The tendon is repaired without complication.

During the case, the resident inadvertently cuts a flexor tendon.

The attending tells the resident that the patient will do fine, and there is no need to report this minor complication that will not harm the patient, as he does not want to make the patient worry unnecessarily.

He tells the resident to leave this complication out of the operative report.


Pure tone audiometry shows a sensorineural hearing loss of 45 dB.

He received this first course of neoadjuvant chemotherapy 1 week ago.


He has type 2 diabetes mellitus and osteoarthritis of the hips.

Prior to admission, his medications were insulin and naproxen.

His temperature is 38°C (100.4°F), pulse is 93/min, and blood pressure is 125/85 mm Hg.

Examination shows mottled, reticulated purplish discoloration of the feet.

Laboratory studies show:
Hemoglobin count 14 g/dL
Leukocyte count 16,400/mm3
Segmented neutrophils 56%
Eosinophils 11%
Lymphocytes 31%
Monocytes 2%
Platelet count 260,000/mm3
Erythrocyte sedimentation rate 68 mm/h
Serum
Urea nitrogen 25 mg/dL
Creatinine 4.2 mg/dL
Renal biopsy shows intravascular spindle-shaped vacuoles.

He was also started on aspirin, clopidogrel, and metoprolol after the coronary intervention.


Pelvic examination shows mucopurulent discharge from the cervical os and left adnexal tenderness.

Her temperature is 39.1°C (102.3°F), pulse is 126/min, respirations are 28/min, and blood pressure is 80/50 mm Hg.

There is blood oozing around the site of a peripheral intravenous line.

Laboratory studies show:
Platelet count 14,200/mm3
Fibrinogen 83 mg/mL (N = 200–430 mg/dL)
D-dimer 965 ng/mL (N < 500 ng/mL)
When phenol is applied to a sample of the patient's blood at 90°C, a phosphorylated N-acetylglucosamine dimer with 6 fatty acids attached to a polysaccharide side chain is identified.


He has iron deficiency anemia and ankylosing spondylitis.

Current medications include ferrous sulfate, artificial tear drops, and indomethacin.

His vital signs are within normal limits.

He has also been sneezing multiple times a day during this period.

He had a similar episode 1 year ago around springtime.

Visual acuity is 20/20 without correction.

Physical examination shows bilateral conjunctival injection with watery discharge.

The pupils are 3 mm, equal, and reactive to light.

Examination of the anterior chamber of the eye is unremarkable.

He works as an elementary school teacher.


He has a 5-year history of untreated hypertension.

He has smoked 1 pack of cigarettes daily for the past 5 years and started abusing cocaine 2 weeks before his emergency room visit.

The pain radiates to the epigastric area.

The patient is diaphoretic and in marked distress.


He has a history of diabetes and peripheral artery disease.

Physical examination shows abdominal tenderness and right flank tenderness.

An ultrasound shows dilation of the right ureter and renal pelvis.


Current medications include atorvastatin, lisinopril, and an albuterol inhaler.

His pulse is 114/min and blood pressure is 130/88 mm Hg.

An ECG shows ST-segment depressions in leads II, III, and aVF.

Laboratory studies show an increased serum troponin T concentration.

At the time of discharge, echocardiography shows a left ventricular ejection fraction of 58%.

The patient is treated for acute coronary syndrome and undergoes percutaneous transluminal coronary angioplasty.


She has been utilizing oral contraceptive pills (OCPs) for the past 8 years, but asks to switch to an intrauterine device (IUD).

Her vital signs are: blood pressure 118/78 mm Hg, pulse 73/min and respiratory rate 16/min.

Physical examination is within normal limits.


She has no history of serious illness and takes no medications.

She appears well.
A photograph of the nails is shown.


She says she has not experienced vaginal discharge, bleeding, or fluid leakage, and is currently taking no medications.

She has had little prenatal care and uses condoms inconsistently.

Her sexually transmitted infections status is unknown.

On physical examination, her blood pressure is 110/70 mm Hg, heart rate is 86/min, and temperature is 37.6°C (99.7°F).

A confirmatory test is then performed in the mother to confirm the diagnosis of HIV.

As part of the patient’s workup, she undergoes a series of rapid screening tests that result in the administration of zidovudine during delivery.

The infant is also given zidovudine to reduce the risk of transmission.


He had a myocardial infarction 3 years ago.

He has hypertension, diabetes mellitus, and chronic bronchitis.

He has smoked half a pack of cigarettes for the past 45 years.

During this period, he also has excessive night sweats and shortness of breath on exertion.

Over the past 3 months, he has had a 5.6-kg (12-lb) weight loss.

The spleen is palpated 6 cm below the left costal margin.

Laboratory studies show:
Hemoglobin 6.4 g/dL
Mean corpuscular volume 85 μm3
Leukocyte count 5,200/mm3
Platelet count 96,000/mm3
A blood smear is shown.

Bone marrow aspiration shows extensive fibrosis and a few scattered plasma cells.


He has no history of serious medical illness and takes no medications.

He has had intermittent tingling sensations on both cheeks over this time period.

Audiometry shows bilateral sensorineural hearing loss.

Genetic evaluation shows a mutation of a tumor suppressor gene on chromosome 22 that encodes merlin.


He currently has no complaints and claims to be “as fit as a fiddle.” The physical examination findings are unremarkable, except for a mid-systolic murmur heard in the 2nd left intercostal space that radiates to the carotids on auscultation.

The physician instructs the patient to stand from a supine position with the stethoscope still placed on his chest.


After a detailed study of the virus and its life cycle, he proposes a theory: Initially, a host cell is co-infected with 2 viruses from the same virus family.

Within the host cell, concomitant production of various genome segments from both viruses occurs.

Ultimately, the different genome segments from the viruses are packaged into a unique and novel virus particle.

The newly formed virus particle is both stable and viable and is a new strain from the virus family that caused the outbreak of infection.


Her past medical history is significant for recurrent abdominal pain due to cholelithiasis.

Her father died at the age of 60 with some form of abdominal cancer.

She also complains of a dull pain in her back with nausea and vomiting several times.

Her temperature is 37°C (98.6°F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg.

However, a CT scan of the abdomen shows a calcified mass near her gallbladder.


He was diagnosed with asthma when he was 3 years old and has since been on treatment for the condition.

He is currently on a β-agonist inhaler because of exacerbation of his symptoms.

He has observed that his symptoms are more prominent in springtime, especially when the new flowers are blooming.

His mother has a backyard garden and whenever he goes out to play there, he experiences chest tightness with associated shortness of breath.

He has been advised to take more precaution during this seasonal change and to stay away from pollen.

He is also being considered for an experimental therapy, which attenuates the activity of certain mediators which cause his asthmatic attack.

The targeted mediator favors the class switching of antibodies.

A reduction in this mechanism will eventually reduce the exaggerated response observed during his asthmatic attacks, even when exposed to an allergen.


Diagnostic evaluation fails to discover an exact etiology of the boy's symptoms and the episode is classified as a brief resolved unexplained event (BRUE).

The risk profile for BRUE in infants remains largely unknown.

The pediatrician who saw the boy in the emergency department is trying to identify risk factors for BRUE.

She is aware of several confounders, including age, socioeconomic background, and family history of medical illness.

She recruits 75 infants under 1 year of age with BRUE and 75 infants without BRUE of the same age, socioeconomic background, and family history of medical illness.

She then compares the two groups with regard to history of feeding problems and history of recent upper respiratory infection.


The patient has no past medical history.

He has smoked 10 cigarettes per day for the past 7 years and occasionally drinks alcohol.

The pain is sharp, severe, increases when lying down, and improves with leaning forward.

The pain also radiates to his shoulders and neck.

He presents with vital signs: blood pressure 110/70 mm Hg, regular radial pulse of 95/min, and temperature 37.3°C (99.1°F).

On physical exam, a scratching sound of to-and-from character is audible over the left sternal border at end-expiration with the patient leaning forward.

His chest X-ray is normal and ECG is shown in the picture.


He was found on the floor in front of his apartment.

He is somnolent but responsive when aroused.

On physical examination, an alcoholic smell and slurred speech are noted.

His pulse is 64/min, respiratory rate is 15/min, and blood pressure is 120/75 mm Hg.

Neurological exam shows diminished deep tendon reflexes bilaterally and an ataxic gait.


She has a remote history of breast cancer in her 60s that was treated with radiation and chemotherapy.

She also reports a history of extensive travel to Africa and a 30-pack-year history of smoking.

She recently observed an enlargement of her axillary lymph nodes, which she examines on a weekly basis.

On physical exam, several axillary lymph nodes are palpable with a large non-tender palpable mass in her right axilla measuring 10 x 8 cm.

Fine-needle aspiration demonstrates what the pathologist describes as "a centroblastic and immunoblastic cell presence, suspicious for non-Hodgkin’s lymphoma (NHL)–diffuse large B cell variant".


She was born by cesarean section to a G1P1 woman with no prior medical history and had a normal APGAR score at birth.

In addition, she seems to have less energy compared to other babies and appears listless throughout the day.

Physical exam reveals a high-pitched holosystolic murmur that is best heard at the lower left sternal border.

Her parents say that she has never been observed to turn blue.


The patient has asthma that is treated with an albuterol inhaler.

The patient has smoked one pack of cigarettes daily for the past 10 years.

During this period, the patient has had headaches, muscle aches, joint pain, fever, and chills.

Physical examination shows slight wheezes throughout both lung fields.

Laboratory studies and urinalysis are positive for polysaccharide antigen.

Bronchoalveolar lavage using silver/PAS-staining shows macrophages filled with a dimorphic fungus with septate hyphae.

Ten days ago, she was hiking with her family in Mississippi.

Her mother has a lung disease treated with methotrexate.


One week into the hospitalization, he develops a fever and purulent cough.

His vitals include: heart rate 88/min, respiratory rate 20/min, temperature 38.4°C (101.1°F), and blood pressure 110/85 mm Hg.

On physical examination, he has basal crackles on the right side of the chest.

Chest radiography shows a new consolidation on the same side.


He uses a glucocorticoid inhaler and an albuterol inhaler but has missed his medications for the past week while on vacation.

His temperature is 36°C (96.8°F), pulse is 120/min, respirations are 40/min, and blood pressure is 100/80.

Expiratory and inspiratory wheezing is heard throughout both lung fields.

There are moderate intercostal and subcostal retractions and a decreased inspiratory to expiratory ratio.

