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.


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

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

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

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

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

There is no tenderness to palpation of the spinous processes.

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

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

Bilateral patellar and Achilles reflexes are 2+.


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

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

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

Examination reveals an uncomfortable appearing man.

Examination of the patient is shown in Figure A.

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


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

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

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

An ECG is performed as seen in Figure A.


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

He does not smoke tobacco and drinks alcohol socially.

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

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

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

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

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

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

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


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

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

She has felt more fatigued over the past month.

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

Physical exam reveals a thin woman with thinning hair.

She appears pale and her mucous membranes are dry.

Her neurological and cardiac exams are unremarkable.

Laboratory studies are ordered as seen below.

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

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

Another repeat whole blood potassium is 2.5 mEq/L.

Another 40 mEq of potassium is administered.


He has no medical problems and takes no medications.

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

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

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

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

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

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

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

The radial pulse is diminished on the right.


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

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

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

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

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


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

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

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

On physical exam, the patient is in mild distress.

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

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

An abdominal radiograph is performed as in Figure A.

Prior to today, the patient was feeding, voiding, and stooling well.


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

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

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

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

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

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

Her CT scan findings are presented in Figure A.


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

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

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

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

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

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


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

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

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

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

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

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

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

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

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


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

He has no medical history and takes no medications.

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

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

His last tetanus vaccine was 3 years ago.


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

She drinks milk with meals and has juice sparingly.

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

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

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

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

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

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

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

On physical exam, she appears well nourished.


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

Today, he reports minimal improvement in his symptoms.

He denies thoughts of suicide or self-harm.

Exam reveals a depressed, tired appearing man.

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


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

Examination reveals an ill-appearing intubated patient.

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

No external bleeding or wounds are noted on exam.

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

Significant bruising is noted over the abdomen.

Infusion of packed red blood cells is initiated.

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


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

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

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

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

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

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

On physical exam, the patient is in mild distress.

Her abdomen is distended and firm without guarding.

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


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

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

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

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

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

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

He has palpable cervical lymphadenopathy.

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

His abdomen is soft and non-tender without hepatosplenomegaly.

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


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

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

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

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

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

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

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

Her laboratory test results are shown below:

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

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

Ultrasound findings are shown in Figure A.


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

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

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

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

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

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

Examination shows delayed horizontal nystagmus.


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

Her mother has type 1 diabetes mellitus.

She has had only 2 periods in the last year.

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

She has also had more frequent headaches than usual.

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

Cardiopulmonary and abdominal exams are unremarkable.

The patient has Tanner 5 breasts and pubic hair.

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


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.

Microscopic examination of synovial fluid is shown in Figure A.


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.

She presented within 30 minutes of symptom onset.

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.

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

Cardiopulmonary exam reveals mild bibasilar crackles and tachycardia.


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

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

Currently, she is complaining that her vagina hurts.

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

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

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

Laboratory values are obtained and shown below.


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

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

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

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

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

She denies dyspnea on exertion or orthopnea.

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

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

Her current ECG can be seen in Figure A.

Her ECG upon discharge from that hospitalization was normal.


The patient has a medical history of diabetes and hypertension.

His current medications include insulin, metformin, and lisinopril.

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

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

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

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

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

A cardiopulmonary exam is within normal limits.

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

Abdominal exam reveals splenomegaly and hepatomegaly.

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

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


The 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.


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

He is requesting medications and is crying out in pain.

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

Physical exam reveals swelling over his right leg and knee.

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

A radiograph is performed as seen in Figure A.


He recently went camping and hiking in the woods.

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

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

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

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

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

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


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

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

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

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

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

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

Physical examination is notable for a depressed affect.

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

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


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

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

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

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

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

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

The patient reported similar symptoms 2 months ago.

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

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


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

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

Physical exam is notable for the finding in Figure A.

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


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

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

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

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

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

There is no pain with active shoulder rotation.


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

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

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

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

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

A urine dipstick is positive for red blood cells.

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


The patient has a medical history of asthma which is well-controlled with albuterol.

Since then, the patient has developed a nasal discharge with worsening pain.

Inspection of the patient's nose reveals a unilateral purulent discharge mixed with blood.

His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 124/min, respirations are 17/min, and oxygen saturation is 98% on room air.

The cardiopulmonary exam is within normal limits.

The rest of the patient's exam is within normal limits.

Initially, the pediatrician prescribed decongestants and sent the patient home.


The patient has no significant medical history.

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

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

Today, he fainted prompting his presentation.

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

The patient is very thin and appears pale.

Stool fecal occult blood testing is positive.

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

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

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

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


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.


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

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

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

The physician begins counseling the family.

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


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

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

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

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

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

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

He tried ibuprofen with food and thinks it helped.

