure 1).

Optical coherence tomography displayed elevated optic discs and hyperreflective material in the outer plexiform layer temporal to the optic disc in both eyes and a macular neurosensory detachment in the left eye.

Results of visual field testing were normal in the right eye and showed a central scotoma in the left eye.Fundus image of the right eye (A) and left eye (B) showing slight dilation of retinal veins (magenta arrowheads), intraretinal lipid deposits in the papillomacular bundle and the inferonasal macular quadrant forming an incomplete macular star (yellow arrowheads), optic disc edema and epipapillary telangiectasia (blue arrowheads), nerve fiber layer infarcts or cotton-wool nodules (green arrowheads) over the inferior margin of the optic disc in the right eye and juxta and parapapillary in the left eye, and paramacular temporal light-pigmented subretinal dots at the level of the retinal pigment epithelium (white arrowheads) in both eyes, with some already scarred (pigmented dot surrounded by a pale halo; gold arrowhead).


This firm-to-palpation mass was noted at birth and remained proportional in size with the child’s somatic growth, measuring approximately 1 cm in diameter on presentation.

Preoperative magnetic resonance imaging (MRI) documented the mass to be uniformly solid and well circumscribed without cystic components or flow voids, hypointense on T2, and hyperintense with homogeneous contrast enhancement on T1.

His head, neck, and general examination findings were otherwise normal with no cervical lymphadenopathy or additional masses.


Five days after surgery, the patient noted erythema, edema, pain, pruritus, and serous fluid drainage at the mastectomy incision sites (Figure 1).

Two days later, she developed an erythematous papulovesicular rash on her trunk and upper and lower extremities.

The skin swab bacterial culture result was negative, and her skin findings did not improve with antibiotics.

A skin swab was sent for bacterial culture, and she was prescribed cefadroxil (500 mg twice daily for 1 week).


Her course was complicated by severe mucositis, acute kidney injury, and neutropenic fever.

During her admission, the patient also developed painful necrotic skin lesions, a nonproductive cough, and altered mental status.Physical examination findings demonstrated dusky, purpuric, and pink papulonodules, some with overlying eschar, scattered on the scalp, neck, trunk, and extremities (Figure, A).

Laboratory study results revealed a white blood cell count of 150/μL (reference range, 3500/μL to 10 500/μL), an absolute neutrophil count of 130/μL (reference range, 1500/μL to 7400/μL), and a platelet count of 19 ×103/μL (reference range, 150 ×103/μL to 400 ×103/μL).

The results of a computed tomography (CT) scan of the brain showed no acute intracranial hemorrhage, territorial infarction, or mass effect.

The results of a CT scan of the chest demonstrated multifocal bilateral ground-glass patchy opacities, scattered solid bilateral pulmonary nodules, and a moderately sized pericardial effusion.

A biopsy specimen from a skin nodule on the left lateral thigh was obtained for histopathologic examination and tissue culture, and wet mount preparation of a tissue culture colony was performed (Figure, B).A, Physical examination findings demonstrate dusky and pink papulonodules, some with overlying eschar, scattered on the scalp, neck, and extremities.

B, Lactophenol cotton blue staining of a tissue culture colony reveals septated hyphae and oval microconidia.

(To convert the white blood cell and neutrophil counts to cells ×109/L, multiply by 0.001; conversion of the platelet count to cells ×109/L is 1:1.)


He received a diagnosis of primary salivary duct carcinoma of the hard palate 1 year prior and had been receiving treatment with oral bicalutamide and radiotherapy.

He reported that the lesion had been asymptomatic but was increasing in size, with progression from his face to anterior chest.

On clinical examination, a hemorrhagic and erythematous plaque with multiple purpuric-to-blackish infiltrative papules and nodules extending from cheek, lateral neck, to the interclavicular area was found (Figure 1).

An incisional biopsy from the infiltrative nodule on cheek was performed and submitted for histopathologic analysis.Hemorrhagic and erythematous plaque with multiple infiltrative purpuric-to-blackish papules and nodules with varying sizes extending from left cheek, neck, to chest.