His temperature is 36°C (96.8°F), pulse is 150/min, respirations are 22/min, and blood pressure is 100/70.

Nebulized albuterol and ipratropium treatments and intravenous methylprednisolone are given in the emergency department for a presumed asthma exacerbation.

One hour later, the child is limp and lethargic.


The patient's neutrophils are examined in the laboratory and they fail to react during the nitroblue tetrazolium test.


His mother reports that his cough has worsened over the last few hours.

He has a frequent barking cough and a hoarse voice when he speaks.

The patient's blood pressure is 118/78 mm Hg, pulse is 90/min, respiratory rate is 35/min, and temperature is 38.3°C (101.1°F).

On physical examination, the boy is sitting and leaning forward in apparent respiratory distress with suprasternal and intercostal retractions.

Auscultation reveals inspiratory stridor without wheezing.


She is very surprised as she has been taking oral contraceptives regularly.

Her current anti-TB regimen includes rifampin, isoniazid, pyrazinamide, and ethambutol.

After performing a complete physical examination and a screening test for pregnancy, her gynecologist informs her that she is pregnant.


He is normally in daycare; however, he has been home for the past 3 days.

His mother noted bloody stools and decreased oral intake of food and water over the last 24 hours.

The next day, he complains of lower extremity weakness and tingling.

On physical exam his temperature is 102.2°F (39°C), blood pressure is 140/90 mmHg, pulse is 120/min, respirations are 22/min and O2 saturation is 99% on room air.

On abdominal exam you note diffuse tenderness to palpation without rebound or guarding.

There are no masses, hepatosplenomegaly, and bowel sounds are hyperactive.

Ultrasound of the right lower quadrant is negative for appendicitis.

On repeat exam, lower extremity strength is 3/5 with diminished patellar deep tendon reflexes.

He receives 15mg/kg acetaminophen and fluids are started.


He was born at 38 weeks' gestation by cesarean section because of breech presentation.

The pregnancy was complicated by oligohydramnios.

Examination shows concavity of the medial border of the left foot with a skin crease just below the ball of the great toe.

The lateral border of the left foot is convex.

Tickling the lateral border of the foot leads to correction of the deformity.

The remainder of the examination shows no abnormalities.

X-ray of the left foot shows an increased angle between the 1st and 2nd metatarsal bones.


Physical examination shows a distended abdomen and right upper quadrant tenderness with normal bowel sounds.

She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2.

Laboratory studies show:
Leukocyte count 14,000/mm3
Serum
Total bilirubin 1.1 mg/dL
AST 32 U/L
ALT 40 U/L
Alkaline phosphatase 68 U/L
Abdominal ultrasonography is performed, but the results are inconclusive.

Cholescintigraphy shows the intrahepatic bile ducts, hepatic ducts, common bile duct, and proximal small bowel.


A cardiac catheterization is performed and measurements of the left ventricular volume and pressure at different points in the cardiac cycle are obtained.

The patient's pressure-volume loop (gray) is shown with a normal pressure-volume loop (black) for comparison.


Five weeks ago, she was hospitalized and received intravenous antibiotics for treatment of bacterial meningitis while visiting relatives in Guatemala.

She also has a 1-month history of progressive fatigue.

Her temperature is 39.4°C (102.9°F), pulse is 130/min, and blood pressure is 105/70 mm Hg.

Examination shows pallor and scattered petechiae and ecchymoses.

Laboratory studies show a hemoglobin concentration of 9.0 g/dL, a leukocyte count of 1,100/mm3 with 30% segmented neutrophils, and a platelet count of 20,000/mm3 .

Blood cultures grow coagulase-negative staphylococci.


He has had a 3.2-kg (7-lb) weight loss during this time.

Physical examination shows bilateral pitting pedal edema.

An endoscopy shows prominent rugae in the gastric fundus.


The patient is a known IV drug abuser but otherwise has an unknown past medical history.

He currently attends a methadone clinic.

He was brought in by staff from the homeless shelter when they found him unresponsive.

His temperature is 99.5°F (37.5°C), blood pressure is 97/48 mmHg, pulse is 140/min, respirations are 29/min, and oxygen saturation is 98% on room air.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 6.3 mEq/L
HCO3-: 17 mEq/L
Glucose: 589 mg/dL

The patient is given treatment.

After treatment, his temperature is 99.5°F (37.5°C), blood pressure is 117/78 mmHg, pulse is 100/min, respirations are 23/min, and oxygen saturation is 98% on room air.

Initial laboratory values are shown below.


His left knee was swollen a few weeks ago, but now with both joints affected, he has difficulty walking and feels frustrated.

He also has back pain which makes it extremely difficult to move around and be active during the day.

He says his pain significantly improves with rest.

He also suffers from dandruff for which he uses special shampoos.

Physical examination is notable for pitting of his nails.


The weakness is more noticeable when climbing stairs and combing hair.

The weakness improves after brief exercise.

She also has bladder incontinence for the past 4 weeks and was given an anticholinesterase agent with no improvement.


Laboratory results for the HIV are negative by PCR.

He is being evaluated for an immunodeficiency disease.


The novel drug was previously tested in a small population and is now undergoing a larger phase 3 trial in preparation for FDA approval.


Noticeably the patient remains unable to complete tasks involving verbal repetition.

Subsequent neurologic exam finds that the patient is fluent while speaking and is able to comprehend both one and two step instructions.

After acute treatment with tissue plasminogen activator (tPA), the patient is able to recover most of his speech.


She says she has always been "large" and was constantly targeted by her classmates and coworkers for being so.

She has tried numerous diet plans, exercise regimens, and cosmetic products with little to no effect.

She has a family history of type 2 diabetes mellitus and a menstrual cycle that occurs every 45 days.

Her main concern at the moment is her acne and unwanted facial hair on her upper lip, for which she often visits a local spa.

Recently, she underwent a glucose tolerance test that showed a plasma glucose level of 160 mg/dL (8.9 mmol/L) after 2 hours of a 75 g dose of oral glucose.

Her pulse is 72/min and the blood pressure is 138/80 mm Hg.

On physical examination, her height is 160 cm (5 ft 3 in) and her weight is 85 kg (187 lb), and she has severe inflammatory acne over the cheeks and forehead and dark coarse hairs on the back.


Past medical history is significant for type 2 dіаbеtes mellitus for 2 уеаrѕ, inconsistently managed with mеtformіn аnd glіmеріrіdе.

Не also сomрlаіnѕ of реrѕіѕtеnt раіn in his legs whісh is not relieved by over-the-counter analgesics.

Оn physical ехаmіnаtіon, thеrе іѕ dесrеаѕеd ѕеnѕаtіon to pain in both lower lіmbs, but deep tеndon rеflехеѕ аrе іntасt.

Ніѕ vіtаl ѕіgnѕ include: blood рrеѕѕurе 122/84 mm Нg, tеmреrаturе 36.7°C (98.1°F), and rеѕріrаtorу rаtе 10/mіn.

His ankle-brachial pressure index (ABPI) on the right side is 1.1.


He was born at 38 weeks gestation to a 36-year-old gravida 3 via vaginal delivery.

The pregnancy was complicated by gestational diabetes.

The patient’s mother received routine prenatal care and declined first trimester screening.

She subsequently underwent a quadruple screen at 15 weeks gestation that demonstrated decreased maternal serum alpha-fetoprotein (AFP), increased beta-hCG, decreased unconjugated estriol, and increased inhibin A.

Her last ultrasound prior to onset of labor demonstrated an amniotic fluid index (AFI) of 28 cm.

The patient’s two older siblings are both healthy.

The patient’s temperature is 97.8°F (36.6°C), blood pressure is 58/37 mmHg, pulse is 166/min, and respirations are 38/min.

The patient has urinated multiple times since birth but has not yet passed meconium.

His abdomen is firm and distended with hypoactive bowel sounds.

On physical exam, the patient is in moderate distress.


The patient has a past medical history of obesity and type II diabetes on metformin.

Her last child was born four years ago, and she has had five spontaneous vaginal deliveries.

She now soaks one super absorbent tampon every two hours for five days each cycle.

Her cycles have also become irregular, with intermenstrual bleeding for the last two months.

She now experiences significant dysmenorrhea, requiring 400 mg ibuprofen every four hours for the majority of each menses.

In addition, she reports new onset mild dyspareunia with intercourse and a “heavy feeling” in her pelvis.

She has also noticed increased urinary frequency but denies bowel changes.

At this office visit, temperature is 98.5°F (36.9°C), blood pressure is 137/84 mmHg, pulse is 87/min, and respirations are 14/min.


The officer state that the man has been arrested multiple times for public alcohol intoxication, but recently became homeless.

On exam, the man is behaving erratically.

He appears confused and has a slurred speech.

On gait exam, the patient is ataxic and cannot stand without support for more than a few seconds.

His vitals are all within normal limits.

Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2.

His ABG has pH 7.3, PaCO2 13mm, PaO2 130mm, HCO3 7.

Blood salicylate levels return as normal.


The study enrolled a total of 3,000 subjects, 1,500 in each study arm.

Follow-up was conducted at 45 days post-MI.

The following are the results of the trial:
Endpoints Medication 1 Medication 2 P-Value
Primary: death from cardiac causes 134 210 0.03
Secondary: hyperkalemia 57 70 0.4
What is the number needed to treat (NNT) for the primary endpoint of death from cardiac causes?


He has an 8-year history of type 2 diabetes mellitus.

He has smoked two packs of cigarettes daily for 34 years.

He reports that he started exercising regularly 2 months ago and that his right calf cramps when he uses the incline feature on the treadmill, forcing him to take frequent breaks.

The pain completely disappears after resting for a few minutes.

His pulse is 82/min, and blood pressure is 170/92 mm Hg.

Straight leg raise test elicits pallor and tingling pain in the right foot.

Femoral pulses are palpable; right pedal pulses are absent.


She has no history of serious medical illness.

Her last ultrasound at 22 weeks' gestation was normal.

On admission, fetal heartbeats cannot be detected by fetal doppler monitor.

Ultrasound shows decreased amniotic fluid levels and no evidence of fetal movement, respiration, or heart activity.

Physical examination shows no signs of life.

The patient gives birth to a 2296 g (5 lb 1 oz) male infant.


Despite therapy, his shortness of breath continues to worsen and his oxygen saturation decreases to the point where ICU transfer and intubation are required.

