He smokes a pack of cigarettes per day and drinks alcohol occasionally.

He complains of early satiety, abdominal discomfort after food intake, and abdominal bloating.

These symptoms have been present since the patient was 52, but they were milder at that time so he paid little attention to them since.

Tingling and decreased sensation in both lower extremities began a few months ago.

His relatives also note that he has become excessively somnolent and forgetful.

His weight is 61 kg (134.5 lb), height is 181 cm (5 ft 11 in), and BMI is 18.6 kg/m2.

His vital signs include: blood pressure 110/80 mm Hg, heart rate 89/min, respiratory rate 13/min, and temperature 36.1°C (96.9°F).

The patient’s skin is pale, thin, dry, and hypoelastic.

Lung and heart examinations are within normal limits for his age.

The patient’s tongue is bright red with atrophic papillae.

The abdomen is distended and tender to palpation in the epigastric area.

Neurological examination shows symmetrical bilateral distal hypoesthesia for all sensations and decreased muscle strength in both upper and lower extremities.

On a mini-mental status examination, the patient scores 25.

The patient’s medical history is significant for acute hepatitis B 20 years ago.

Lymph nodes and the thyroid gland are not enlarged.


Her mother is concerned about the blood-tinged discharge but states that her daughter has been feeding and voiding well.

The neonate was delivered at 39 weeks gestation by an uncomplicated vaginal delivery, and she and her mother were discharged home after two days.

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

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

At this visit, the neonate’s temperature is 98.5°F (36.9°C), pulse is 138/min, and respirations are 51/min.

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

There are no bruises or marks on her skin.

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


His past medical history is notable for hypertension, diabetes, and stable angina.

He takes lisinopril, metformin, glyburide, and aspirin.

He has a history of intravenous drug use and was homeless in his early 30’s.

He drinks alcohol socially and has a 30 pack-year smoking history.

His temperature is 98.6°F (37°C), blood pressure is 130/85 mmHg, pulse is 95/min, and respirations are 18/min.

He reports a 6-month history of slowly progressive tiredness associated with dull achy pain in his knees, hips, and shoulders.

Physical examination reveals a generally well-appearing male without evidence of ascites, peripheral edema, or jaundice.


The patient’s medical history is negative for similar symptoms or a thyroid disorder.

The small, round, and painless swelling, which was detected 3 weeks ago in the middle of her neck, has now increased in size.

The swelling is associated with sweaty palms and soles, insomnia, irritability, nervousness, and fatigue; however, the patient does not complain of fever, cervical lymphadenopathy, weight loss, vision problems, or body swelling.

The vital signs are within normal limits.

Local examination reveals a 3 x 3 cm round, non-tender, non-fluctuant, and non-pulsatile swelling in the anterior triangle of her neck.

The patient carries a total white blood cell count of 10,200/mm3, including 70% neutrophils, 30% lymphocytes, and zero eosinophils.The erythrocyte sedimentation rate is 20 mm/hr (normal, 0–29 mm/hr).


She reports that her fingers feel stiff in the morning and the symptoms tend to improve as the day progresses.

Her temperature is 37°C (98.6°F), blood pressure is 120/70 mm Hg, respiratory rate is 16/min, and heart rate is 70/min.

On physical examination, her metacarpophalangeal joints are erythematous and tender.

She denies any recent trauma or other inciting events.

Family history is significant for a grandmother who suffered from fibromyalgia.


He has hypertension and rheumatoid factor-positive rheumatoid arthritis.

He has a history of chronic alcohol abuse.

During this time he has felt like his eyes have been unusually puffy in the mornings and his urine has been frothy.

His temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 148/86 mm Hg.

Physical examination shows pallor, periorbital edema, 2+ pedal edema, and ascites.

He has swan-neck deformities and nodules of multiple fingers and swelling and restricted range of motion of bilateral knee joints.

Laboratory studies show:
Hemoglobin 8.2 mg/dl
Prothrombin time 12 seconds
Serum
Albumin 2.8 g/dl
Total bilirubin 1.0 mg/dl
Alkaline phosphatase 120 U/L
AST 20 U/L
ALT 19 U/L
Urea 18 mg/dl
Creatinine 1.2 mg/dl
Urine
Protein 3+
WBCs 5–10/hpf
RBCs negative
Bacteria negative
Ultrasound of the liver and kidneys shows no abnormalities.

Current medications include amlodipine, methotrexate, and ibuprofen.


Her past medical history is relevant for depression, personality changes, and declining work performance, for which she has been put on leave from her current job as an elementary school teacher.

On physical examination, patient has dysarthria, dystonia, and an ataxic gait.

Ophthalmologic examination reveals multi-colored irises with concentric rings around the periphery (findings shown in the photo).

Sensation and motor functions are preserved.


On examination of the oropharynx, you note a grayish-white pseudomembrane and uneven elevation of the soft palate.

The patient displays marked enlargement of the cervical lymph nodes.


He has a past medical history of asthma, depression, and anxiety.

He is not currently taking any medications.

The patient then presents 4 months later to his primary doctor with weakness.

The patient's strength in his upper extremities is 1/5.

He has reduced sensation in his upper extremities as well.

His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 115/min, respirations are 22/min, and oxygen saturation is 99% on room air.

The patient's cardiopulmonary exam is within normal limits.

The patient is breathing on his own and has strong distal pulses.

The patient's lower extremities reveal 5/5 strength with intact sensation.

Ultimately, the patient is discharged with follow up instructions after no significant fractures or injuries are found.

The patient was an unrestrained driver in a head-on collision.

A chest radiograph and basic labs are ordered.


She has smoked 1 pack of cigarettes daily for the last 15 years.

Current medications include glyburide and amlodipine.

The physician prescribes a medication that decreases the production of mevalonate.


Menses occur irregularly at 45 to 65-day intervals.

Physical examination shows facial acne and growth of coarse dark hair on the face, chest, and lower back.

She is 159 cm (5 ft 3 in) tall and weighs 59 kg (130 lb); BMI is 23 kg/m2.

Pelvic examination shows no abnormalities.

Serum studies show:
Sodium 141 mEq/L
Potassium 4.2 mEq/L
Glucose 109 mg/dL
Cortisol (1600 h) 4 μg/dL
Prolactin 14 ng/mL
17-hydroxyprogesterone 390 ng/dL (N=20–300 ng/dL)
Testosterone 91 ng/dL (N=8–60 ng/dL)
A urine pregnancy test is negative.


Current medications include aspirin, atorvastatin, hydrochlorothiazide, and metoprolol.

Three weeks ago, he was also started on amlodipine.

His blood pressure ranged from 160/100 mm Hg to 150/94 mm Hg on his previous 3 visits over the past 4 months.

His blood pressure today is 158/98 mm Hg.

Physical examination shows no other abnormalities.

Renal duplex ultrasonography shows 90% occlusion of the right renal artery.


She has chronic migraines, hypertension, and type 2 diabetes mellitus.

Her medications include lisinopril and metformin, but she ran out of her anti-hypertensive medications over the weekend.

When he left their lakeside cabin 6 hours before to go ice fishing and get more firewood, she did not have any symptoms.

She is confused and oriented only to person and place.

She recalls only one of three objects after 5 minutes.

Her temperature is 37.1°C (98.8°F), pulse is 110/min, respirations are 21/min, and blood pressure is 154/92 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 98%.

Physical examination shows no abnormalities.


Imaging reveals transmural myocardial infarction in the posterior 1/3 of the ventricular septum.


He also reports abdominal pain, intermittent nausea, and fever.

He has not had vomiting, tenesmus, or rectal pain.

His vital signs are within normal limits.

Abdominal examination reveals tenderness of the right lower abdomen without rebound tenderness.

Laboratory studies show a leukocyte count of 14,800/mm3 and an erythrocyte sedimentation rate of 51 mm/h.

Test of the stool for occult blood and stool studies for infection are negative.

A CT scan of the abdomen shows mural thickening and surrounding fat stranding of discrete regions of the terminal ileum and transverse colon.

A colonoscopy is performed and biopsy specimens of the affected areas of the colon are taken.


He describes the pain as dull and constant, boring in nature, and localized deep below the thigh muscle.

Physical examination is significant for tenderness and warmth over the anterior aspect of the left thigh.