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

He denies any diarrhea or change in his stools.

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


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

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

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

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

He was not stabbed or otherwise injured elsewhere.


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

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

Prior to the procedure, he was also on dialysis.

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

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

He is currently recovering and doing well.

The patient successfully recovers over the next few days.


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

She denies alcohol use, smoking, and recreational drugs.

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

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

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

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

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


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

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

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

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

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

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

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

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


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

The patient has a medical history of polycystic ovary syndrome.

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

She also has worsening acne that started several weeks ago.

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

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

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

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

Transvaginal ultrasound is performed and shown in Figure A.


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.


The patient was born to a G1P1 mother at 39 weeks gestation.

The mother had diabetes that was managed with exercise and insulin during the pregnancy.

The mother has never been vaccinated and did not follow routine prenatal care.

The newborn's temperature is 99.5°F (37.5°C), blood pressure is 70/30 mmHg, pulse is 160/min, respirations are 27/min, and oxygen saturation is 80% on room air.

The initial workup of the patient includes a chest radiograph seen in Figure A as well as lab values as seen below.

Hemoglobin: 14 g/dL Hematocrit: 42% Leukocyte count: 6,500/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 101 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 12 mg/dL Glucose: 99 mg/dL Creatinine: 0.5 mg/dL Ca2+: 10.0 mg/dL AST: 12 U/L ALT: 10 U/L An electrocardiogram is obtained as seen in Figure B.


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

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.

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


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

He has a rash by the corners of his mouth.

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

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

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

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

The patient is subsequently admitted to the intensive care unit.

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

He is extubated the next day and appears well.


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

She takes oral contraceptive pills and a multivitamin daily.

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

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

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

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

Her physical exam is within normal limits.

All of her age appropriate immunizations are up to date.

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

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


She has no significant medical history and takes no medications.

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

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

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

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

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


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

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

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

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

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

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

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

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

Physical exam reveals the finding seen in Figure A.


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

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

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

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

The patient’s 3 older siblings are all healthy.

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

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

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


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

The patient has a past medical history of bulimia nervosa but has not been symptomatic in 2 years.

She also had an appendectomy at age 15 for appendicitis.

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

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

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

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

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

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

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

After 24 hours, she saw that it was positive.


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 has a history of type II diabetes mellitus and hypertension.

He takes metformin, insulin, and lisinopril.

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

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

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

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

Physical exam is otherwise unremarkable.


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.

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.

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

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

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.


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

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

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

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

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

An ECG is performed, as shown in Figure A.

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


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

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

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

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

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

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

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

The child is assessed as developmentally normal.


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

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

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

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

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

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

Her neck is thick with a posterior cervical fat pad.

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


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).


His medical history is pertinent for intravenous drug use.

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

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

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

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


Her medical history is notable for medullary thyroid cancer status post total thyroidectomy.

She enjoys a diverse diet and takes levothyroxine.

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

She further complains that her lips and feet feel numb.

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

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

Extraocular movements are intact, albeit slow.

Her visual acuity is decreased bilaterally.

The remainder of her physical exam is unremarkable.


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

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

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

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

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

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

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


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.


Her daughter has been feeding and voiding well.

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

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

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

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

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

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

There are no bruises or marks on her skin.


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

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

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

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

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

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

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

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

A digital rectal exam fails to relieve the obstruction.

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


He 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.

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.

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


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

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

The patient now vomits after every feed.

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

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

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

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

On physical exam, the patient has dry mucous membranes.


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

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

She has unprotected sexual intercourse with 3 male partners.

She has mild morning sickness but no other symptoms.

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

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

There are no lesions appreciated on skin exam.

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

The patient is started on an appropriate treatment regimen.


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

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

The mother declined all prenatal screening tests during this pregnancy.

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

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

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

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

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

The infant was eventually delivered via Caesarean section.


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

She noticed the weakness approximately 3 months ago.

It has gotten progressively worse since that time.

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

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

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

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


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

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.

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.


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

Three weeks ago, the patient began vomiting after meals.

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

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

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

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

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

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

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

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


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

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.

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

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.

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

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


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

Her last menstrual period was 3 months ago.

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

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

Cardiopulmonary and abdominal exams are unremarkable.

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

Transvaginal ultrasound is performed and shown in Figure A.


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

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

She noticed her symptoms while in the bathtub at home.

She has never had symptoms like this before.

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

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

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


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

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

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

Breath sounds are decreased at the bases bilaterally.

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

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

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

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

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

His chest radiograph can be seen in Figure A.


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

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

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

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’s anterior fontanelle is soft and flat, and his eyes are moderately icteric.

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

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


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

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

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

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

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

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


He has no significant medical history and takes no medications.