Respiratory viral panel returns positive for influenza A and the patient is started on a standard five day course of oseltamivir.

Chest radiograph shows bilateral infiltrates.

Clinical criteria are consistent with development of Acute Respiratory Distress Syndrome (ARDS).

After several weeks of supportive therapy, the patient improves with lung function returning to near normal.


He has had no recent changes to his medication regimen, which includes hydrochlorothiazide, lisinopril, and amlodipine.

His temperature is 98.0°F (36.7°C), blood pressure is 174/111 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air.

The patient's cardiopulmonary and abdominal exams are unremarkable.

Laboratory values are ordered as seen below.


Examination shows jaundice of the skin and scleral icterus.

Urinalysis shows an elevated concentration of bilirubin and a low concentration of urobilinogen.


Two weeks later, the patient develops vomiting, mild crampy abdominal pain, and watery, nonbloody diarrhea.

Treatment with galantamine is initiated.


He resides in an inpatient psychiatric facility where he has been successfully treated with haloperidol for the past several months.

These symptoms started slowly about 2 weeks ago and have become more pronounced, but they do not seem to bother the patient.

His physical exam and vitals are within normal limits.


He says this started during summer workouts leading up to this season.

He denies having any rash anywhere else on his body.

The blood pressure is 123/78 mm Hg, pulse is 67/min, respiratory rate is 15/min, and temperature is 38.1°C (98.7°F).

Physical examination reveals an erythematous, well-demarcated patch with peripheral scale on the left thigh, pubic region, and perineum.

There is no apparent scrotal involvement with the rash.


She also says she has been nauseous for the past 3 hours and has vomited twice.

The patient mentions she has had heavy menstrual bleeding for the past few days.

Her blood pressure is 95/80 mm Hg and her temperature is 40.0°C (104.0°F).

On physical examination, the patient appears diaphoretic.

A pelvic examination reveals a tampon in her vagina.


The patient's father states that they returned early from a 6-week roadtrip in Mexico because of these symptoms.

One week ago, he experienced abdominal pain, vomiting, and bloody diarrhea that have since subsided.

His temperature is 38.4°C (101.1°F), pulse is 130/min, respirations are 35/min, and blood pressure is 95/50 mm Hg.

The abdomen is soft and nontender; there is no rebound or guarding.

Laboratory studies show:
Hemoglobin 8.5 g/dL
Mean corpuscular volume 94 μm3
Leukocyte count 18,000/mm3
Platelet count 45,000/mm3
Prothrombin time 12 sec
Partial thromboplastin time 34 sec
Serum
Urea nitrogen 28 mg/dL
Creatinine 1.6 mg/dL
Bilirubin
Total 2.5 mg/dL
Direct 0.1 mg/dL
Lactate dehydrogenase 1658 U/L
A blood smear shows schistocytes.

His parents have been giving him oral rehydration solution.

The remainder of the examination shows no abnormalities.


She has been visiting the same dentist since childhood and for the past 2 years has had at least 2 visits for dental caries.

She eventually admitted to him that she regularly induces vomiting by putting her fingers down her throat.

She says she has been doing this for the last few years and purging at least once a week.

More recently, she has been inducing emesis more often and even looked into diuretics as she feels that she is gaining more and more weight compared to her ‘skinny friends’.

Her BMI is at the 50th percentile for her age and sex.


She returned from Indonesia 2 weeks ago, where she spent the summer with her grandparents.

Her symptoms began one week ago, when she had several days of low-grade fever and constipation.

Examination shows diffuse abdominal tenderness and mild hepatosplenomegaly.

There is a faint salmon-colored maculopapular rash on her trunk and abdomen.


At a party shortly afterward she experiences facial flushing, nausea, tachycardia, dyspnea, headache, and abdominal cramps after consuming alcohol.


She takes folic acid, iron, and vitamin D supplementation.

She complains of increased fatigability, but is otherwise well.

Her vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 86/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉).

The physical examination is unremarkable.


During the physical, the patient mentions some discomfort in his abdomen and pelvis and during a records review it is noted that he has not passed urine in the PACU, step-down unit, or since arriving on the med-surg floor.

On the med-surg floor, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, the blood pressure is 100/75 mm Hg, the oxygen saturation is 90%.

His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.

His incision site is clean, dry, and intact with an appropriate level of swelling and erythema.

A bladder scan is inconclusive due to body habitus.

He had undergone a successful hernia surgery 14 hours ago.

Before the surgery, he was pre-treated with atropine, scopolamine, and morphine and recovered well in the PACU after the surgery.

There were no complications in the step-down unit and the patient continued to recover.

On physical exam, he is a well-developed, obese man.


He is a competitive swimmer and has had 8 sexual partners in the past year.

He intermittently uses barrier protection.

He reports that he noticed a white film on his tongue and the sides of his mouth 2 days ago while brushing his teeth.

He also complains of a bitter metallic taste in his mouth but otherwise denies pain, burning, dysphagia, or hoarseness.

On exam, he is well-appearing and in no acute distress.

His oral examination demonstrates patches of white pseudomembranes that can be wiped away to reveal erythematous mucosa.

He is otherwise healthy and takes no medications.


He could not recall any precipitating event except for an amateur weight-lifting competition that he participated in 2 months ago.

Past medical history is significant for non-small cell lung cancer that was diagnosed and successfully treated.

The pain is described as a dull, constant ache that is worse at night.

Physical exam was unremarkable except for some point tenderness along the lumbosacral area.

A PET scan 1 year ago demonstrated no recurrence.


He has not had bowel movements in the past 24 hours.

He appears ill. His temperature is 37.8°C (100°F) and pulse is 122/min.

There is tenderness to palpation in the lower abdomen; guarding and rebound tenderness are present.

An x-ray of the abdomen shows dilated loops of bowel.

The surgeon recommends an emergency laparotomy.

He has been accompanied by his 14-year-old brother.

The parents are away visiting friends and cannot be reached.


He was born at 38 weeks' gestation via normal vaginal delivery.

He has been latching on and breastfeeding well since birth.

His mother has a history of Graves' disease and underwent near-total thyroidectomy in the second trimester of her pregnancy after her symptoms could not be controlled with antithyroid drugs.

She is currently receiving L-thyroxine therapy.

He weighed 3005 g (6 lb, 10 oz) at birth and currently weighs 2835 g (6 lb, 4 oz).

The patient's temperature is 38.9°C (102°F), pulse is 176/min, and respirations are 42/min.

Examination shows a diaphoretic infant with a paucity of subcutaneous fat.

There is swelling of the neck at the midline.


She is accompanied by her partner, who reports that she had been complaining of black and tarry stools for the past several days.

Vital signs are temperature 37 degrees celsius, heart rate 141 beats per minute, blood pressure 90/60, respiratory rate 20, and oxygen saturation 99% on room air.

On physical examination, she has splenomegaly and a positive fluid wave.

The remainder of her examination is within normal limits.

Subsequent emergent upper endoscopy reveals bleeding from the submucosal veins in the lower 1/3 of the esophagus, but no gastric bleed.

The patient is stabilized with intravenous fluids, and her blood pressure improves.

In the endoscopy suite she also receives IV octreotide.


He feels well and currently drinks 5 glasses of wine each night.

Medications include atenolol and lisinopril.

On physical exam, temperature is 98.1 deg F (36.7 deg C), blood pressure is 151/82 mmHg, pulse is 71/min, and respirations are 14/min.

He has spider angiomata on his chest; no asterixis, jaundice, ascites, or peripheral edema is noted.

Screening ultrasound reveals a new liver nodule, and follow up CT demonstrates a 2 cm right hepatic lobe lesion with enhancement in the arterial phase.

No hypodense attenuation is seen on the venous or delayed phase.


His past medical history is significant for alcoholic liver cirrhosis.

The patient’s wife says that he has been sleeping much more than usual for the past 5 days.

On physical examination, the patient is altered and not responsive to commands.

His bowel and bladder habit have not changed.

His vital signs include: pulse 76/min, respiratory rate 15/min, temperature 38.0°C (100.4°F) and blood pressure 122/75 mm Hg.

Shifting dullness is present and a positive fluid wave can be elicited.

Laboratory findings are significant for the following:
Laboratory test
Sodium 140 mEq/L
Potassium 3.5 mEq/L
Chloride 97 mEq/L
Glucose 90 mg/dL
Ammonia 100 µg/dL (ref: 19-60 µg/dL)
Arterial blood gas
pH 7.4
pCO2 40 mm Hg
pO2 90 mm Hg
HCO3 26 mEq/L
An abdominal ultrasound shows surface nodularity compatible with cirrhosis but no other changes aside from ascites.

An upper GI endoscopy is performed which shows gastric varices with no signs of active bleeding.


The patient was the front seat unrestrained driver in a head on collision.

The patient is currently complaining of chest pain.

Physical exam is notable for an uncomfortable young man with bruising over his chest wall.

The patient’s echocardiogram (ECG) is notable only for sinus tachycardia.

His temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Initial workup demonstrates that the patient’s pulmonary capillary wedge pressure and troponins are elevated.

The patient is given 2 liters of Ringer lactate solution and morphine.


He recently started melatonin and magnesium supplementation in hopes of improving his sleep.

Medical history is significant for alcohol use disorder that required multiple hospital admissions for management of acute pancreatitis and cirrhosis.

He states that he occasionally injects heroin intravenously.

He reports that his symptoms began approximately 1 week ago and he has noticed episodes of diarrhea.

Temperature is 100°F (37.8°C), blood pressure is 105/70 mmHg, pulse is 92/min, and respirations are 17/min.

Physical examination is significant for scleral icterus, hepatomegaly, ascites, and diffuse abdominal tenderness.

Laboratory testing is significant for leukocytosis and metabolic acidosis.

Ascitic fluid analysis demonstrates a polymorphonuclear cell count of 280 cells/mm^3, serum-ascites albumin gradient of 1.3 g/dL, and a culture positive for Escherichia coli sensitive to cefotaxime and ceftriaxone.

Laboratory testing is significant for a serum sodium of 131 mEq/L and creatinine of 1.8 mg/dL (it was 0.9 mg/dL on admission).

Urine studies are significant for a low urine sodium level, without evidence of blood or protein.

A paracentesis is performed and he is admitted into the hospital to receive intravenous cefotaxime and albumin.

On hospital day 2, the nurse reports that the patient is oliguric in the setting of constant fluid intake.