A plain radiograph of the left femur shows increased cortical thickness with widened intercortical space.

Laboratory studies show:
Alkaline phosphatase
925 U/L
Serum calcium
9.2 mg/dL
Serum phosphorus 4.4 mg/dL
Findings on bone biopsy are shown in the image.


He has major depressive disorder with psychosis.

Current medications include sertraline and haloperidol.

He has had around 3–4 episodes of greenish colored vomit during this period.

His temperature is 37.3°C (99.1°F), pulse is 87/min, and blood pressure is 118/72 mm Hg.

The pupils are equal and reactive to light.

He is diagnosed with acute appendicitis and is taken to the operating room for an emergency laparoscopic appendectomy.

Just after the appendiceal base is ligated, the patient shows muscle rigidity and profuse diaphoresis.

The appendix is gangrenous and perforated with purulent fluid in the pelvis.


It passes through several stages during its maturation.

Positive selection is an important process during maturation of T lymphocytes, and it ensures the preservation of self-major histocompatibility complex (MHC)-restricted T cells.


The patient reports that he returned from active duty in Iraq 3 months ago and was adjusting to life back at home until about 7 weeks ago when he began having intense fear of loud noises and seeing sudden flashbacks to bombing attacks he endured during his time in Iraq.

He had to take a leave from his army instructor duties as he was not able to handle the familiar settings of practice shooting ranges and sudden loud explosions during battalion training.

After refusing to leave his house, he was finally persuaded by his wife to visit your clinic.


He was diagnosed with type 2 diabetes mellitus 1 year ago.

He also mentions that he has had a weight gain of 4 kg (8.8 lb).

His serum glucose is 186 mg/dL and his hemoglobin A1c is 7.6%.

The physician prescribes an additional antidiabetic drug and counsels the patient on its delayed onset of action.


The patient fervently denies being underweight claiming that she is ‘a fatty’ and goes on to refuse any further intravenous fluid and later, even the hospital meals.

Her vitals taken by the emergency medical services (EMS) include blood pressure 88/55 mm Hg, pulse 55/min.

She was given a liter of isotonic fluid while en route to the hospital.

At the emergency department, she is alert and oriented and is noted to be anorexic.


He was taking triple antiretroviral therapy but stopped a few months ago because he was feeling well.

Cardiopulmonary examination shows no abnormalities.

His CD4+ T-lymphocyte count is 47/mm3 (N ≥ 500).

The patient currently refuses to restart antiretroviral therapy.


He was in his normal state of health until 2 weeks ago when he went abroad on a vacation.

During his trip he went kayaking, visited spas, interacted with local animals, and ate local foods.

He drinks socially and has a 15-pack-year history of smoking.

Since returning he has had 3-day history of fever, cough, headache, and diarrhea.

On presentation his temperature is 102.3°F (39.1°C), blood pressure is 105/62 mmHg, pulse is 91/min, respirations are 18/min, and O2 saturation is 91% on room air.

Chest exam reveals fine crackles on auscultation.

Chest radiograph reveals patchy infiltrates in both lungs and labs reveal mild hyponatremia and mild elevation of AST/ALT levels.


His past medical history is significant for infectious mononucleosis last year and type 1 diabetes mellitus for which he has an insulin pump.

He reports that he lost his balance while attempting a new trick and fell on his outstretched hands.

He has been icing his hand and taking several tablets of ibuprofen every few hours, but the pain and swelling have not improved.

The patient reports that he has not been able to use the hand to take notes in school.

On physical exam, there is mild swelling over the dorsal aspect of the hand and wrist.

He has tenderness in the region between the extensor pollicus longus and the extensor pollicus brevis of the right hand.


Menses have occurred at 45- to 90-day intervals since menarche at the age of 15 years.

Over the past two years, she was unable to become pregnant despite having unprotected sexual intercourse with her husband on a regular basis.

There is no personal or family history of serious illness.

The patient reports that she was too embarrassed to discuss this issue with anyone until now.

Examination shows oily skin and severe facial acne.

There is abnormal pigmented hair on the upper lip and around both nipples.

She is 170 cm (5 ft 7 in) tall and weighs 85 kg (187 lb); BMI is 29.4 kg/m2.

Her vital signs are within normal limits.

Her last menstrual period was 5 weeks ago.


He has type 2 diabetes mellitus, for which he takes metformin and sitagliptin.

He has smoked 1 pack of cigarettes daily for 20 years.

He also reports lightheadedness that started earlier in the day.

He appears pale and diaphoretic.
A 12-lead ECG is shown.


He complains of severe pain that prevents him from participating in physical therapy and wakes him from sleep.

Physical examination of the left knee shows a healing incision; there is no joint effusion, erythema, or evidence of wound dehiscence, and his gait is normal.

He was discharged with prescriptions for oxycodone and acetaminophen.

When the physician recommends switching to ibuprofen for pain, he becomes visibly angry and demands a refill of oxycodone.


This patient also has type 2 diabetes mellitus which is well controlled with metformin.

Three months ago, she presented with complaints about facial asymmetry.

Her daughter has noticed that her mother’s mouth is droops downwards on the right side of her face and that she cannot close her right eye well.

The same side also lacks wrinkles on the forehead.

Since then, the patient feels like her facial muscles have gotten weaker.

Upon being asked to close her eyes, the patient has difficulty doing so and fails to completely close her eyelids.

On examination, there is no loss of pain, temperature, or crude or tactile touch sensations in the whole face.

The neurological exam is otherwise unremarkable.

She was given a course of corticosteroids, but she has still not recovered fully.

The neurologist recommends a therapy that will help relieve her symptoms.


He was treated for a neck abscess 6 months ago.

He has smoked one pack of cigarettes daily for 10 years and drinks two to three beers daily.

He has been using intravenous cocaine and heroin for 6 years.

He appears ill. His temperature is 38.6°C (101.5°F), pulse is 112/min, respirations are 20/min, and blood pressure is 110/70 mm Hg.

Examination shows track marks on both cubital fossae.

There are retinal hemorrhages with pale centers.

A grade 3/6 holosystolic murmur is heard best at the lower left sternal border.

Laboratory studies show:
Hemoglobin 13.3 g/dL
Leukocyte count 14,300/mm3
Platelet count 278,000/mm3
Serum
Glucose 96 mg/dL
Creatinine 1.0 mg/dL
Total bilirubin 0.4 mg/dL
AST 18 U/L
ALT 22 U/L
Transthoracic echocardiography shows multiple vegetations on the tricuspid valve and moderate tricuspid regurgitation.

Two sets of blood cultures are collected.


She has no history of major medical illness.

Her temperature is 36°C (96.8°F), pulse is 121/min, and blood pressure is 120/78 mm Hg.

Physical examination shows pale conjunctivae.


He admits to drinking alcohol almost every night since the age of 17.

He says that he often gets similar pain but less severe and that it worsens with meals.

The pain sometimes radiates to his back.

He recently lost 15 kg (33.6 lb) of weight secondary to his lack of appetite since his last visit 2 months ago.

His temperature is 37.0° C (98.6°F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg.

Physical examination reveals moderate epigastric tenderness.

An abdominal CT scan reveals calcifications as shown by the white arrows.


He is a financial director with a 15-pack-year history of smoking who tried quitting several times.

The patient has gastrointestinal reflux disease and takes omeprazole.

The medical history is significant for a head trauma after which he had two seizure episodes.

He does not have a history of any other disorders.

Currently, he is not on any antiepileptic medication.

He heard from his friend about an antidepressant that efficiently helps with smoking cessation.

He tried different nicotine replacement products, none of which helped him.

He would like to try this medication, and asks his physician for an advice.


The abdomen is nontender, and regular contractions are felt every 2 minutes.

There is blood on the vulva, introitus, and medial aspect of the thighs.

Her temperature is 37.2°C (99.0°F), pulse is 102/min, respirations are 16/min, and blood pressure is 138/82 mm Hg.

The uterus is consistent in size with a 20-week gestation.

Ultrasound shows complete detachment of the placenta from the uterus.

An emergent cesarean delivery is performed.

Following the procedure, the patient becomes tearful and distraught.


He has not had any changes in his weight.

He has a history of hypertension, type 2 diabetes mellitus, and chronic shoulder pain.

He does not drink alcohol and does not smoke.