A partially regressive change of the palatal tumor was noted radiographically during regular follow-up 3 months previously.


Her personal, past, and family histories were unremarkable.On physical examination, there was a 6 × 6-cm protuberant, thick-walled, and well-defined red bullalike tumor on the right upper arm, which extended 1 to 3 cm from the epidermal surface (Figure, A).

The lesion initially started as a small cutaneous nodule without obvious triggers that gradually developed and enlarged to form a red-colored tumor with a hard nodule inside.

Inside the tumor, a nontender, firm-to-hard nodule was palpated.

There was no regional lymphadenopathy, and results of the rest of the physical and systemic examinations were normal.

Laboratory examinations of hematologic, biochemical, and urinalysis tests were normal.

The tumor was excised completely under local anesthesia, and part of the tissue was sent for pathological examination.A, A tumor on the patient’s right shoulder.

There was no history of local trauma or insect bite.

B, The excisional tumor showed multilocular spaces below the epidermis and a solid tumor present in the deep dermis with a chalky-white cut surface and lobulated appearance.

C and D, Histological examination revealed basophilic cells and shadow cells as well as dilated lymphatic vessels (hematoxylin-eosin; original magnification ×100).


She had a history of optometric examinations with no known ocular disease.

On review of systems, the patient noted a long-standing growth on her cheek, which on examination was a 4 × 3-mm exophytic, brownish-red vascular papule (Figure, B), as well as a history of lightly pigmented patches of skin and multiple subungual fibromas on her toes.

Visual acuity with correction was 20/40 in the right eye and 20/20 in the left eye.

Anterior segment examination of both eyes was unremarkable, and the retina in the left eye appeared normal.

In the right eye, there was an area of superior macular whitening with associated intraretinal hemorrhages and exudates.

Fluorescein angiography showed abnormally dilated and tortuous retinal vessels, irregular capillary branching patterns, and bulblike telangiectasis with late leakage in the superior macula.

Optical coherence tomography showed disorganized and hyperreflective inner retinal thickening (Figure, A) and intraretinal and subretinal fluid in the central macula.

Systemic blood pressure was normal.Features of tuberous sclerosis complex.

Two optical coherence tomography line scans inset through the main lesion (orange) and through the fovea (blue) with relative location marked with dotted lines, demonstrating disorganized and hyperreflective inner retinal thickening consistent with type 1 astrocytic hamartoma of the retina and associated macular edema.

Arrowhead indicates bulblike telangiectasis on fluorescein angiography and blocking from intraretinal hemorrhage.

A, An area of superior macular whitening following the superior arterial arcade with associated intraretinal hemorrhages and exudate.


He reported no known ill contacts or recent travel outside the US.

He had no nausea, vomiting, abdominal pain, melena, or hematochezia but reported a cough productive of yellow sputum, dyspnea on exertion, and fatigue.

At presentation, his heart rate and blood pressure were normal, and oxygen saturation was 95% on room air.

Physical examination revealed a maculopapular rash over his neck and chest (Figure, left panel) and bibasilar crackles on lung auscultation.

Laboratory testing showed a white blood cell count of 14.3 × 103/μL (reference, 4.2-9.1 × 103/μL); creatine kinase level, 2060 U/L (34.40 μkat/L) (reference, 44-196 U/L [0.73-3.27 μkat/L]), aldolase level, 18 U/L (0.30 μkat/L) (reference, <8 U/L [<0.13 μkat/L]), C-reactive protein level, 30 mg/L (reference, <8 mg/L), and erythrocyte sedimentation rate, 35 mm/h (reference, <20 mm/h).

Antinuclear antibody immunofluorescent assay findings were positive.

Results from testing for HIV, hepatitis B, and hepatitis C were negative.

A barium swallow study showed no visualized aspiration.

Endoscopy revealed clean-based esophageal and duodenal ulcers and nonspecific gastritis.