Since the hospital admission, he has not been started on any new medications.


She has not changed her diet or exercise habits.

She noticed a 6.8 kg (15 lb) unintentional weight loss over the preceding several months.

She also reports feuding with her boyfriend over the temperature of their shared apartment, as she always feels warmer than he does.

She also exhibits a fine tremor in her hands when her arms are outstretched.

The vital signs include: heart rate 110/min and blood pressure 146/78 mm Hg.

The physical exam is notable for warm and slightly moist skin.


He works as an office manager and has no known exposure to melanocytotoxic chemicals.

He has been sexually active with three female partners over the past year and uses condoms inconsistently.

He is 183 cm (6 ft) tall and weighs 80 kg (176 lb); BMI is 23.9 kg/m2.

One month ago, his hemoglobin A1C was 7.8%.

He first noticed the symptoms after returning from a business trip last week in the Bahamas.

The rash initially started as a single lesion on his upper back but since then has extended to his shoulders.

His temperature is 37.2°C (99°F), pulse is 78/min, and blood pressure is 130/84 mm Hg.

While he was there, he visited a couple of beaches and went hiking with some coworkers.


She is only able to verbalize two word sentences and has generalized developmental delay.

When she was born it was noticed that she had a high pitched mewing cry and subsequent physical exam revealed microcephaly, prominent epicanthal folds, and a holosystolic murmur best heard in the left 5th intercostal space near the sternum.


She has hypertension, hypercholesterolemia, and diabetes.

Medications include atorvastatin, hydrochlorothiazide, metformin, and aspirin.

She is sexually active with her husband.

She has had no fever, abdominal pain, or diarrhea.

Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 12/min, and blood pressure is 155/65 mm Hg.

Pelvic exam demonstrates a 4 x 3 cm firm, immobile erythematous mass on the right inner vaginal wall.

Her last Pap smear 1 year ago was normal.


He has had diabetes mellitus for 2 years which is not well controlled with medications.

There is swelling and tenderness over the first, second, and third metacarpophalangeal joints of both hands.

Lab studies show a transferrin saturation of 88% and serum ferritin of 1,200 ng/mL.


He then develops progressive respiratory failure and is admitted to the neonatal ICU.

A single loud S2 heart sound is appreciated as well as a machine-like murmur at the left upper sternal border.

Radiography shows an enlarged "egg-shaped" heart.

The newborn is then taken for a atrial septostomy to alleviate the condition pending definitive surgical correction.


The patient is unconscious and cannot provide any further history.

On physical examination, the patient is diaphoretic and unresponsive.

Vitals show a temperature of 37-0°C (98.6°F), blood pressure of 85/55 mm Hg, pulse of 115/min, respirations of 19/min, and oxygen saturation of 92% on room air.

There is a 3-inch long penetrating wound between the 3rd and 4th intercostal space on the left side of the chest, which is bleeding profusely.

Transthoracic echocardiography reveals a full thickness penetrating injury to the right ventricular free wall.

There are no apparent injuries to any coronary arteries or major branches.

The patient is intubated and aggressive fluid resuscitation is initiated, including a blood transfusion.


He has well-controlled hypertension and diabetes but has otherwise been healthy.

He does not smoke but drinks socially with his friends.

Physical exam reveals enlarged nodules that are not tender to palpation.

A biopsy is obtained showing a characteristic change in chromosome 18.


She is concerned about cancer because her uncle died of metastatic melanoma 1 year ago.

She has no history of serious illness and does not take any medication.

She has been working in a law firm for the past 20 years and travels to the Carribean regularly with her husband.

Examination of her skin shows no abnormal moles or warts.


The patient’s past medical history is positive for diverticulosis.

The daughter reports that her mother has recently been having difficulty combing her hair in the mornings.

Her blood pressure is 120/70 mm Hg, heart rate is 75/min, respiratory rate is 14/min, and temperature is 37.6°C (99.7°F).

On physical examination, the patient’s neck is stiff and she also has bilateral shoulder tenderness; muscle strength is intact.

The patient’s family history is significant for an ischemic stroke in her father.


She is sexually active with her husband and does not use contraception.

The patient also reports episodic pelvic and back pain accompanied by painful diarrhea for 5 years.

She has about one such episode on average per month for 4–6 days.

She has taken ibuprofen for the pain, which has provided some relief.

Analysis of her husband's semen has shown normal sperm counts during this time.

Pelvic and bimanual examinations are normal; rectal examination is unremarkable.

A hysterosalpingogram 6 months prior showed normal results.

Menses have occurred at regular 29-day intervals since menarche at the age of 14 years and last for 7 days.


The patient has been previously hospitalized for a tricuspid valve replacement surgery 1 year ago and takes aspirin daily.

The medical history is also relevant for myocardial infarction 3 years ago and hypertension for the past 10 years, for which he takes lisinopril.

She states that her husband developed a fever and began feeling weak 3 days ago, but has refused medical help.

He has been unable to go to work because of his symptoms.

His blood pressure is 140/80 mm Hg, the pulse is 82/min, the respirations are 18/minute, and the temperature is 37.2°C (98.9°F).

On examination, several hemorrhages are noted on the nail beds of several fingers.


She uses a combined oral contraceptive pill.

She also reports frequent episodes of crampy pelvic pain that starts one day before menses and lasts for 7 days.

Her symptoms are not relieved with pain medication.

Her vital signs are within normal limits.

Physical examination shows rectovaginal tenderness.

Cervical and urethral swabs are negative.

Transvaginal ultrasonography shows no abnormalities.

Menses occur at regular 28-day intervals and last 5 days.

Her last menstrual period was 2 weeks ago.


The patient has no active complaints and says he feels healthy; however, he does not exercise regularly and lives a sedentary lifestyle.

He is employed as an administrative position at a local college, and is seated at a desk most of the day.

His father had a heart attack at age 54 and his mother is still alive with no health concerns.

He does not smoke, only drinks socially, and does not use drugs.

Today, his blood pressure is 130/90 mm Hg, pulse is 84/min, and respiratory rate is 14/min.

Physical examination reveals an obese male with no significant findings.

He is concerned about his health after a colleague recently had a heart attack.


On arrival, she is lethargic and incoherent.

She has severe facial lacerations and is in respiratory distress.

Her pulse is 130/min, respirations are 29/min, and blood pressure is 90/58 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 70%.

Examination shows multiple facial lacerations.

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

Abdominal examination shows diffuse tenderness with no guarding or rebound.

Her hemoglobin concentration is 12.1 g/dL.

An x-ray of the chest shows a fractured left second rib, depression of the left mainstem bronchus, deviation of the nasogastric tube to the right, and a widened mediastinum.


She denies having similar symptoms in the past or starting any new medications or illicit drugs.

She is currently 10 weeks pregnant and is closely followed by her obstetrician.

She finds it difficult initiating sleep, occasionally has palpitations, and feels fatigued.

Her temperature is 98.6°F (37°C), blood pressure is 125/70 mmHg, pulse is 105/min, and respirations are 18/min.

On physical exam, the patient is mildly diaphoretic.

The skin is warm and the thyroid gland is diffusely enlarged with thyroid bruits.

Laboratory studies are significant for a thyroid-stimulating hormone level of 0.01 µU/mL (normal is 0.5-5.0 µU/mL) and an elevated free thyroxine (FT4) that is inappropriate for her pregnancy.


She immigrated to the US from Uganda 6 weeks ago.

Abdominal examination shows diffuse tenderness with no guarding or rebound.

The liver is firm and palpable 3 cm below the right costal margin, and the spleen is palpable just below the left costal margin.

Her leukocyte count is 12,800/mm3 (12% eosinophils).

Stool culture shows several oval-shaped eggs with lateral spines.

Microscopic examination of a liver biopsy specimen shows granulomatous inflammation with periportal fibrosis.


She has central cyanosis without signs of respiratory distress or signs of heart failure.

An echocardiogram reveals severe pulmonary outflow obstruction, right ventricular hypertrophy, a ventricular septal defect, and an overriding of the aorta.

An elective primary surgical repair is planned at 4 months of age.


Her husband says that she usually drinks one to two glasses of wine weekly.

Her only current medication is oxycodone for pain.

She is unarousable during the day, but then is awake and impulsive during the night, requiring frequent reorientation.

She is distressed and oriented to person but not to place or time.

Her vital signs are within normal limits.

Neurologic examination shows inattentiveness but no focal deficits.


Her caretakers state that the patient’s gait suddenly became ataxic, and she became less responsive than her normal non-verbal baseline.

Her temperature is 98.5°F (36.9°C), blood pressure is 125/68 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam is notable for an unremarkable HEENT exam with normal facial features and no signs of airway compromise.

Neurological exam is remarkable for new onset spasticity.

The patient has 3+ reflexes and a positive Babinski sign.

Musculoskeletal exam is only notable for symmetric swelling and deformities of the patient’s hands bilaterally.

Additionally, there is a "clunk" when posterior force is applied to the head while anterior force is applied to the cervical spine.


On arrival, he has rapid, shallow breathing and appears anxious.

His pulse is 135/min, respirations are 30/min and shallow, and palpable systolic blood pressure is 80 mm Hg.

Examination shows no active external bleeding.

There is a 2.5-cm single stab wound to the left chest at the 4th intercostal space at the midclavicular line.

Cardiovascular examination shows muffled heart sounds and jugular venous distention.

He is intubated and mechanically ventilated.


He has a 10-year history of hypertension that remains poorly controlled on maximum doses of lisinopril, hydrochlorothiazide, and amlodipine.

His past medical history is otherwise unremarkable.

He has no smoking history, drinks alcohol occasionally, and denies any illicit drug use.

His father required a kidney transplant in his forties.

He is asymptomatic at his office visit and denies any new complaints.

The physical exam is notable for palpable flank masses bilaterally.

Laboratory studies show a creatinine of 2.5.

The physician orders a renal ultrasound, and the results are shown.


She has no previous medical history and does not recall anything that could have provoked these symptoms.

She says that the chest pain is worse when she breathes or coughs.

Furthermore, on the way to the hospital she noticed that there were specks of blood on a tissue that she coughed into.

On presentation her temperature is 99°F (37.2°C), blood pressure is 107/65 mmHg, pulse is 102/min, respirations are 21/min, and O2 saturation is 91% on room air.

Further testing shows a large filling defect in the pulmonary vessels, and the patient is started on an appropriate treatment intravenously.