His diet has mostly consisted of potatoes and lean meats since his wife passed away 1 year ago.

His pulse is 92/min and blood pressure is 135/80 mm Hg.

Examination shows conjunctival and mucosal pallor.

Abdominal and rectal examination shows no abnormalities.

Neurological exam shows mild postural tremor.

Peripheral blood smear shows red blood cells with increased zones of central pallor and anisocytosis.

Current daily medications include hydrochlorothiazide, metformin, and ibuprofen.


Her younger brother has mild developmental delay, pale complexion, and has to limit his dietary intake of phenylalanine.

She has no similar symptoms and is in good health.


He has had approximately 10 different sexual partners in the past 3 months.

He noticed the swelling a day ago while preparing for the college basketball game.

Synovial fluid tap shows a WBC count of 90,000 cells/mm3.


His neighbor says that he never really knew the patient that well and that he mostly kept to himself.

They have been neighbors for the past 3 years at an apartment close to the hospital.

The patient appears disheveled, has a flat affect, and appears to be having auditory hallucinations.

He suddenly seemed interested in attending all the local council meetings and social gatherings.

He is very talkative at these events and boasts highly of himself and starts suggesting changes that the committee could make with his help.

He gets very agitated when they deny accepting his suggestions.

He is alert and oriented to time, person, and place and has an intact long-term and short-term memory.

What worried the neighbor was a sudden change in the patient's behavior which started last week.


The patient has been relatively healthy and just recently started “intermittent fasting” to try to lose weight.

He recalls a similar episode 4 years ago when he was recovering from an emergency appendectomy.

The patient denies smoking but endorses an episode of binge drinking 2 days ago.

He is sexually active with both men and women.

His physical examination is unremarkable besides scleral icterus.


She reports that she has had episodic tinnitus in her right ear for the past 3 years.

Neurologic examination shows hearing loss in the right ear.


She says that the pain of passing the stone was excruciating and asks how she can prevent kidney stones in the future.

CT scan in the ED revealed a 4-mm stone occluding the right ureter.

Pathology report on the stone states it was composed of calcium oxalate.

She was able to pass the stone without assistance over the course of 5 hours.


His father had a similar condition that was treated with medications.

He reports that certain daily activities have become more difficult to perform.

Examination shows a low-amplitude tremor bilaterally when the arms are outstretched that worsens when reaching out to grab a pen.

Muscle strength and tone is normal bilaterally.

Deep tendon reflexes are 2+ bilaterally.

On mental status examination, his mood is good.

His speech is normal in rate and rhythm.


He has adult polycystic kidney disease and was on maintenance hemodialysis for 2 months prior to transplantation.

Current medications include azathioprine, cyclosporine, prednisone, and enalapril.

During the past 2 days, he has had decreasing urinary output.

He passed 5 liters of urine on the second postoperative day and serum studies showed a creatinine concentration of 2.1 mg/dL.

His temperature is 37.8°C (100°F), pulse is 101/min, and blood pressure is 164/94 mm Hg.

Examination shows a healing surgical incision in the right lower abdomen.

The graft site shows tenderness to palpation.

His blood urea nitrogen concentration is 52 mg/dL, creatinine concentration is 4.1 mg/dL.

A biopsy of the transplanted kidney shows tubulitis.


She recently underwent routine screening for bone density due to a history of hypothyroidism.

She also has a history of gastroesophageal reflux disease (GERD) that is being treated with a proton-pump inhibitor (PPI) and more recently with a histamine2 receptor antagonist (H2RA), hypertension being treated with a thiazide diuretic, depression being treated with lithium, and hormone replacement therapy.

Her results meet the criteria for osteopenia, with a T-score of -1.6.

She is concerned about progressive bone loss and the risk of fractures.


His respirations are 24/min, and palpable systolic blood pressure is 60 mm Hg, and pulse is 141/min and irregularly irregular.

Examination shows multiple ecchymoses over the chest.

There is a 3-cm (1.2-in) laceration over the abdomen and a 4-cm (1.6-in) laceration over the scalp.

Bilateral crackles are heard at the lung bases.

Cardiac examination shows no murmurs, rubs, or gallops.

Focused assessment with sonography in trauma (FAST) is negative.

An electrocardiogram shows absent p-waves.

Two large bore intravenous catheters are inserted and 0.9% saline infusion is begun.

After 5 minutes, his pulse is 160/min and palpable systolic blood pressure is 50 mm Hg.


Vital signs are stable.
Routine labs show K 7.5 and Cr 5.1.


His personal history is relevant for cigarette smoking and a sedentary lifestyle.

He has type-2 diabetes mellitus which is under control with oral medications.

Upon physical examination, he is found to have a blood pressure of 130/70 mm Hg, a pulse of 72/min, a respiratory rate of 18/min, and a body temperature of 36.5°C (97.7°F).

The rest of the examination is unremarkable except for an enlarged, nontender left supraclavicular node.


She says she is now having trouble walking a full block.

For the past week, she also has noticed bilateral swelling of the lower legs.

She denies chest pain, fever, chills, syncope, or bloody sputum.

Current vitals include: temperature 37.0°C (98.6°F), pulse 63/min, blood pressure 128/91 mm Hg and respiratory rate 15/min.

On physical examination, there is elevated jugular venous pressure, decreased breath sounds bilaterally at the lung bases, and 1+ non-pitting edema bilaterally in the lower extremities.

A chest X-ray demonstrates a slightly enlarged cardiac silhouette.


She has been living alone since the death of her husband 1 year ago.

She appears thin and has temporal wasting bilaterally.

Physical examination shows bruises on her lower legs, swollen gums, and petechiae on the hard palate.


Upon arrival, the patient regained consciousness and complained of intense bilateral flank pain and a recent decrease in urination.

Urine microscopy demonstrated abundant square crystals of calcium oxalate that looked like “folded envelopes."


He reports improvement in his symptoms and has not experienced any adverse effects.


Her boyfriend says she recently returned from a trip to Southeast Asia.

Physical examination shows jaundice and tender hepatomegaly.

Laboratory studies show the presence of anti-hepatitis A IgM antibodies.


The patient is a current smoker and is sexually active.

He admits to having unprotected sex with many different partners this past year.

The patient has no significant past medical history and is not currently taking any medications.

The patient describes the pain as feeling worse in the morning.

He says it is a general stiffness that improves when he goes to the gym and lifts weights.

He also states that his symptoms seem to improve when he leans forward or when he is cycling.

On physical exam, the patient demonstrates notable kyphosis of the thoracic spine and decreased mobility of the back in all 4 directions.

The patient’s strength is 5/5 in his upper and lower extremities.

The rest of his physical exam is within normal limits.


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

He is up to date on all vaccines and is meeting all developmental milestones.

He was breastfed for the first 3 months and then switched to cow’s milk and about two months ago she started giving him fruits and vegetables.

Today, his heart rate is 120/min, respiratory rate is 40/min, blood pressure is 90/50 mm Hg, and temperature of 37.0°C (98.6°F).

On examination, he has a heartbeat with a regular rate and rhythm and his lungs are clear to auscultation bilaterally.

His weight and height fall within the expected range.


Three months later, his blood pressure appears to be adequately controlled on this therapy.

While working in his garden one afternoon, the patient is stung by a wasp and experiences a severe anaphylactic reaction that is subsequently treated with epinephrine.


Three years ago, he had an asthma attack that was treated with albuterol and a one-week course of steroids.

His mother has Hashimoto's thyroiditis and had precocious puberty.

His mother's height is 147 cm (4 ft 10 in) and his father's height is 160 cm (5 ft 3 in).

Neither his clothing nor his shoe size have changed over the past year.

He also frequently bumps into obstacles such as furniture and has headaches at night.

He is always thirsty for cold water and has been urinating more frequently.

He is at the 5th percentile for height and 5th percentile for weight.

His temperature is 37°C (98.6°F), pulse is 98/min, respirations are 16/min, and blood pressure is 100/64 mm Hg.

Examination shows a soft and nontender abdomen.

The genitals and pubic hair are both Tanner stage 1.


Her first child was born at term by vaginal delivery.

She has no history of any serious illnesses.

She does not drink alcohol or smoke cigarettes.

Current medications include vitamin supplements.

Speculum examination demonstrates clear fluid at the cervical os.

Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg.