Chest computed tomography (CT) showed bibasilar pulmonary consolidations and ground glass opacities (Figure, right panel).Left, Shawl-like rash on patient’s chest.

The patient had been treated for presumed pneumonia with 3 courses of azithromycin over the prior 3 months due to infiltrates on a chest radiograph.


He denied pain, aspiration, noisy breathing, obstructive episodes, dysphonia, and weight loss.A physical examination revealed fullness in the left oropharynx and left level 3 of the neck.

Findings of flexible laryngoscopy showed a submucosal mass in the left oropharynx extending inferiorly into the hypopharynx, obliterating the left pyriform sinus, abutting the base of tongue with hooding over the epiglottis.

The supraglottis and glottis were unremarkable.

Computed tomography imaging with contrast of the neck revealed a 4.6 × 4.0 × 8.0-cm heterogeneously enhancing mass in the left oropharynx and hypopharynx with cystic components and clear planes separating the mass from the spinal musculature and carotid sheath (Figure 1).Computed tomography imaging with contrast of the neck with the coronal cut demonstrating the well-circumscribed heterogeneous mass involving the retropharyngeal space, abutting the great vessels, and extending from superiorly in the oropharynx to inferiorly in the hypopharynx.


She had brisk reflexes, poor coordination, and a wide-based unsteady gait.

She demonstrated sluggish but reactive pupils and new-onset ophthalmoplegia.

She was readmitted to the hospital and demonstrated diminished reflexes bilaterally and unsteady gait.

On examination, pupils were fixed and dilated to 8 mm, extraocular movements were intact, and fundus examination was normal.

Bloodwork revealed leukocytosis and an elevated erythrocyte sedimentation rate; cultures remained without growth.

Lumbar puncture with cerebrospinal fluid studies, computed tomography scan, and magnetic resonance imaging of brain and orbits were normal.

The patient was discharged 3 days later following improvement in lethargy and gait with a diagnosis of acute cerebellar ataxia.When she presented to ophthalmology for 1-week follow-up, her visual acuity was central, steady, and maintained in both eyes.

She was unable to move either eye in any direction, including with doll’s head maneuver.

Two weeks prior, she had upper respiratory symptoms and bacterial conjunctivitis treated with topical ofloxacin.


The patient was a construction worker and used tobacco daily.

He reported limited shoulder movements and denied other symptoms.

It began with a quarter-size maculopapular lesion and continued to progress during the next 3 years.

On physical examination, there was a 24 × 15-cm fungating, necrotic, and ulcerated left shoulder mass (Figure 1A).

A punch biopsy showed sheets of highly pleomorphic atypical spindle and epithelial cells within the superficial and deep dermis, extending into the subcutaneous tissue, and with 18 mitoses/mm2.

Immunohistochemistry demonstrated SOX10-positive and pankeratin-negative tumor cells.

A whole-body positron emission tomographic and computed tomographic scan revealed an intensely hypermetabolic left shoulder mass and multiple hypermetabolic enlarged left axillary lymph nodes, with no distant metastases (Figure 1B).

Brain magnetic resonance imaging was negative for intracranial metastasis.A, Left shoulder giant fungating mass in a 46-year-old man.

There was no medical or surgical history, and he had a negative personal or familial oncologic history.

B, Positron emission tomographic and computed tomographic (PET-CT) scan shows the hypermetabolic left shoulder mass and no distant metastases.


The referring retina specialist noted vitritis and vasculitis intraoperatively, but the result of vitreous biopsy cytology was negative for malignant cells.At presentation to our institution, the patient was taking oral prednisone, 40 mg/d.

The patient noted blurry vision started around the time of cabozantinib therapy initiation.

His visual acuity was 20/500 OD and hand motions OS, with an intraocular pressure of 18 mm Hg in both eyes.

Right eye slitlamp examination results showed pigmented cells in the anterior chamber and lens capsule; the left eye showed prolapsed pigmented vitreous at the pupillary margin.