After drug administration, the effects of the drug are monitored using a standard blood test.

Surprisingly, the test results come back within normal parameters.


A urethral smear shows gram negative diplococci within white blood cells.

The organism grows well when cultured on Thayer-Martin agar.

The patient is prescribed a course of ceftriaxone and the infection resolves without further complication.

One year later, the patient returns with the same infection.


He reported significant neck pain to emergency responders, but otherwise denies weakness, numbness or tingling in his extremities.

His vitals on presentation to the ED are HR 90, BP 140/80, RR 20, SpO2 98%.


He is concerned about abnormal discharge from both nipples over the past 3 months.

The fluid is white, and he wonders if it could be milk.

On further review of systems, he endorses a diminished sexual drive.

The physician suspects that one of the patient's medications may be the culprit for these symptoms.


He was born at 38 weeks' gestation via uncomplicated vaginal delivery and weighed 3.1 kg (6 lb 13 oz).

The mother has no medical insurance and did not receive prenatal care.

The newborn's 4-year-old brother has sickle cell disease.

The liver is palpated 1 cm below the right costal margin and the spleen tip is palpated just below the left costal margin.


He says he has also noticed hand tremors, which increase at rest and decrease with focused movements.

On examination, the patient does not swing his arms while walking and has a shortened, shuffling gait.

An antiviral drug is prescribed which alleviates the patient’s symptoms.


Examination shows absent deep tendon reflexes bilaterally.


She was found wandering next to the highway.

The patient was unable to answer questions and collapsed in transit.

Her vitals are: temperature, 33.0°C (91.4°F); pulse, 40/min; respirations,12/min; blood pressure, 80/50 mm Hg; and oxygen saturation, 85% on room air.

Physical examination shows decorticate posturing, incomprehensible speech, eyes opening to pain, dry hair, coarse and waxy skin, and non-pitting edema around the face and all extremities.

Electrocardiogram shows sinus bradycardia.


His past medical history is significant for hypertension that is well-controlled with lisinopril.

He notes that this is particularly obvious when he is mowing his lawn or climbing the stairs in his home.

His vital signs are as follows: T 37.6 C, HR 88, BP 136/58, RR 18, SpO2 97% RA.

Physical examination is significant for an early diastolic blowing, decrescendo murmur heard best at the left sternal border, a midsystolic murmur heard best at the right upper sternal border, and a late diastolic rumbling murmur heard best at the apex on auscultation.

In addition, an S3 heart sound is also present.

Bounding pulses are palpated at the radial arteries bilaterally.


Her family members describe her as being very impulsive and frequently acting to manipulate people’s feelings.

The patient denies any history of smoking, alcohol use, or recreational drug use.

She says that her attempt was a result of a fight with her boyfriend and that she slit her wrists in an attempt to keep him from breaking up with her.

Since she was admitted to the hospital, she has spit at several staff members and alternated between sobbing and anger.

In the past, she has had many turbulent relationships, both romantic and in her family life.


The patient reports no pain in his lower abdomen or groin, no constipation, and states that he enjoys his usual diet.

He denies any use of alcohol, tobacco, or illicit drugs.

He has returned to work as a cruise ship attendant.

Preoperative workup included chest radiography which demonstrated an opacification in his right middle lobe.

The patient agrees to undergo computed tomography (CT) of his chest without contrast for further evaluation.

The radiologist reports an 8 mm nodule in the patient's peripheral right middle lobe that has regular margins and appears calcified.

One year later, the patient obtains another chest CT without contrast that reports the nodule size as 10 mm with similar characteristics.


He has been trying to conceive for over 2 years with his wife and previous evaluation of his wife's fertility revealed no abnormalities.

Physical exam reveals a tall man with long extremities, sparse body hair, gynecomastia, and small testes.

Laboratory studies reveal increased serum follicle-stimulating hormone concentration and an increased estradiol:testosterone ratio.

Genetic studies reveal a cytogenetic abnormality.


The patient has a past medical history notable only for obesity and asthma.

Physical exam is notable for an inability of the patient to bear weight on his left leg and limited range of motion of the left hip.

His temperature is 98°F (36.7°C), blood pressure is 124/65 mmHg, pulse is 128/min, respirations are 14/min, and oxygen saturation is 99% on room air.


He has had up to 4 bowel movements per day.

Several times he noticed mucoid strings with the stool.

Over the past month, has had a 3.2-kg (7-lb) weight loss.

He has not had fever, cough, or bloody stools.

He had a painful rash on his lower extremity 3 weeks ago that resolved spontaneously.

His temperature is 37.3°C (98.8°F), pulse is 85/min, and blood pressure is 115/77 mm Hg.

His hemoglobin concentration is 11.9 g/dL, MCV is 79 fL, ferritin is 106 ng/dL, and platelet count is 410,000/mm3; serum concentrations of glucose, creatinine, and electrolytes are within the reference range.


He was diagnosed with hepatitis C 3 years ago but refused treatment.

There is no family history of serious illness.

His only medication is a calcium supplement.

His wife states that he has been unable to recall his birthday or her name.

He is confused and oriented only to person.

He appears ill. His temperature is 38.3°C (100.9°F), pulse is 101/min, and blood pressure is 104/68 mm Hg.

Examination shows scleral icterus and spider angiomas.

There are fine tremors of the hands bilaterally.

The abdomen is distended and shifting dullness is present.

There is diffuse tenderness to palpation with no guarding.

Laboratory studies show:
Hemoglobin 12.6 g/dL
Leukocyte count 13,900/mm3
Platelet count 342,000/mm3
Serum
Albumin 2.6 g/dL
Total bilirubin 2.56 mg/dL
Alkaline phosphatase 54 U/L
AST 17 U/L
ALT 44 U/L
Paracentesis is performed.

Ascitic fluid analysis shows an albumin concentration of 0.8 g/dL, glucose concentration of 62 mg/dL, and a leukocyte count of 1900/mm3 with 60% neutrophils.

He has been treated twice in the past year for acute pancreatitis.


She has had a runny nose and a low-grade fever for the past 2 days, with some hoarseness and a rough-sounding cough that started this afternoon.

This evening she began making some high-pitched sounds when taking breaths, and she seemed to be having some trouble breathing.

She is alert and does not appear to be in acute distress.

She has a temperature of 38.0°C (100.4 °F), with a respiratory rate of 50/min and O2 saturation of 97%.

There is audible inspiratory stridor that worsens when she starts to cry during the examination.

Her pharynx is mildly erythematous with normal tonsils and no exudate.

A frontal X-ray of the upper chest airways is obtained (shown in the image).


Her past medical history is unknown and this is her first time seeing a doctor.

She states she is otherwise healthy and review of systems is notable for episodic hand pain that is worse in the winter as well as a chronic and severe cough with dyspnea which she attributes to her smoking.

It has persisted for the past several years but has been getting worse.

Her temperature is 97.7°F (36.5°C), blood pressure is 174/104 mmHg, pulse is 80/min, respirations are 22/min, and oxygen saturation is 92% on room air.

Physical exam is notable for a young appearing woman with coarse breath sounds.

Laboratory studies and urinalysis are ordered and currently pending.


He has a 20-year history of poorly-controlled type 2 diabetes mellitus.

Current medications include metformin and insulin.

Examination shows conjunctival pallor and bounding pulses.

Laboratory studies show:
Hemoglobin 8.6 g/dL
Mean corpuscular volume 90 μm3
Reticulocyte count 0.5%
Serum
Ferritin 325 ng/mL
Urea nitrogen 45 mg/dL
Creatinine 2.2 mg/dL
The patient is prescribed a drug to treat the cause of his current symptoms.


His past medical history is significant for obesity, sleep apnea, and type 2 diabetes that is well controlled on metformin.

He also has gastroesophageal reflux disease for which he occasionally takes antacids.

He says that these symptoms came on rapidly but does not recall anything that may have triggered the episode.

He has never experienced these symptoms before.

On presentation he is found to have fast, shallow breathing and abdominal pain that is poorly localized.


She has identified a drug that selectively inhibits phosphate release by the myosin head.


He does not make eye contact and sits very close to his mother.

Physical examination shows a grade 3/6 holosystolic murmur at the cardiac apex.

Neurological examination shows decreased strength in the right lower leg with normal strength in the other extremities.

Fundoscopic examination shows several multinodular, calcified lesions in the retina bilaterally.

A photograph of his skin findings is shown.


His past medical history is notable for diabetic nephropathy, hypertension, dyslipidemia, depression, and morbid obesity.

He also is currently being treated for an outbreak of genital herpes.

He endorses diffuse abdominal tenderness.

His temperature is 99.0°F (37.2°C), blood pressure is 184/102 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Physical exam is notable for an obese man in no acute distress.

A CT scan of the abdomen with contrast is performed and is unremarkable.

The patient is admitted to the observation unit for monitoring of his pain.

Notably, the patient's abdominal pain improves after an enema and multiple bowel movements.

The patient's evening laboratory values are ordered and return as seen below.


He is a former construction worker, and worked in a steel mill when he was in high school.

He is an active smoker with a 36-pack-year smoking history.

He presents with a 1-year history of worsening shortness of breath and weight loss.

The blood pressure is 130/78 mm Hg, pulse rate is 90/min, respiratory rate is 17/min, and the BMI is 31 kg/m2.

The patient is afebrile and the oxygen saturation at rest is 95% on room air.

The pulmonary examination reveals a mildly prolonged expiratory phase, and no wheezing or crackles are auscultated.

A pulmonary function test is recommended for the patient, and 2 weeks later he returns with a report that shows an FEV1/FVC ratio of 60% and FEV1 of 50% of the predicted value.

The lung volumes show a total lung capacity of 110% of predicted value, a residual volume of 115% of predicted value, and a DLCO of 60% of predicted value.


He is otherwise fine and denies recent travel or trauma.

Medical history is unremarkable and he does not take any medications.

He does not smoke cigarettes or drinks alcohol.

Allergies include peanuts, dust, and pollen.

He states that the symptoms come in episodes at the end of the workday and last a few hours.

He also mentions that he is fatigued all the time.

Chest X-ray reveals diffuse haziness in both lower lung fields.

His job includes taking care of various types of birds.


She underwent menopause ten years prior.

She has a past medical history of hypertension and diabetes mellitus.

In the immediate postoperative period, the patient develops left-sided flank pain and oliguria.

On physical examination, her uterus is uniformly enlarged.