The fetal heart rate is reactive at 160/min with no decelerations.


Abdominal examination shows left lower quadrant tenderness with no guarding or rebound.

Laboratory studies show a leukocyte count of 19,000/mm3.

A CT scan of the abdomen shows segmental wall thickening of the descending colon with multiple diverticula and a 5.0-cm, low-attenuation pelvic lesion with air-fluid levels.

CT-guided drainage of the fluid collection yields 250 mL of yellow-greenish fluid.


He is curious if patients with diabetes (defined as fasting serum glucose ≥126 mg/dL on two separate readings) are at increased risk of developing open-angle glaucoma over time.


Results:
The rate of exacerbations was reduced by 47% (95% confidence interval [CI], 29 to 61) among patients receiving intravenous mepolizumab and by 53% (95% CI, 37 to 65) among those receiving subcutaneous mepolizumab, as compared with those receiving placebo (p<0.001 for both comparisons).

Exacerbations necessitating an emergency department visit or hospitalization were reduced by 32% in the group receiving intravenous mepolizumab and by 61% in the group receiving subcutaneous mepolizumab.

At week 32, the mean increase from baseline in FEV1 was 100 ml greater in patients receiving intravenous mepolizumab than in those receiving placebo (p=0.02) and 98 ml greater in patients receiving subcutaneous mepolizumab than in those receiving placebo (p=0.03).

The improvement from baseline in the SGRQ score was 6.4 points and 7.0 points greater in the intravenous and subcutaneous mepolizumab groups, respectively than in the placebo group, and the improvement in the ACQ-5 score was 0.42 points and 0.44 points greater in the two mepolizumab groups, respectively than in the placebo group (p<0.001 for all comparisons).

Patients were assigned to receive mepolizumab, a humanized monoclonal antibody against interleukin-5, which was administered as either a 75-mg intravenous dose or a 100-mg subcutaneous dose or placebo every 4 weeks for 32 weeks.

Methods:
In this randomized, double-blind clinical trial we assigned 576 patients with recurrent asthma exacerbations and evidence of eosinophilic inflammation despite high doses of inhaled glucocorticoids to one of three study groups.

The primary outcome was the rate of exacerbations.

Other outcomes included the forced expiratory volume in 1 second (FEV1) and scores on the St. George’s Respiratory Questionnaire (SGRQ) and the 5-item Asthma Control Questionnaire (ACQ-5).

Conclusions:
Mepolizumab administered either intravenously or subcutaneously significantly reduced asthma exacerbations and was associated with improvements in markers of asthma control.


She says she was only unconscious for a moment and recovered quickly.

She reports increasing fatigue and joint pain for the past 4 months.

Her blood pressure is 90/60 mm Hg, and her temperature is 36.6°C (98.0°F).

On physical examination, the patient is fully conscious.

Her radial pulse is absent at her right wrist and 1+ at her left wrist.


She is sexually active with her boyfriend and states that she has been having pain during vaginal intercourse lately.

She also reports some pain while sitting and walking.

Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure 120/80 mm Hg.

Pelvic examination shows a left-sided, tender mass surrounded by edema and erythema in the left inner labia.


She was born with a disease that has led her to have recurrent upper respiratory infections throughout her life requiring antibiotic prophylaxis and chest physiotherapy as well as pancreatic enzyme replacement therapy.

She marries a man (without this disease phenotype) from a population where the prevalence of this disease is 1/100.


She was diagnosed with hypertension in the past and is now regularly taking antihypertensive medication (amlodipine 10 mg once daily).

She has had a diffuse thyroid swelling for the past 4 months.

She complains of pain in the long bones of her arms and legs for the past 3 months.

She is slightly built, appears thin, and is anxious and apprehensive.

Her weight is 45 kg (99.2 lb) and height is 146 cm (4 ft 7 in); BMI is 21.12 kg/m2.

Her pulse is 116/min, the blood pressure is 196/102 mm Hg, the respiratory rate is 29/min, and the temperature is 37.2°C (99.0°F).

Diffuse and firm thyromegaly is present.

Her upper extremities exhibit fine tremors during an anxiety attack.

The laboratory test results reveal elevated 24-hour urinary VMA and metanephrines.

Serum epinephrine, calcitonin, and parathormone levels are also elevated.

Hypercalcemia and hyperglycemia are also noted.


He has worked as a car salesman for 15 years and worked in a shipyard before that for 22 years.

He smoked half a pack of cigarettes daily for 13 years but stopped 25 years ago.

The cough had been initially nonproductive.

His temperature is 37.1°C (98.8°F), pulse is 86/min, respirations are 16/min, and blood pressure is 130/80 mm Hg.

Fine expiratory crackles are heard at both lung bases.

An x-ray of the chest shows patchy infiltrates and supradiaphragmatic pleural thickening in both lungs.

He is originally from China and visits his family there once every year.

A photomicrograph from a sputum sample is shown.


Her past medical history is significant for varicose veins in her lower extremities, well-controlled diabetes mellitus type 2, and a 25 pack-year smoking history.

The patient currently takes metformin and pioglitazone.

On physical examination, the patient is pale and diaphoretic.

Her temperature is 37.8°C (100.0°F), the pulse is 111/min, the respirations are 18/min, and the blood pressure is 130/60 mm Hg.

Cardiac exam is significant for an S3 gallop.

There is erythema and swelling over multiple varicose veins in her left leg.

Ultrasound of her left leg is positive for a deep vein thrombosis.

The patient is admitted, and anticoagulation is started with a vitamin K inhibitor.

Family history is significant for her sister who died at the age of 35 because of a pulmonary embolism.

However, despite these interventions, she dies shortly after admission.


The boy has no significant medical history.

He emigrated to the United States with his family from Nigeria 1 month ago.

He is in the 85th percentile for height and weight, and he has been meeting all developmental milestones.

She notes that he has been treated several times with different antibiotics, but that they have not helped.

She reports no recent history of fever, chills, or night sweats.

On physical examination, the patient has a prominent 8 × 8 cm mass over the right mandible.

The mass has partially distorted the borders of the mandible and cheek.

The contralateral side of the face shows no abnormalities.

An oral examination shows the disruption of the ipsilateral lower teeth and oral mucosa.

The remainder of the physical exam is unremarkable.

A biopsy of the mass is performed and a histopathologic analysis is seen in the image.


A urinalysis revealed a high level of uric acid.

A family history is notable for two similar cases in male cousins on the mother's side.


She has a 10-year history of hypertension and an esophageal stricture due to severe gastroesophageal reflux disease.

She was diagnosed with endometrial hyperplasia 20 years ago and treated with medroxyprogesterone.

Menarche started at 11 years of age and her last menstrual period was 8 years ago.

Current medications include lansoprazole and hydrochlorothiazide.

Her last mammography and PAP smear 6 months ago showed no abnormalities.

Physical examination shows no abnormalities.

Treatment is begun with a drug that prevents further bone resorption and reduces her risk of developing breast cancer.

Her mother died of breast cancer at the age of 45 years.


They are planning to travel to Ethiopia next month to visit the husband's family.

Medications include folic acid and an iron supplement.

Vital signs are within the normal range.

Abdominal examination shows a uterus that is consistent with a 20-week gestation.


He is a non-smoker and does not drink alcohol.

He states that his pain is worse a few hours after he eats.

The vital signs include blood pressure 120/90 mm Hg, heart rate 83/min, and temperature 37.0°C (98.6°F).

Physical examination is insignificant except for mild epigastric tenderness.

A metabolic panel reveals the following:
Serum sodium 136 mEq/L
Serum potassium 4.2 mEq/L
Calcium 13.2 mg/dL
Bicarbonate 26 mEq/L
Upper gastrointestinal endoscopy reveals multiple duodenal ulcers.


The patient’s blood glucose levels have been difficult to control on his current insulin regimen due to poor adherence to recommended therapy, and he has had difficulty putting on weight despite eating copiously.

The patient is afebrile and his vital signs are within normal limits.


Three months ago, she was in India for 3 weeks to attend a family wedding.

She worked as a seamstress in a textile factory for 50 years.

She has smoked one pack of cigarettes daily for 47 years.

Her current medications include enalapril, digoxin, isosorbide, spironolactone, and metoprolol.