Right eye fundus examination results revealed sheets of pigmented cell and vascular sheathing with optic nerve pallor.

The left eye had a poor view, with 90% gas fill.

Fluorescein angiography illustrated disc and vessel leakage (predominantly arteriole), capillary dropout, and peripheral nonperfusion in the right eye (Figure 1A) with no view in the left eye.

Optical coherence tomography revealed debris at the vitreoretinal interface (Figure 1B).Fluorescein angiography and optical coherence tomography on presentation demonstrate retinal vasculitis and vitritis (right eye results shown).

A, Fluorescein angiography shows dense vitritis, predominantly arteriole leakage (arrowheads), and nonperfusion.

Cabozantinib therapy was discontinued for surgery and resumed 3 days later.


Ten years prior to presentation, he underwent surgical decompression for syringomyelia.

A magnetic resonance imaging (MRI) scan of his cervical and thoracic spine performed 2 years prior to presentation revealed a recurrent syrinx extending from C1 to T11, which was not resected because it did not cause symptoms at that time.

On physical examination, he had mild tenderness to palpation and reduced range of motion of the left shoulder with abduction and flexion limited to 120° (normal range of motion, 180°).

The left scapular muscles were atrophic, and pain and temperature sensation were reduced in his proximal left arm, and dorsal aspect of his left shoulder.

His complete blood cell count, serum glucose levels, C-reactive protein levels, and erythrocyte sedimentation rate were normal.

Results of tests for rheumatoid factor and antinuclear antibody were negative.

Left shoulder radiograph showed complete absence of the left humeral head and a well-demarcated smooth osseous margin of the proximal humerus with associated soft tissue swelling and periarticular calcification (Figure 1).

A chest radiograph taken 2 years prior revealed a normal left shoulder joint.

The patient was hospitalized for further evaluation and treatment.Anteroposterior radiograph of the patient’s left shoulder demonstrating complete destruction of the proximal humeral head.


Before presentation, the patient reported good health with satisfactory employment-mandated routine physical examinations.

She denied a history of smoking, alcohol, or illicit drug use.

She was not taking hormonal birth control or hormone therapy.

Laboratory values demonstrated a normal complete blood cell count and metabolic panel.

She was noted to have tachycardia (110 beats/min) and hypoxemia (90% receiving room air) with a blood pressure of 106/81 mm Hg.

She denied any clear physical or emotional triggers preceding presentation.

Cardiac, respiratory, and pulse examination results were unremarkable.

Chest radiograph results were unremarkable.

A computed tomographic chest scan excluded pulmonary embolism but suggested pulmonary and interstitial edema.

Results of an electrocardiogram revealed sinus tachycardia with premature ventricular contractions, subcentimeter ST-segment elevation in leads I and aVL and 1-mm ST-segment depression in leads II, III, aVF, and V5 through V6.

Initial high-sensitivity troponin was 110 000 ng/mL (to convert to micrograms per liter, multiply by 1).

Results of cardiac point-of-care ultrasonography demonstrated a severely reduced left ventricular ejection fraction of 40%, with hypokinesis of the anterolateral and posterior walls.

Emergent cardiac catheterization revealed spontaneous coronary artery dissection (SCAD) of the left main coronary artery (Figure 1 and Video).Angiographic image of left main spontaneous coronary artery dissection (A) and intravascular ultrasonography image of left main spontaneous coronary artery dissection (B).


Medical history included hypertension, for which he took losartan, and seasonal allergies, for which he used fexofenadine and fluticasone.

Review of symptoms was negative for fatigue, weight loss, cough, shortness of breath, joint pain, ocular symptoms, mucosal ulcerations, history of blood clots, photosensitivity, pleurisy, urine changes, and diarrhea.

Laboratory evaluation revealed mild neutropenia and lymphopenia with normal hemoglobin and platelet counts.

Antinuclear antibody screening results were negative.

The results of a comprehensive metabolic panel, C3, C4, serum protein electrophoresis, serum free light chains, methylmalonic acid, homocysteine, ferritin, copper, zinc, haptoglobin, HIV, hepatitis B and C serologic tests, and rapid plasma reagin were negative.