Ultrasound reveals a thickened endometrial stripe and tissue biopsy reveals neoplastic endometrial cells.

Serum creatinine is found to be 1.4 mg/dl whereas it was 1.0 mg/dl prior to the operation.

A workup for metastatic disease is negative and the gynecologist recommends a laparoscopic hysterectomy.

During the procedure, the surgeon ligates multiple vessels in order to remove the entire uterus.


He also says he frequently sweats profusely at night and has a recurring low-grade fever, for which he takes acetaminophen.

His temperature is 37.1ºC  (98.8ºF), pulse is 76/min, blood pressure is 116/78 mm Hg, and respiratory rate is 13/min.

On physical examination, he has generalized pallor.

Bilateral cervical lymphadenopathy is present.

Examination of his abdomen reveals non-tender hepatosplenomegaly in the right upper quadrant.

Laboratory evaluation confirms the diagnosis of Hodgkin’s lymphoma.

The patient denies any symptoms like cough, breathlessness, or gastrointestinal symptoms.


A week prior to her symptoms, she had traveled to Brazil where she spent most of the evenings hiking.

She did not use any mosquito repellents.

There is no personal or family history of chronic or congenital diseases.

Medications include iron supplementation and a multivitamin.

She received all of the recommended childhood vaccinations.

She does not drink alcohol or smoke cigarettes.

Early in the 1st trimester, she had fevers and headaches for 1 week.

She also experienced myalgias, arthralgias, and a pruritic maculopapular rash.

The IgM and IgG titers for toxoplasmosis were negative.

The symptoms resolved without any medications.


Patient has no significant past medical history and takes no medications.

Her last two pregnancies ended with spontaneous abortions before the 10th week of gestation.

Her vital signs include: blood pressure 130/90 mm Hg, pulse 58/min, respiratory rate 11/min, and temperature 36.8℃ (98.2℉).

Physical examination shows 3+ deep tendon reflexes and increased muscle tone in the left upper and lower extremities.

Laboratory findings are significant for the following:
Platelet count 230,000/mm3
Fibrinogen 3.5 g/L
Activated partial thromboplastin time  70 s
Thrombin time 34 s
 A non-contrast CT of the head is performed and shown in the picture.


While there, he delivers a baby who he suspects has congenital hypothyroidism, most likely caused by inadequate maternal iodine intake.


She denies any cough, shortness of breath, hemoptysis, weight loss, fatigue, fevers, or night sweats over the last several months.

Her temperature is 97.0°F (36.1°C), blood pressure is 120/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air.

An initial chest radiograph is unremarkable.


Past medical history is significant for hypertension and atrial fibrillation.

Medications are lisinopril, metoprolol, and warfarin.

The son reports that the patient was in her usual state of health until she complained of chest palpitations.

This startled her while she was climbing down the stairs and lead to a fall.

Temperature is 99°F (37.2°C), blood pressure is 152/96 mmHg, pulse is 60/min, respirations are 12/min, and pulse oximetry is 98% on room air.

On physical examination, she is disoriented and at times difficult to arouse, the left pupil is 6 mm and non-reactive to light, and the right pupil is 2 mm and reactive to light.

A right-sided visual field defect is appreciated on visual field testing.

There is 1/5 strength on the right upper and lower extremity; as well as 5/5 strength in the left upper and lower extremity.

A computerized tomography (CT) scan of the head is shown.


A complete blood count, serum creatinine, and serum electrolyte concentrations are within the reference ranges.

A bone marrow biopsy shows 6% monoclonal plasma cells.

Further analysis shows that class I major histocompatibility molecules are downregulated in these monoclonal plasma cells.

The proliferation of these monoclonal plasma cells is normally prevented by a class of immune cells that lyse abnormal cells without the need for opsonization, priming, or prior activation.


She has a 5-year history of hyperlipidemia controlled with fluvastatin.

She feels that the muscles in her shoulders and hips have been getting weaker and sometimes feel sore.

She now has difficulty getting up from chairs, climbing stairs, and combing her hair.

She has also noticed new difficulty with swallowing solid foods, but has no trouble with liquids.

Neurologic examination shows moderate weakness in the arm abductors and hip flexors bilaterally.

Deep tendon reflexes are 2+ bilaterally.

Her maternal uncle died at age 26 from Duchenne's muscular dystrophy and her mother has Hashimoto's thyroiditis.


He states that he was resting at home when he noticed he had difficulty reading.

Currently, he is also starting to see double, and is seeing two images on top of each other.

Earlier today, he felt ill with nausea, vomiting, and watery diarrhea, which he attributed to food he had eaten at a picnic the day before.

When asked which foods he ate, he lists potato salad, a hamburger, deviled eggs, and pickles made by his neighbor.

He also heard that his friend who went to the picnic with him has developed similar symptoms and was seen in another hospital earlier.

While in the emergency room, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 122/84 mmHg, and respirations are 13/min.

Cranial nerve exam is notable for fixed pupillary dilation, and difficulty depressing both eyes.


The patient was delivered vaginally at 38 weeks' gestation.

Pregnancy and delivery were uncomplicated.

The mother has noticed that the girl's stools have become pale over the past week.

Examination shows scleral icterus and jaundice.

She is at the 50th percentile for length and at the 60th percentile for weight.

The liver is palpated 2 cm below the right costal margin.

Cardiopulmonary examination shows no abnormalities.

Neurologic examination shows no focal findings.

She was breastfed since birth but her parents switched her to formula feeds recently after reading on the internet that breastfeeding could be the cause of her current symptoms.


His only medication is a multivitamin supplement.

While measuring the patient's blood pressure, the nurse observes a spasm in the patient's hand.

Physical examination shows a well-healing surgical wound on the neck.

3 days ago, he underwent a total thyroidectomy for treatment of papillary thyroid cancer.


Her last menstrual period was 16 years ago.

She also says she has suffered from mild constipation for the past few years.

The patient denies any recent weight change or urinary symptoms.

Her body temperature is 37.8°C (100.0°F), pulse is 102/min, respiratory rate is 16/min, and blood pressure is 133/87 mm Hg.

On physical examination, tenderness to palpation in the left lower quadrant is present.


His past medical history is notable for diabetes, coronary artery disease, and hypertension, and he has a 40 pack-year smoking history.

He states that for the past month he has been unable to engage in sexual intercourse with his wife despite having appropriate sexual desire.

He also endorses deep and burning buttock and hip pain when walking, which is relieved by rest.

The patient states that he does not have erections at night or in the morning.

Physical exam is notable for weak lower extremity and femoral pulses.


He isolates a group of cells that are shown by flow cytometry to be positive for the cell surface marker CD8.

He then mixes this cell population with a group of infected cells, crosslinks extracellular interactions, and immunoprecipitates the CD8 protein.

He identifies a protein bound to CD8 that is composed of two chains from an adjacent cell.


He states that he is worried about his heart, as his father died at age 62 from a heart attack.

He reports that his chest pain worsens with large meals and spicy foods and improves with calcium carbonate.

He denies dyspnea on exertion and an ECG is normal.


Her past medical history is unremarkable.

She reports a 20-pack-year smoking history and is currently a daily smoker.

She also notes having occasional palpitations, nervousness, sweating, and heat intolerance.

Physical examination shows an anxious, trembling woman.

She has eyelid retraction bilaterally, with an inability to fully close her eyes.

Her extraocular motility is limited on upgaze.

There is no thyromegaly, and no thyroid nodules are noted.

Laboratory studies reveal a thyroid-stimulating hormone level of 0.1 μU/mL and total T4 of 42 μg/dL.

Thyroid-stimulating immunoglobulin is positive.

CT scan of the orbits shows proptosis and marked enlargement of the extraocular muscle with sparing of the tendons.


A detailed history reveals that there has been no history of urinary incontinence during the day since the boy was 4 years of age, but that he has never been dry at night continuously for 1 week.

On physical examination, the boy’s vital signs are stable.

His neurologic and abdominal examinations are completely normal.

There is no history of urinary tract infections, urgency, frequency, or hesitancy.


At autopsy, examination of the spinal cord shows unilateral atrophy of the neurons in the area indicated by the arrow.


Past medical history is noncontributory.

She takes a multivitamin with iron and folate every day and has been receiving regular prenatal care and the pregnancy is progressing normally.

She also complains of headaches and difficulty moving her neck.

On examination, an erythematous rash is seen on her right arm, as shown in the accompanying photograph.

Ultrasound of the fetus is reassuring with a normal heartbeat and no gross abnormalities.

Further questioning reveals that she had a tick bite on her arm while gardening a few days ago.

A specimen is collected to test for Lyme disease.


She has only had one menstrual period in the last four months and has never been pregnant.

She smokes a pack of cigarettes every day and does not take any medications.

The weakness has been progressive to the point where she cannot climb stairs and stand from a sitting position.

Her temperature is 98°F (36.7°C), blood pressure is 160/100 mmHg, pulse is 70/min, and respirations are 15/min.

Her laboratory workup is notable for the following:

Serum:
Na+: 142 mEq/L
Cl-: 102 mEq/L
K+: 3.9 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 314 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.1 mg/dL
AST: 9 U/L
ALT: 8 U/L
24-hour urinary cortisol: 470 µg (< 300 µg)
Serum cortisol 30 µg/mL (5-23 µg/dL)
Serum adrenocorticotropin-releasing hormone (ACTH) 2 pg/mL (> 5 pg/mL)

A 48-hour high dose dexamethasone suppression trial shows that her serum cortisol levels do not decrease.


Physical examination shows decreased sensation to light touch in all distal extremities.

Knee and ankle deep tendon reflexes are decreased.

Her last cycle of chemotherapy with vincristine was 1 week ago.


A CT scan of the urinary tract shows areas of bladder wall thickening.

Cystoscopy shows several sessile masses with central necrosis arising from the bladder wall.

A biopsy specimen of the bladder masses shows moderately differentiated urothelial cells with abundant mitotic figures and nuclear atypia.


Her father reports he had a short stature during his teenage years; he is currently 177 cm (5 ft 10 in) tall.

She feels well overall, but is concerned because all of her friends are taller than her.

She is at the 2ndpercentile for height and 35th percentile for weight.

An x-ray of the left hand and wrist shows a bone age of 11 years.


Two weeks ago, he had a sore throat that resolved spontaneously.

His temperature is 37°C (98.6°F), pulse is 107/min, and blood pressure is 94/67 mm Hg.