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

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

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

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

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

He has taken acetaminophen and ibuprofen for the pain.


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

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

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

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


As the infant is resting, vital signs are taken.

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

The patient’s neurological exam is within normal limits.


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

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

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

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

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

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

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

They deny any drainage from the swelling.


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 is otherwise doing well in school and enjoys playing basketball.

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

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

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

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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

A vacuum-assisted vaginal delivery was eventually performed.

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


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

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

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

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

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

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

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

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

There is no discoloration of the overlying scalp.


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.

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

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


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

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

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

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

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

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

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

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

His neurological exam is within normal limits.

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

He denies feeling fatigued or tired currently.


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

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

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

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

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

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

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


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

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

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

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

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

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

PO2: 55 mmHg
PCO2: 60 mmHg
pH: 7.30

The patient is intubated.

He was receiving gentamicin infusions for his infections.


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

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

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

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

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

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

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

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

Her abdominal radiograph can be seen in Figure A.


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

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

The patient’s 2 older siblings are both healthy.

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

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

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

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

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

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

A nasogastric tube is placed to decompress the stomach.

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


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

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

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

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

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

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

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


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.


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 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 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.

His chest has a normal appearance other than mild gynecomastia.

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.


Otherwise, he is not currently taking any medications.

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

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

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

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

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

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


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.

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

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

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

Her parents are certain the bottle was new.


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

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

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

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

Taking time off from training does not improve his symptoms.

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

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

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

He is currently not taking any medications.


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.


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

He has no significant medical history and takes no medications.

He feels disappointed because his voice has not changed.

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

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

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

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

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

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

Chest palpation and abdominal examination are unremarkable.

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


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

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

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

He does not engage in any physical or strenuous activity.

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

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

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

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


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

She also has migraines and gastroesophageal reflux disorder.

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

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

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

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

She took loperamide with symptomatic relief.

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


She is otherwise healthy and does not take any medications.

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

Bloody discharge is expressed from the right nipple.

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

Exam of the right breast reveals no mass on palpation.


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

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

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

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

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


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

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

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

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

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

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

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

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

His patellar reflexes are 4+ bilaterally.


She says that his first seizure occurred 1 year ago.

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

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

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

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

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

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

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

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

An EEG is performed, which is unrevealing.

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


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

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

He also endorses lightheadedness and fatigue but denies chest pain.

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

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

He has normal cardiac sounds with an irregular rhythm.

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

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

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


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

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

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

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

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

She denies dysuria, vaginal discharge, or vaginal pruritus.

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

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

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

Her medical history is otherwise unremarkable.


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

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

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

She immediately washed the puncture wound with saline.

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


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

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

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

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

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

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

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

He arrived within 20 minutes of the accident.


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

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

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

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

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

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

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

He works in a large industrial compound that manufactures semiconductors.


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

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

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

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

On lung exam, scattered crackles are appreciated.

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


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

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

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

Her last menstrual period was 7 weeks ago.

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

Physical examination is notable for diffuse abdominal tenderness upon palpation.

Pelvic examination demonstrates uterine and adnexal tenderness and uterine bleeding.

Laboratory studies are shown below:

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

The patient is started on intravenous fluids.

She denies any recent abdominal or vaginal trauma.


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

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

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

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

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

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


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 a medical history of obesity, anxiety, and constipation.

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

He has been taking his medications and resting.

The patient states he feels better since the incident.

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

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

An ECG is obtained and is seen in Figure A.

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


Pregnancy and delivery were uncomplicated.

The mother denies that anyone in the house smokes.

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

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

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

The patient's physical exam is otherwise unrevealing.

The newborn had been sleeping regularly and feeding well.

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


His family history is unknown as he was adopted.

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.

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.

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

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


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

She states that she feels well and has no complaints.

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

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

A transvaginal ultrasound is performed and demonstrates two intramural leiomyomas.

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


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

His medical history is significant for migraines and hypertension.

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

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

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

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

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

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

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


He admits to occasional cocaine and marijuana use.

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

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

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

On physical exam, the patient is a tired and anxious appearing young man.

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

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

His neurological exam is within normal limits.


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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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


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

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

She works as a receptionist at a marketing company.

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

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

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

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

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

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

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

Her medical history is significant for acne, hypothyroidism, obesity, and endometriosis.


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

His medications include atorvastatin and lisinopril.

He lost consciousness for about 30 seconds.

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

During the ride, he became gradually more somnolent.

He is difficult to arouse with a GCS of 7.

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

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

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

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


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.

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

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


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

Her symptoms started yesterday and have been getting progressively worse.

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

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

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

Her neurological exam is within normal limits.

Fundoscopic exam reveals mild bilateral papilledema.

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

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

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

Her mother fears that her daughter may have caught measles.


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.