Lactate dehydrogenase was mildly elevated.

Erythrocyte sedimentation rate was elevated at 41 mm/h.

Routine cancer screening was up to date.

Treatments included hydroxychloroquine, 400 mg/d, for 4 years; mycophenolate mofetil, 1000 mg/d, for 6 months; and oral prednisone tapers, starting at 40 mg/d.

Of these, only prednisone appeared to elicit a response.

Therapeutic trials of dapsone and dapsone in combination with colchicine were not effective.

The result of a skin biopsy performed 4 years prior was interpreted as subacute cutaneous lupus erythematosus (SCLE).


However, her younger sister had developed the same skin symptoms.

In early childhood, she had developed asymptomatic yellowish coalesced papules confined to flexural areas.

Subsequently, severe skin sagging occurred on her abdomen with loss of elasticity, then spread extensively with developmental growth.

The results of a physical examination showed thick and leathery skinfolds on the neck, axillae, inguinal regions, abdomen, and limbs (Figure, A), with yellowish papules scattered on the dorsal neck.

Coagulation-related tests indicated a low clotting activity of factor X (52.2%; reference range, 77%-131%) and a prolonged prothrombin time (12.8 seconds; reference range, 10.4-12.6 seconds).

The results of other laboratory investigations were unremarkable.

Echocardiographic and fundoscopic examination results were normal.

A skin biopsy specimen was obtained from her neck for histopathologic examination (Figure, B).A, Clinical image of the neck, axillae, and abdomen.

B, Skin biopsy specimen taken from the neck shows excessive calcification of elastic fiber fragments scattered in the reticular dermis (von Kossa).

The patient had no extracutaneous involvement and was born to healthy nonconsanguineous parents.

Severe skin laxity with deep cutaneous folds on the cervical, axillary, and abdominal regions.


He lived in rural China and had close contact with dogs, cattle, and sheep.

Lung auscultation revealed absent breath sounds on the right hemithorax.

His blood pressure was 93/60 mm Hg; heart rate, 100/min; respiratory rate, 26/min; and oxygen saturation, 94% on room air.

His abdomen was soft and nontender, without hepatosplenomegaly.

His white blood cell count was 8000/μL, with 25.8% eosinophils (reference range, 0%-9%).

C-reactive protein level and results from tuberculin skin test, interferon-γ release assay, nucleic acid amplification testing for tuberculosis, acid-fast bacilli smear microscopy, and HIV antibody testing were normal.

A thoracoabdominal computed tomography (CT) scan showed a ruptured 10 × 9 × 5–cm right upper lobe pulmonary cyst compressing the right main bronchus and 3 liver cysts (Figure 1).Left, Chest computed tomography (CT) scan (transverse view) showing a giant cystic mass in the right upper lobe of the lung with rupture and compression of the right main bronchus.

Right, Abdominal CT scan (coronal view) showing 3 round water-density cysts in the right anterior lobe, right posterior lobe, and left lateral lobe of the liver.


The patient did not take any prescription medications or herbal supplements and had immigrated to the US from Samoa 4 years prior.

He reported numbness and paresthesia in the areas of affected skin and an inability to fully extend his fingers.

Physical examination revealed multiple tattoos and annular erythematous plaques on his face, chest (Figure, left panel), back, arms, and legs.

The patient had bilateral palpable thickened auricular and ulnar nerves, claw-hand deformity (Figure, right panel), foot drop bilaterally, and decreased sensation to temperature over the areas of skin plaque.

Results of testing for rapid plasma reagin, antinuclear antibodies, and rheumatoid factor were negative.

Examination of punch biopsy samples from 2 plaques on his back revealed granulomatous periadnexal and perivascular dermatitis with diffuse granulomatous infiltrate and foamy histiocytes.

Findings on acid-fast bacilli stains and mycobacterial polymerase chain reaction (PCR) testing were negative.