During this period, she also has had a 4.5-kg (10-lb) weight loss and has become increasingly short of breath with mild exertion.

Her temperature is 37.0°C (98.6°F), pulse is 90/min, respirations are 25/min, and blood pressure is 110/70 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 94%.

There is dullness to percussion and decreased breath sounds over the right lung base.

The remainder of the examination shows no abnormalities.

Laboratory studies show a glucose level of 90 mg/dL, serum lactate dehydrogenase of 227 U/L, and serum protein of 6.3 g/dL.

An x-ray of the chest shows nodular pleural lesions on the right side and a moderate-sized pleural effusion.

Thoracentesis shows 250 ml of turbid fluid.

She has congestive heart failure and hypertension.


Menses have occurred at 30- to 90-day intervals since menarche at the age of 12 years.

She is sexually active with her husband and they do not use condoms.

There is no personal or family history of serious illness.

Examination shows oily skin and severe acne on the face.

There is dark hair on the upper lip and around both nipples.

Her last menstrual period was 6 weeks ago.

She is 170 cm (5 ft 7 in) tall and weighs 73 kg (161 lb); BMI is 25.3 kg/m2.

Her vital signs are within normal limits.

Laboratory studies show:
Dehydroepiandrosterone sulfate 6.2 μg/mL (N=0.5–5.4)
Follicle-stimulating hormone 20 mIU/mL
Luteinizing hormone 160 mIU/mL
Testosterone 4.1 nmol/L (N < 3.5)
A urine pregnancy test is negative.


She recently joined a walking program with her friends in order to lose weight; however, she noticed that she was not able to keep up with her friends during the program.

She has a 60-pack-year history of smoking as well as hypertension well-controlled on medication.


Physical examination shows mild wheezing over bilateral lung fields and enlarged supraclavicular and cervical lymph nodes.

A biopsy specimen of a cervical lymph node shows organized epithelioid histiocytes and multinucleated giant cells without focal necrosis.


She attained menarche at 10 years of age.

She has a history of hypothyroidism and type 2 diabetes mellitus.

She has smoked 1 pack of cigarettes daily for 20 years but quit 5 years ago.

Current medications include levothyroxine and metformin.

She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2.

Physical examination shows mild vaginal atrophy and a normal cervix.

The uterus and adnexa are nontender to palpation.

Transvaginal ultrasonography shows an endometrial thickness of 6 mm.

Endometrial biopsy shows non-invasive proliferation of endometrial glands with no nuclear or cytological atypia.


Six months ago, combined antiretroviral therapy consisting of dolutegravir, tenofovir, and emtricitabine was initiated.

Laboratory studies show a decrease in the CD4 count and an increase in the viral load despite ongoing treatment.

The patient is switched to a new treatment regimen, including a drug that acts by preventing viral DNA synthesis without undergoing intracellular phosphorylation.


The patient’s mother says that the patient was recently in northern Maine and spent most of her time during the trip outdoors.

Physical examination reveals a slight asymmetry of the facial muscles with an inability to whistle or close the right eye.

There is also decreased taste sensation.

A circular red rash with central clearing is present on the trunk.


Current medications include simvastatin, metformin, fenofibrate, hydrochlorothiazide, aspirin, glyburide, and lisinopril.

He has a blood pressure of 136/92 mm Hg and a heart rate of 69/min.

On physical examination, his heart sounds are regular and lung sounds are clear.


During the first 2 days of clinical manifestations, the parents of the child tried to control the symptoms using acetaminophen; however, the newborn continued to be ill, and blisters were noticeable around the buttocks, hands, and feet.

During the physical examination, the vital signs include body temperature 39.0°C (102.3°F), heart rate 130/min, and respiratory rate 45/min.

Ears, nose, and oral mucosa preserved their integrity, while the skin presents with diffuse blanching erythema and flaccid blisters with a positive Nikolsky’s sign.


Her medical history is remarkable for diet-controlled type 2 diabetes mellitus and hypertension treated with hydrochlorothiazide.

She mentions that she has tried over-the-counter lubricants, but lubricants do not seem to provide substantial relief.

She has been sexually active with her husband until recently and reports severe pain during vaginal intercourse.

The physical examination reveals dry, thin, white plaque-like lesions in the vulvar area with atrophy of the labia minora.

The perianal skin appears pale and wrinkled.


Other than SLE, her medical history is unremarkable.

She notes that she was in her usual state of health until 3 days prior to presentation when she noticed some mild tenderness around her left eye, unrelieved by any pain relievers.

This morning when she woke up she was unable to see out of her left eye and made an appointment to come see you.

She has had no additional symptoms other than pain and vision loss.

Her vital signs are all within normal limits.

On exam, she has no vision in her left eye, but 20/30 visual acuity in her right eye.

When you shine a light in her left eye there is no response.


Her past medical history is non-contributory and she is not currently taking any medications.

She states that she was walking up the stairs at work when she felt sudden and severe abdominal pain followed by nausea and vomiting.

The patient's symptoms persisted after ibuprofen and acetaminophen.

Her temperature is 99.7°F (37.6°C), blood pressure is 122/78 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for an absence of abdominal tenderness, a left adnexal mass, and left adnexal tenderness.

A transvaginal ultrasound demonstrates free fluid surrounding the ovary with edema and the presence of doppler flow.


His pulse is 95/min and blood pressure is 120/70 mm Hg.

During this time, he has also had shortness of breath and palpitations on exertion.

He has noticed blood in his stools on three separate occasions in the past 4 months.

The abdomen is soft with no organomegaly.

His hemoglobin concentration is 7.2 g/dL, hematocrit is 32%, and mean corpuscular volume is 68 μm3.


She works as an event manager and has had more stress than usual due to a recent concert tour.

She was seated and was being tattooed on her right upper flank when she became diaphoretic, pale, and passed out.

According to her boyfriend, the patient slipped to the floor and her arms and legs moved in a jerky fashion for a few seconds.

Her temperature is 37°C (98.4°F), pulse is 68/min, respirations are 16/min, and blood pressure is 120/72 mm Hg.

Her cardiopulmonary examination shows no abnormalities.

Neurologic examination shows no focal findings.

An ECG shows an incomplete right bundle branch block.

She regained consciousness within half a minute and was alert and fully oriented immediately.


He has nausea and severe pain in the right shoulder.

His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 15/min, and blood pressure is 135/85 mm Hg.

Examination shows swelling and tenderness over the right clavicle and pain exacerbated by movement; range of motion is limited.

The radial pulse in the right arm is intact.

Sensory examination of the right upper limb shows no abnormalities.

The boy was racing with his cousin when he lost control and fell onto his right side.


His wife reports he has been preoccupied with gambling at the local casino.

He becomes restless and irritable when his wife attempts to restrict his gambling.

Four months ago, he was diagnosed with Parkinson disease and treatment was initiated.


Her temperature is 101°F (38.3°C), blood pressure is 110/70 mmHg, pulse is 96/min, and respirations are 15/min.

Physical exam reveals several oral mucosal petechiae, bleeding gums, bilateral submandibular lymphadenopathy, and hepatosplenomegaly.

Initial laboratory workup shows the following:

Leukocyte count and differential:
Leukocyte count: 6,600/mm^3
Segmented neutrophils: 60%
Bands: 20%
Eosinophils: 9%
Basophils: 1%
Lymphocytes: 0%
Monocytes: 10%
Platelet count: 99,000/mm^3

Hemoglobin: 8.1 g/dL
Hematocrit: 25%

Prothrombin time: 25 sec
Partial thromboplastin time: 50 sec
International normalized ratio: 1.6
D-dimer: 2,000 µg/mL
Fibrinogen: 99 mg/dL

A bone marrow biopsy demonstrates 34% myeloblasts with Auer rods that are myeloperoxidase positive.


He reports that he has experienced similar symptoms multiple times over the past 5 years since he started working at his local zoo as a reptilian caretaker.

He takes fish oil and a multivitamin daily.

Two hours prior to presentation, he developed muscle cramps and nausea.

He has had 3 episodes of non-bloody watery stools since his symptoms started.

His temperature is 101°F (38.3°C), blood pressure is 130/90 mmHg, pulse is 90/min, and respirations are 17/min.

On exam, he demonstrates sensitivity to bright light.

A stool sample and culture demonstrates abundant non-lactose fermenting, oxidase-negative, and H2S-producing gram-negative bacilli.