Examination shows pitting edema of the upper and lower extremities as well as periorbital edema.


The patient’s medical history is unremarkable, and he is currently working reduced hours at his job as an accountant.

Physical examination reveals confluent scaly patches, plaques, and generalized erythroderma along the torso and lower extremities (see image).

There is also a solid skin lesion with a diameter greater than 1 cm.

The dermatologist suspects a malignancy and orders a biopsy.


She works at an accountant's office and reports difficulty in concentrating on her work.

She is married and frequently fights with her husband.

During this period, she has found it difficult to relax.

She states that her head is full of worries.

She has been working longer shifts because one of her coworkers is on vacation and reports feeling more tired than usual.

The patient states that in order to deal with her stress, she goes shopping.

While shopping, she steals small trivial items and feels immediately relieved thereafter.

Her husband is concerned about her behavior, but she is unable to stop shoplifting.

Her vital signs are within normal limits.

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

Physical examination shows no abnormalities.

She discards the objects she steals and has feelings of shame and guilt about her actions.


Initially, the patient was noted to be behaving inappropriately including using foul language and grabbing people unexpectedly.

This has progressed to a worsening of his memory and trouble caring for himself.

When he is engaged in conversation, he exhibits word finding difficulty and is rather inattentive.

His temperature is 98.1°F (36.7°C), blood pressure is 162/103 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Physical exam is notable for an elderly man who laughs inappropriately at times and who is a poor historian.


His birth history is insignificant, and his immunizations are up to date.

She notes that he is eating less and is more cranky than usual.

Vital signs include: temperature is 37.8°C (100.0°F), pulse is 98/min, and respiratory rate is 16/min.

The rash features thin-walled, fluid-filled blisters that rupture easily.

Fluid samples from the lesions are sent for analysis to a microbiology lab.

The results reveal an infection by the gram-positive bacterium Staphylococcus aureus.

The patient is diagnosed with staphylococcal scalded skin syndrome.


He also reports that he has had 3 episodes of watery diarrhea per day for the last 2 days.

His temperature is 38.0°C (100.4°F), pulse is 65/min, respirations are 15/min, and blood pressure is 140/78 mm Hg.

Diffuse crackles are heard over bibasilar lung fields.

Laboratory studies show:
Hemoglobin 13.8 g/dL
Leukocyte count 16,000/mm3
Platelet count 150,000/mm3
Serum
Na+ 131 mEq/L
Cl-
102 mEq/L
K+ 4.7 mEq/L
HCO3- 26 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 1.2 mg/dL
An x-ray of the chest shows patchy infiltrates in both lungs.


Both the ovaries are enlarged and have multiple thin-walled, septated cysts with clear content.


The patient lives with her son and his family and her son reports that other members of the family have had similar symptoms during the past week but that he has not had any symptoms.

The result of a polymerase chain reaction test confirms that the woman is infected with a virus that has a helical capsid and a segmented genome.


His psychiatric history is significant for major depression with psychotic features.

He was diagnosed after his wife died from pancreatic cancer four years earlier.

He lives alone in his apartment and has no children.

He does not possess a firearm at home but has access to weapons at a local hunting club.

Today, he feels well but still wakes up frequently at night and cannot sleep through the night.

Three years ago, he deliberately overdosed on sleeping pills.

The patient currently denies suicidal thoughts or thoughts of self-harm.


He returned from a camping trip 1 week ago.

During this period, he has had severe itching and was not able to sleep well.

He has also had fever, headache, and some muscle pain.

Five days ago, he had a runny nose which subsided with over-the-counter medications.

The patient is at the 55th percentile for height and at the 50th percentile for weight.

His temperature is 38.2°C (100.7°F), pulse is 97/min, and blood pressure is 96/60 mm Hg.

Examination of the skin shows several macules, papules, and crusted lesions over his face, trunk, and extremities.

There are a few fluid-filled vesicles over his abdomen and back.


He has a history of major depressive disorder and seasonal allergies.

Current medications include amitriptyline and diphenhydramine.

The patient does not respond to questions and repeatedly says, ""The government is following me everywhere.""

After the examination, the patient starts screaming and tries to bite the physician.

His temperature is 37.9°C (100.2°F), pulse is 115/min, respirations are 24/min, and blood pressure is 160/89 mm Hg.

Neurologic examination shows dilated pupils bilaterally and diffuse hyperreflexia.

His feet are cold, and capillary refill time is 3 seconds.

Urine toxicology screening is positive for ethyl glucuronide.


His past medical history is notable for schizophrenia and asthma and he currently takes albuterol as well as another medication whose name he does not remember.

He reports that his neck started “locking” three hours ago.

His temperature is 99.0°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min.

On physical examination, the patient appears anxious and diaphoretic.

He speaks in full sentences and is oriented to person, place, and time.

The patient’s neck is flexed and rotated to the right approximately 40 degrees.

The right sternocleidomastoid and trapezius are firm and contracted.

Extraocular movements are full and intact.


Physical examination shows hepatosplenomegaly.

A venous blood sample obtained for routine screening tests is milky.

After refrigeration, a creamy supernatant layer appears on top of the sample.

Genetic analysis shows a mutation in the apolipoprotein C-II gene (APOC2) on chromosome 19.


Six months ago, he underwent a Roux-en-Y gastric bypass to treat obesity.

He underwent a total thyroidectomy to treat a Hurthle cell lesion 4 days ago.

He has smoked 1 pack of cigarettes daily for 22 years.

His only current medication is a multivitamin supplement.

His abdominal discomfort is worse shortly after meals.

He has also had progressive perioral numbness and upper-extremity muscle cramping for the past 24 hours.

Physical examination shows a well-healing surgical wound on the neck.

His temperature is 36°C (96.8°F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/70 mm Hg.

While measuring the patient's blood pressure, the nurse observes spasm of the patient's hand.

The abdomen is mildly tender to palpation with well-healed laparoscopic incisional sites.

The remainder of the examination shows no abnormalities.

His mother died of lung cancer at age 68.


He prefers watching television rather than going out and playing with other kids.

The patient was delivered healthy and is fully immunized.

The medical history is unremarkable, and he takes no medications.

The mother mentions that her boy is always tired, and seems to be getting worse.

Furthermore, he has had frequent episodes of constipation since birth.

The pulse is 90/min, the blood pressure is 110/75 mm Hg, and the respiratory rate is 15/min.

He is in the bottom 10th percentile for height and weight according to his age.

The remainder of the physical examination is unremarkable.

He recently had a urinalysis that showed elevated urinary calcium excretion.

Except for frequent cravings for salty foods, the boy eats a regular diet.

His father is a banker and his mother is a librarian.


His mother reports intermittent episodes of jaundice with joint and bone pain since he was 5 months old.

The child is clutching his abdomen and crying about pain in his belly.

At presentation, the patient’s vital signs are within normal limits.

Physical examination reveals slight jaundice and pale conjunctiva.

The spleen is tender and easily palpable.

After a complete blood count with differential and an abdominal ultrasound, the patient is found to have sickle-cell disease with splenic infarct.

After the operation, the physician provides vaccines against Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae.

The picture shows a slide obtained from the resected portion of the patient’s spleen.


She has a history of hypertension, for which she takes hydrochlorothiazide (HCTZ), but she has no other medical problems.

Family history is significant for her grandmother having systemic lupus erythematosus.

She says the dryness has become so severe that she has difficulty swallowing food.

On physical exam, she has tender parotid glands bilaterally and dries mucous membranes.

The vital signs include: blood pressure 118/76 mm Hg, heart rate 78/min, and respiratory rate 15/min.

The presence of serum anti-Ro and anti-La autoantibodies is confirmed at high titers.


Past medical history is significant for hypertension and hyperlipidemia.

He takes chlorthalidone and atorvastatin.

He has smoked 20–30 cigarettes daily for the past 26 years.

He reports feeling ill for the past 3 weeks.

Anti-glomerular basement membrane serologies are positive.


Current medications include trimethoprim-sulfamethoxazole, dolutegravir, and tenofovir-emtricitabine.

Physical examination shows nuchal rigidity.

Kernig and Brudzinski signs are present.

A lumbar puncture is performed and shows an opening pressure of 32 cm H2O (N: < 20).

The pathogen isolated from the cerebrospinal fluid (CSF) can be cultured on Sabouraud agar.


She has a history of hypertension and gastroesophageal reflux.

Current medications include ramipril and pantoprazole.

The patient appears healthy and well nourished.

For the past six days, she has had a burning pain in her upper right back and chest.

She cannot recall any recent injury and has no prior history of back pain.

Her temperature is 36.9°C (98.42°F), pulse is 76/min, and blood pressure is 145/92 mm Hg.

Examination shows a long erythematous rash covered with multiple clear vesicles and crusty lesions extending from her back to below her right breast.


It is determined that patients have a 4-year asymptomatic period prior to developing clinical symptoms from this adrenal cancer.

A new screening test is developed, and the cancer can now be detected 2 years prior to developing clinical symptoms.

A new observational case-control study of screened and unscreened patients measures the median 5-year survival of patients who decline medical and surgical treatment.

The screened population has statistically better outcomes.


He has been working in the glass manufacturing industry for 20 years.

The shortness of breath started a year ago and is exacerbated by physical activity.

His vital signs include: heart rate 72/min, respiratory rate 30/min, and blood pressure 130/80 mm Hg.

On physical exam, there are diminished respiratory sounds on both sides.

On the chest radiograph, interstitial fibrosis with reticulonodular infiltrate is found on both sides, and there is also an eggshell calcification of multiple adenopathies.


The patient recently lost her husband in a car accident and is still extremely shocked by the event.

On physical examination, her blood pressure is 105/67 mm Hg, the heart rate is 96/min and regular, breathing rate is 23/min, and the pulse oximetry is 96%.

An S3 heart sound and rales in the lower right and left lung lobes are heard.

A 12-lead ECG shows no significant findings.

Echocardiography shows an enlarged left ventricle and left atrium.

The patient is stabilized and informed about the diagnosis and possible treatment options.


The staff recognizes him as a local homeless man with a long history of alcoholism.

He was found unconscious on the street.
He smells of alcohol.

At the hospital, his pulse is 95/min, the blood pressure is 110/70 mm Hg, the respirations are 20/min, and the oxygen saturation is 98% on room air.

On physical exam, the unconscious man is covered in bloody vomit with small clots and food particles.