He is tired-appearing but alert and fully oriented.


He has type 2 diabetes mellitus and hypertension.

Current medications include ramipril and metformin.

He has had multiple falls over the past 4 months.

Over the past 6 months, he has had progressive urinary urgency and now wears an adult diaper as is not always able to control the urge to void.

His appetite has also decreased in this time period.

He used to drive, but his wife convinced him to stop after she noticed that he was becoming increasingly inattentive while driving.

His temperature is 37.1C (98.8F), pulse is 90/min and blood pressure is 132/88 mm Hg.

Examination shows a broad-based gait with slow and short steps.

On mental status examination, he is oriented to person and place but not to time.

Attention and concentration are impaired.

He recalls only one of three objects after 5 minutes.


She lives with her sister and works as a cashier in a local retail store.

During this period, the patient has had several episodes of dizziness as well as double vision.

She also reports that she has lost control of her bladder on several occasions lately.

Her vital signs are within normal limits.

On mental status examination, she is oriented to person and place only.

There is moderate weakness of the upper and lower extremities.

Sensory examination shows no abnormalities.

Deep tendon reflexes are 3+ bilaterally.

She has not had any trauma or weight changes.


She has been living alone since her husband passed away 2 years ago.

She has remained an active member of her retirement community's wine club; however, she stopped attending the meetings 3 weeks ago.

She is generally able to her maintain her house, but her house appears more disorganized over the past 2 weeks.

She generally drives short distances but avoids driving long distances as she occasionally gets lost when navigating new areas.

She feels like her balance is getting worse, but she has not fallen.

She has noticed increased urinary urgency over the past 8 months and has had 2 episodes of incontinence.

Her temperature is 99.8°F (37.7°C), blood pressure is 115/65 mmHg, pulse is 95/min, and respirations are 17/min.

On examination, she is oriented to person and time but not place or situation.

She does not seem to recognize her doctor despite knowing him for many years.

She becomes somnolent intermittently throughout the interview.

She can recall 0/3 words after 5 minutes.

She has a low-frequency tremor in her right arm that increases in severity with deliberate movement.

She was started on multiple medications for worsening anxiety by her psychiatrist 1 month ago.

Despite these changes, she reports feeling well.


He reports that he feels well and has no complaints.

One month later, the patient returns to the physician complaining of new onset lower extremity swelling.

His temperature is 98.8°F (37.1°C), blood pressure is 155/90 mmHg, pulse is 80/min, and respirations are 16/min.

His physician adds another anti-hypertensive medication to the patient’s regimen.


A week ago, she returned from India, where she was working with an NGO to build houses in rural areas.

She has no history of a serious illness.

Her temperature is 39.3°C (102.7°F), pulse is 102/min, respirations are 22/min, and blood pressure is 112/78 mm Hg.

The remainder of the examination shows no abnormalities.

Her hemoglobin concentration is 10 g/dL and a blood smear shows fragmented erythrocytes and occasional ring-shaped inclusion bodies within erythrocytes.

The patient took one dose of chloroquine one week before her trip.

She also took a further dose during her trip.


She eats a healthy, varied diet and exercises at the gym 4 days a week, including 20 minutes of aerobic exercise.

Although she feels generally healthy she has noticed gaining about 9 kg (20 lb) over the last year.

On further questioning, she has also noted fatigue and constipation.

She denies shortness of breath, chest pain, lightheadedness, or blood in her stool.

At the clinic, the vital signs include: pulse 52/min, blood pressure 110/72 mm Hg, and oxygen saturation 99% on room air.

The physical exam is notable only for slightly dry skin.

The complete blood count (CBC) is within normal limits.


She has a history of bronchial asthma and bulimia nervosa.

She does not smoke and drinks 1–2 beers on the weekend.

Current medications include fish oil, a multivitamin, and a salbutamol inhaler.

She has had up to 12 watery stools per day.

Sometimes she awakens at night because she has to defecate.

She has had a 2-kg weight loss in the past month.

Her temperature is 36.8°C (98.2°F), pulse is 65/min, and blood pressure is 100/75 mm Hg.

Abdominal and rectal examinations are unremarkable.

Laboratory studies show:
Hematocrit 46%
Leukocyte Count 6,500/mm3
Platelet Count 220,000/mm3
Serum
Na+ 136 mEq/L
K+ 3.2 mEq/L
Cl- 102 mEq/L
HCO3- 33 mEq/L
Mg2+ 3.3 mEq/L
Urea nitrogen 14 mg/dL
Creatinine 0.8 mg/dL
Abdominal ultrasound shows no abnormalities.

Colonoscopy shows dark colored mucosa with interspersed white spots.

Biopsies of colonic mucosa are obtained and sent for pathological evaluation.

She returned from a trip to Costa Rica 7 weeks ago.


He drinks three to five beers on weekends.

He has problems getting to sleep at night and frequently falls asleep during class.

Recently he has started skipping classes altogether.

He goes to bed between 11 p.m. and 1 a.m. but cannot fall asleep for 2–3 hours.

When he wakes up at 8:30 a.m., he feels extremely drowsy, and he tries to overcome his fatigue by drinking 2–3 cups of coffee a day.

He naps at various times during the afternoon, often for more than an hour.

He states that he has tried over-the-counter melatonin pills and exercising at 8 p.m. without success.

Physical examination shows no abnormalities.

He stopped watching videos on his smartphone at night because of suggestions from his peers.


Over the past 3 years, he has been dressing all in black and wears a long black coat, even in the summer.

The mother reports that her son has always had difficulties fitting in.

He does not have any friends and spends most of his time in his room playing online games.

Rather than doing his coursework, he spends most of his time reading up on paranormal phenomena, especially demons.

He is anxious at college because he is uncomfortable around other people, and his academic performance is poor.

For example, a breeze in an enclosed room is likely the “breath of a demon”.

Mental status examination shows laborious speech.

He says that he has never seen any demons, but sometimes there are signs of their presence.


He has a medical history of 25 years of heavy smoking.

His vitals include: heart rate 89/min, respiratory rate 27/min, and blood pressure 120/90 mm Hg.

The physical exam shows increased resonance to percussion, decreased breath sounds, and crackles at the lung base.

Chest radiography shows signs of pulmonary hyperinflation.

Spirometry shows a forced expiratory volume in the first second (FEV1) of 48%, a forced vital capacity (FVC) of 85%, and an FEV1/FVC ratio of 56%.


His medications include hydrochlorothiazide.

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.

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

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

A right-sided carotid bruit is appreciated.

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


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


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.


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.

An ECG is performed as seen in Figure A.


The patient is sexually active with multiple male partners and reports inconsistent condom use.

She has a history of intravenous drug use and has not been to a doctor in the last 2 years.

It is constant and “all over” but gets worse when she is lying down or in the setting of bright lights.

A review of systems is significant for a low-grade fever, night sweats, cough, malaise, poor appetite, and unintentional weight loss of 12 pounds in the last 2 months.

Her temperature is 100.4°F (38.0°C), blood pressure is 110/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% O2 on room air.

On physical exam, pain is elicited upon passive flexion of the patient’s neck.

A CT scan shows ventricular enlargement.


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

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

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

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

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

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

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

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

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

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


He denies recent trauma and he has no known medical problems.

He denies tobacco use and will often drink 6-8 beers or spirits on weekend nights.

He woke last night with sudden-onset, sharp, 10/10 non-radiating pain in his right knee.

His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 140/90 mmHg, respirations are 16/min, and oxygen saturation is 97% on room air.

Physical exam reveals an erythematous, edematous right knee.

Passive extension of the knee is limited by pain.

Synovial fluid aspiration is performed and sent for analysis, which reveals 20,000 leukocytes/mm^3, and no organisms visualized.


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.


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.


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

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

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 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.

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

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


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

He denies having nausea, vomiting, or diarrhea.

His temperature is 98.6°F (37°C), blood pressure is 115/72 mmHg, pulse is 98/min, and respirations are 14/min.

Physical exam reveals conjunctival icterus, bilateral flank tenderness, and erythema of the left leg.

He was recently diagnosed with cellulitis of his left leg, for which he was prescribed trimethoprim-sulfamethoxazole.


He reports that he traveled to Africa last year and returned from a vacation to Thailand 10 days ago.

His immunizations are up to date, although he missed the pre-departure travel medicine consult before his trip to Thailand.

He also endorses sweats, headache behind the eyes, sore throat, muscle and joint pain, and a new rash seen in Figure A.

His temperature is 101.5°F (38.6°C), blood pressure is 125/80 mmHg, pulse is 105/min, and respirations are 14/min.


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.


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

Her medications consist of lamotrigine and valproic acid.

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

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

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

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


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

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

He returns 1 month later stating that his symptoms are roughly the same.

Physical exam is notable for the findings in Figure A.

The patient is started on benzoyl peroxide and topical retinoids.


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

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

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

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

Physical examination shows poor skin turgor.

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

The patient undergoes surgical management of her condition.


The 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.


He has no significant medical history and takes no medications.

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

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

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

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

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

He has taken acetaminophen and ibuprofen for the pain.


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

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

The pain is over his chest and in his left arm.

2 days later, he complains of chest pain.

An ECG is performed and is seen in Figure A.

His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.

A repeat ECG is performed and is seen in Figure B.

The patient is appropriately managed and is admitted to the step-down unit.


He has never had any serious injuries but that he always seems to bruise easily, especially after he started playing soccer this fall.

He has dull, aching pain along his left side where he hit the ground.

On physical exam, the patient has extensive bruising of the lateral left thigh and tenderness to palpation.

His temperature is 98.6°F (37°C), blood pressure is 112/74 mmHg, pulse is 82/min, and respirations are 11/min.

He fell sideways off the scooter as he rounded a curve in the road.

His parents deny that he has an abnormal number of nosebleeds or bleeding from the gums.

They have never seen blood in his stool or urine.

His mother notes that her brother has had similar problems.


He was born at home via spontaneous vaginal delivery at 37 weeks of gestation to a G1P1 mother.

His mother did not receive prenatal care.

His parents are concerned that he is not feeding well and has lost weight over the last 2 weeks.

He does not appear to respond to visual stimuli, and further examination reveals bilateral clouding of the lens.

His blood pressure is 70/44 mmHg, pulse is 151/min, and respirations are 41/min.

His weight is 3 kg (4th percentile) compared with 3.5 kg at birth (45th percentile).

On physical exam, he is jaundiced with an enlarged liver and spleen.


Whenever he eats solids, he regurgitates them back up.

Several hours later, the patient presents to the emergency department with chest pain and shortness of breath.

His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air.

On physical exam, the patient demonstrates a normal cardiopulmonary exam.

His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy.

Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test.


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

She is currently not on any medications.

She was given an exercise program but she has not been compliant with these exercises.

They found her somnolent next to her computer with an empty pill bottle around 3 hours ago.

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

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

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

Her parents are certain the bottle was new.


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

Her medical history and current medications are unknown.

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

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

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


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

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

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.

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

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.

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


He is otherwise healthy and does not take any medications.

The patient’s wife states she found him lethargic at home.

He has been sick the past week with diarrhea and has been staying home from work.

The patient has profuse, bloody diarrhea while in the emergency department.

He continues to have diarrhea while in the emergency department.

His temperature is 97.5°F (36.4°C), blood pressure is 62/32 mmHg, pulse is 185/min, respirations are 25/min, and oxygen saturation is 98% on room air.

An ECG is performed as seen in Figure A.

The patient is given 3L of ringer lactate and subsequently appears less confused, with a blood pressure of 100/70 mmHg.

He is able to drink oral fluids and protect his airway.


He has no medical problems and takes no medications.

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

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.

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

He does not appear to be reacting to internal stimuli.


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

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

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.


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

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

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

A cardiopulmonary exam is notable for a benign flow murmur.

A musculoskeletal exam reveals the findings shown in Figure A.


Medical history is significant for rheumatoid arthritis diagnosed approximately 10 years ago and treated with methotrexate as well as type 2 diabetes mellitus treated with metformin.

Her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities.

She also notices increased urinary frequency.

Her temperature is 98.6°F (37°C), blood pressure is 138/92 mmHg, pulse is 92/min, and respirations are 17/min.

On physical exam, there is mild tenderness to palpation of the metacarpophalangeal and proximal interphalangeal joints.

There is 4/5 power throughout the lower extremity.

Approximately 1 month ago, she was diagnosed with calcium phosphate nephrolithiasis.


He regurgitates a moderate amount of formula through his nose and mouth after most feeds.

He does not seem interested in additional feeding after these episodes of regurgitation and he has become progressively more irritable around meal times.

The patient is starting to refuse some feeds.

His mother denies seeing blood or streaks of red in his stool and she denies any family history of food allergies or dermatological problems.

The patient’s weight was in the 62nd percentile 4 weeks ago and he is now in the 48th percentile.

His height and head circumference have followed similar trends.

His temperature is 98.2°F (36.8°C), blood pressure is 72/47 mmHg, pulse is 125/min, and respirations are 27/min.

On physical exam, the patient smiles reciprocally and can lift his head and chest when in the prone position.

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

The patient drinks 4 ounces of cow’s milk formula every 3 hours.

He usually stools 1 time per day and urinates up to 6 times per day.


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

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

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

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

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


The patient 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.


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

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

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

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

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

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

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

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

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

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


She has a history of hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin.

She immigrated from Vietnam 6 months ago.

She has experienced these symptoms daily for the past 3 months.

She feels bloated and has episodic loose and watery stools.

Her temperature is 98.6°F (37.0°C), blood pressure is 110/60 mmHg, pulse is 70/min, and respirations are 18/min.

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

Cardiac and lung examinations are unremarkable.

Laboratory results are as follows: Leukocyte count: 13,000/mm^3 Segmented neutrophils: 54% Bands: 2% Eosinophils: 6% Basophils: 0.4% Lymphocytes: 30% Monocytes: 5% A vitamin D level is 26 ng/mL (reference: >= 30 ng/mL).


The patient has a medical history of diabetes.

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

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

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

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

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

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

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


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.


The child has a medical history of obesity and atopic dermatitis and uses topical steroid cream.

His family history is notable for asthma in his older sister and irritable bowel syndrome in his father.

On exam, he appears uncomfortable, is coughing continuously, and is drooling.

His temperature is 98.5°F (36.9°C), pulse is 120/min, blood pressure is 90/52 mmHg, and respirations are 32/min.

Cardiopulmonary and abdominal exams are unremarkable.

A chest radiograph is performed and the results are shown in Figures A and B.


The patient has no significant medical history.

For the past 3 months, the patient has been coughing when he drinks liquids.

His speech also sounds different according to his wife.

His temperature is 98.6°F (37.0°C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min.

On physical exam, he is unable to fully extend his tongue, and there are fasciculations on his tongue.

When tapping the mandible at the chin while the mouth is held open, there is pronounced upward movement of the lower jaw.


His medical history is significant for an episode of pancreatitis 2 years ago for which he was hospitalized for several days.

He drinks 2-3 beers on the weekend and he has never smoked.

He has no family history of colon cancer.

He reports that he also noticed some blood mixed with his stool.

He notes a weight loss of 8 pounds in the last 2 months with no changes in his diet or exercise habits.

His temperature is 97.6°F (36.4°C), blood pressure is 135/78 mmHg, pulse is 88/min, and respirations are 14/min.

On physical exam, his abdomen is soft and non-tender to palpation.

Bowel sounds are present, and there is no hepatomegaly.

The patient denies abdominal pain or any changes in his stool habits.


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

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

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

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

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

A chest radiograph is ordered as seen in Figure B.

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

His cardiac exam is notable for tachycardia.

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


He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD).

He hopes to play baseball in college and has begun lifting weights daily in preparation for baseball season.

The patient has a healthy diet to fuel his exercise regimen.

His parents have no concerns and are pleased with the recent improvement in his grades.

His chest has a normal appearance other than mild gynecomastia.

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

On physical exam, the patient has tall stature with average muscle mass for his age.

The patient has sparse facial hair and a moderate amount of coarse pubic hair that extends across the pubis and spares the medial thighs.

He was started on methylphenidate at that time and the patient now reports improvement in his ability to concentrate in school and at home.


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.

Her current medications include metformin, insulin, lisinopril, and valproic acid.

She was at a rehabilitation hospital when her symptoms started.

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

Physical exam reveals anasarca and asymmetric lower extremity swelling.

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 has a medical history of sinusitis, constipation, diabetes, and pelvic inflammatory disease.

Her current medications include fexofenadine, oral contraceptive pills, and metformin.

She is currently taking amoxicillin for a sinus infection.

She smokes 1 pack of cigarettes per day and drinks 2-3 alcoholic beverages daily.

She was at home when a sudden headache began with greater severity than she had experienced in the past.

Neurological exam reveals a confused woman who is now complaining of "seeing double."

Her temperature is 99.5°F (37.5°C), blood pressure is 187/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Cardiopulmonary exam reveals mild bibasilar crackles and tachycardia.

She presented within 30 minutes of symptom onset.

On physical exam, the patient is noted to be uncomfortable with the appearance shown in Figure A.


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.


She has no medical history and has never been hospitalized.

She has been complaining of pain in her right leg for the last few days.

The open wound remains present on the thigh with surrounding erythema and edema.

Her temperature is 102.2°F (39°C), blood pressure is 118/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 99% on room air.

At the time of the bite, they cleaned the wound and irrigated it with sterile saline water from a first aid kit.

Her neighbor’s cat bit her last week and her parents attributed the pain to her healing bite.


He has no medical history and takes no medications.

He recently started experimenting with alcohol and marijuana that one of his friends has been stealing from their parents.

He says that the spasms usually occur after he wakes up as he is getting ready for school, and consist of disorganized jerking motions that stop after a few minutes.

He has also noticed that they occur when he stays up late to cram last minute for exams.

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


One week ago, he began vomiting and regurgitating breastmilk through his nose after most feedings.

His stools over the past week have also become blood-streaked.

The patient does not seem to be in any distress when he passes these bloody stools.

The patient surpassed his birth weight by 2 weeks of age but has fallen 1 standard deviation on the growth curve since then.

His temperature is 98.6°F (37°C), blood pressure is 78/47 mmHg, pulse is 115/min, and respirations are 28/min.

The patient is breastfed and typically feeds for 20-30 minutes every 2 hours.

On physical exam, the patient is well-appearing.

The patient’s abdomen is soft, non-tender, and non-distended.

A digital rectal exam reveals a small amount of blood in the rectal vault.

His face and back have the physical exam finding seen in Figure A.


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.

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

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.

Faint rhonchi are heard at the lung bases bilaterally.


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.


Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating.

The patient states that she struggles with her romantic relationships though she deeply desires them.

The patient states she knew her boyfriend was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist.

When interviewing the patient, she is teary and apologizes for her behavior.

Her temperature is 98.6°F (37°C), blood pressure is 112/71 mmHg, pulse is 73/min, and respirations are 14/min.

On physical exam, you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts.

In the emergency department, the bleeding has stopped and the patient is currently medically stable.

You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious.

She is grateful to you for her care and regrets her actions.


The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours.

Her older son had a similar problem with vomiting that resolved around 12 months of age.

Four weeks ago, the patient’s height and weight were in the 40th and 34th percentiles, respectively.

His height and weight are now respectively in the 37th and 36th percentiles.

The patient’s mother is concerned that her milk production is not keeping up with the patient’s nutritional requirements.

She reports that about 2 weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds.

He seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards.

His mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of regurgitation.

His temperature is 98.6°F (37°C), blood pressure is 72/49 mmHg, pulse is 121/min, and respirations are 32/min.

On physical exam, the patient is cooing in his mother’s lap and smiles reciprocally with her.

He lifts his head and shoulders off the examination table when placed in the supine position.

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

She denies any diarrhea, hematochezia, or family history of food allergies.


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

The patient has no medical conditions and takes no medications.

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

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.

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 has a medical history of asthma and seasonal allergies.

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

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

Physical exam reveals the finding in Figure A.

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

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


The patient’s medical history is significant for hypertension, for which he takes lisinopril.

His family history is unknown as he was adopted.

The patient met his mother once and never knew his father but was told he died in his 50s.

He drinks a few glasses of wine per week and has never smoked.

His wife reports that her husband has not been himself for the last 2 months.

Whereas he was previously outgoing and “the life of the party,” the patient is now irritable and withdrawn.

He is a partner at an accounting firm, but his colleagues are threatening to fire him if he continues to perform poorly at work.

The patient cannot explain the recent changes to his mood and tearfully admits he fears there is something seriously wrong with him.

His temperature is 98.6°F (37°C), blood pressure is 141/87 mmHg, pulse is 81/min, and respirations are 12/min.

On physical exam, the patient has a flat affect with a facial grimace and sudden jerky movements of his upper extremities.


He does not see a primary care physician and is not currently taking any medications.

He drinks alcohol socially and does not smoke.

The patient has presented 3 times this month with similar complaints.

He states his shortness of breath started when he was walking from his car to a local restaurant.

His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air.

On physical exam, he appears fatigued and the cardiovascular exam reveals an additional heart sound after S2.

A pulmonary exam is notable for bilateral crackles and an abdominal exam reveals an obese abdomen without pain in any of the quadrants.

Lower extremity pitting edema is noted bilaterally.


She started treatment for a skin condition with a new oral medication 2 months prior.

She has not noticed any changes in her complexion as of yet.

Her temperature is 98.2°F (36.8°C), blood pressure 100/65 mmHg, pulse 87/min, and respiratory rate 14/min.

She is oriented to person, place, and time.

Neurological exam reveals papilledema upon examination of both eyes.

Skin examination is notable for the findings 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.


Her medical history is significant for hyperlipidemia, mild intermittent asthma, and type 2 diabetes mellitus.

She has never smoked and has 10-15 alcoholic drinks per week.

Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw.

This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast.

Her temperature is 100.8°F (38.2°C), blood pressure is 133/74 mmHg, pulse is 105/min, and respirations are 14/min.

On physical exam, there is a bluish hue to the skin on the lower left side of the patient’s face.

A 3x4 cm non-tender mass can be palpated inferior to the angle of the left mandible.

Thick exudate is draining from an opening in the skin.

The gram stain of the exudate can be seen in Figure A.

Two months ago, the patient had a root canal on a left molar.


The child was recently adopted and little is known about his medical or family history.

He eats a varied diet at home and with limited juice and snack foods.

The child seems to be doing well, but the patient is much larger than any of the other 3-year-olds in his preschool class.

He appears mildly developmentally delayed.

He appears to have poor visual acuity and is referred to an ophthalmologist, who finds downward lens subluxation of the right eye.

His temperature is 98.6°F (37°C), blood pressure is 101/67 mmHg, pulse is 110/min, and respirations are 24/min.

On physical exam, the patient is in the 73rd percentile for weight, 99th percentile for height, and 86th percentile for head circumference.

He has a fair complexion and tall stature with a prominent sternum.

The patient also has joint hypermobility and hyperelastic skin.


The patient has dementia at baseline and is minimally interactive.

This morning, she was found to be obtunded.

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

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.

There are no signs of trauma noted on exam.

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.

She was last known to be normal the night before.


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.


He has hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin.

The mass has been slowly enlarging over the past 1 year.

He reports no dysphagia, difficulty breathing, or changes to his voice.

He also denies heat intolerance, palpitations, tremors, or diarrhea.

His temperature is 37.1°C (98.8°F), blood pressure is 130/84 mmHg, pulse is 86/min, respirations are 12/min, and oxygen saturation is 99% on room air.

Bedside ultrasound reveals a 1x2 cm hypoechogenic nodule with microcalcifications in the right thyroid lobe, which is biopsied.

Pathology results are shown in Figure A.


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

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

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

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

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

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

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

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

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

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


The parents have no concerns at this time and note he is starting to run around and speak in 3-word sentences.

He has no remarkable medical history and his mother had an uncomplicated full-term pregnancy and delivery.

He is appropriately meeting the developmental milestones for his age.

The patient’s temperature is 98.4°F (36.9°C), blood pressure is 96/52 mmHg, pulse is 102/min, and respirations are 25/min.

He is in the 55th percentile for height and 62nd percentile for weight, which is consistent with his documented growth curves.

Fundoscopic exam shows the finding in Figure A.

His pediatrician continues the ocular examination and further notes that the pupils are equal, round, and reactive, extraocular movements are full, and ocular alignment appears normal.