A digital exam reveals black tarry stool in the rectal vault.

The patient is given oxygen, IV fluids, and an NG-tube is placed and set to intermittent suction.

Labs are sent and the patient is prepared for a procedure.


Two weeks ago, she had a sore throat that resolved without treatment.

Physical examination shows 1+ pitting edema of the lower legs and ankles.

Urinalysis shows numerous RBCs and 3+ proteinuria.

Her antistreptolysin O titer is elevated.


He was found down in the middle of the street.

His temperature is 99.0°F (37.2°C), blood pressure is 104/64 mmHg, pulse is 70/min, respirations are 5/min, and oxygen saturation is 91% on room air.

The patient is being resuscitated in the trauma bay.


The patient’s previous pregnancies were uncomplicated, and she delivered three healthy babies at full term.

She reports that she feels well and has not experienced any contractions or vaginal bleeding.

On the ultrasound, the technician observes a male fetus with likely intrauterine growth restriction (IUGR).

She also notes microcephaly, convex-rounded feet, and clenched fists with overlapping fingers.

The technician further notes a medium-sized ventricular septal defect (VSD).

The amniotic fluid index (AFI) is 26 cm.

The patient declined prenatal screening earlier in the pregnancy for religious reasons but would now like an anatomy ultrasound to ensure the fetus is growing appropriately.


During the evening, the patient becomes irritable.

He is talking to someone despite nobody being present in the room.

He is easily agitated and attempts to strike a nurse with a remote control to his TV.

Subsequently, the patient keeps getting out of bed and trying to walk away despite being a fall risk.

He is diagnosed with urosepsis based on urinalysis and culture and started on ceftriaxone and intravenous fluids.

By hospital day 3, he is clinically improving.


There is no personal or family history of serious illness.

A metyrapone stimulation test is performed and the results rule out a diagnosis of adrenal insufficiency.


One subset of study participants consists of asymptomatic individuals who were diagnosed with GBM after undergoing a screening MRI of the brain.

Results from the study show that the asymptomatic patients who were diagnosed with screening MRI had an average survival time that was 6 weeks longer than that of the patients who were diagnosed after symptom onset.

The other subset of study participants was diagnosed with GBM only after they developed symptoms.


On questioning by the paramedics, he reported severe chest pain and mild dyspnea.

On arrival, he is confused and unable to provide a history.

His pulse is 93/min, respirations are 28/min, and blood pressure is 91/65 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 88%.

He is able to move his extremities in response to commands.

Examination shows multiple bruises over the trunk and extremities.

There is a 3-cm (1.2-in) wound at the left fifth intercostal space at the midclavicular line.

Decreased breath sounds and hyperresonance on percussion are noted on the left.


The scan is found to be positive in 590 of the 600 patients with known PD, and positive in 20 of the 600 patients without PD.

A clinical research study has enrolled 1,200 patients, half of whom have the disease.


The patient was a professional athlete who retired at age 50.

He also notes morning stiffness in his joints that lasts approx.

He denies joint swelling, color changes in his digits, dryness of mucous membranes, and constitutional symptoms such as fever and chills.

On physical exam, the physician notes several non-tender nodules on the left 1st, 3rd, and 4th distal interphalangeal joints.

There is also tenderness with palpation at the base of both thumbs.

The patient’s knees are enlarged, bilaterally, and he has pain and crepitus on passive range of motion.


His blood pressure is 125/75 mm Hg, pulse 86/min, respiratory rate 13/min, temperature 36.8°C (98.2°F).

A T2-weighted MRI shows a left C5 hemicord lesion.

The patient is treated with cervical immobilization, a course of steroids, and physical therapy.


He is sexually active with one female partner and does not use condoms.

He has also had a burning sensation on urination and increased urinary frequency for the past 3 days.

Physical examination shows a tender right testicle; lifting it provides relief.

The penis appears normal, with no discharge at the meatus.

Laboratory studies show a normal complete blood count; urinalysis shows 3 WBC/hpf.

A Gram stain of a urethral swab shows polymorphonuclear leukocytes but no organisms.

Testicular ultrasound shows increased blood flow to the right testicle compared to the left.


He has a 1-month history of multiple bruising that measures 1 cm in diameter each in the hands and feet, and tiny red spots that appeared in the upper and lower extremities without any trauma either.

He has no prior bleeding history nor any relevant family history.

The vital signs include: heart rate 190/min, respiratory rate 40/min, blood pressure 99/42 mm Hg, and temperature 36.6 °C (97.9 °F).

His physical exam shows pale skin color, petechiae in the soft palate and in the upper and lower extremities as well as ecchymosis in the back of the hands and feet.

The complete blood count results are as follows:
Hemoglobin 8.9 g/dL
Hematocrit 41%
Leukocyte count 10,500/mm3
Neutrophils 53%
Bands 2%
Eosinophils 1%
Basophils 0%
Lymphocytes 33%
Monocytes 2%
Platelet count 450,000/mm3
The coagulation test results are as follows:
Partial thromboplastin time (activated) 30.0 sec
Prothrombin time 13.6 sec
International normalized ratio 0.99
Fibrinogen 364.9 mg/dL
The blood smear shows hypochromia, poikilocytosis, and large platelets, while a platelet aggregation test with ristocetin is normal.


Vital signs are within normal limits.
Urinalysis shows cloudy, red urine.


The patient has cryptorchidism as an infant and underwent a successful orchiopexy.

In addition, he was recently diagnosed with ADHD and is currently on methylphenidate with improvement in his symptoms.

He has a family history of type I diabetes in his father and breast fibroadenoma in his mother.

He noticed it last month and felt that it has increased slightly in size.

It is tender to touch but has no overlying skin changes.

On exam, the patient is at the 82nd percentile for height, 79th percentile for weight, and 80th percentile for BMI.

Testicular volume is 7 mL on each side, and both testes are smooth and freely mobile.

Breast exam shows a normal right breast and a 3-centimeter round, firm, and slightly tender discrete mass under the left nipple.


She is otherwise healthy and takes no medications.

She experienced a similar episode affecting the opposite leg one year ago and was diagnosed with a thrombus in the right femoral vein.

On examination, the left leg is erythematous and swollen.

She reports that she developed painful left-sided leg swelling and redness earlier in the day.

Passive dorsiflexion of the left ankle elicits pain in the left calf.

Ultrasound of the leg reveals a thrombus in the left popliteal vein.

A genetic workup reveals that she has an inherited condition.


He had been living independently but came to live with his daughter temporarily after he complained that he was unable to perform some of his daily activities.

He has hypertension treated with amlodipine.

He has left the front door wide open and tap water running on multiple occasions.

He does not sleep well and wakes up 6–7 times during the night.

He does not leave his room and rarely makes conversation with his daughter.

He says that he used to enjoy playing the piano but has not played for several months.

Attention and concentration are impaired.

He is very concerned about his memory lapses.

Mental status examination shows orientation to person, place, and time and psychomotor retardation.

Short- and long-term memory is impaired.

Neurologic examination shows no focal findings.

Serum concentration of electrolytes, thyroid-stimulating hormone, and vitamin B12 are within the reference range.


Examination shows a 6-cm, nonmobile mass in the left upper quadrant that crosses the midline.

24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid.

The physician recommends the established standard treatment, which is initiation of neoadjuvant chemotherapy followed by surgical resection, if possible.

Further evaluation including biopsy confirms the diagnosis of intermediate-risk neuroblastoma.

After a thorough discussion of the risks and benefits of chemotherapy, the likelihood of unresectability without neoadjuvant treatment, and the prognosis without it, the patient's parents steadily refuse chemotherapy because they do not want their son to suffer the side effects.

They prefer to take their son home for supportive care only.


In order to do so, they biochemically charge a Lys-tRNA with valine instead of lysine and insert the tRNA into the cell.

They design an mRNA sequence that contains only codons for lysine.


He has required escalating doses of oral morphine, but is now having dose limiting side-effects.

His pain management team recommends using a medication that can reduce his opioid need through interaction with the NMDA-receptor.


He is an amateur tennis player who practices on weekends.

He denies any trauma during his practice sessions.

He says that the pain often worsens when he tries to sleep on his left side.

Although he tried several pain medications, none of the pain medications helped.

The range of motion was limited to the left side.

On examination of the shoulder joint, severe tenderness was present localized to the greater tuberosity of the left shoulder joint along with biceps tendon tenderness over the bicipital groove.

An X-ray of the joint showed narrowing of the acromiohumeral space with sclerosis and spurring of the acromion.

Routine blood test results are normal except for the rheumatoid factor, which is positive.


She states that menses began at age of 13 and has been regular until two months ago.

She denies sexual activity, and urine pregnancy test is negative.

She says that she has been very stressed with school and has recently been binge eating.

On exam, she appears well-nourished with a BMI of 21 kg/m^2, but you note that she has enlarged cheeks bilaterally and has calluses on the dorsum of her hands.


He has no past medical history; the physical exam is unremarkable.

He reports that, about once per month for the past 8 or 9 months, he's had episodes of "feeling like my chest is going to explode."

During these episodes, he also feels shortness of breath, feels shakiness throughout his arms and legs, and sweats so heavily that he needs to change his shirt.

He is unsure of any clear precipitating factors but thinks they may occur more often around important exams or when big school projects are due.

He shares that, as these episodes continue to recur, he has had mounting anxiety about having one when he is in class or at a restaurant.

As a result, he is leaving the house less and less.


Examination of the stillborn shows a small pelvis, shallow intergluteal cleft, and club feet.

An x-ray shows the absence of the sacrum and lumbar vertebrae.


They decide to stratify their results by CD4+T-lymphocyte count at the time of diagnosis.

Among patients with CD4+ cell counts below 200/mm3, cART adherence was a significant predictor of DLBCL risk (RR = 0.52, p = 0.01).

However, among patients with CD4+ cell counts above 200/mm3, no relationship was found between DLBCL risk and cART adherence (RR = 0.96, p = 0.36).


In addition, the secreted factors help activate macrophages to produce mediators such as NO, which are capable of destroying the invading pathogen.

Furthermore, activation of the macrophages by the secreted factor eventually leads to the formation of a tubercle.


His mother says he has been increasingly irritable recently.

His vocabulary consists of 50 words and he does not use sentences.

He refers to himself by name but is unable to name body parts or count to three.

Physical examination shows pale conjunctivae and abdominal tenderness.

Peripheral blood smear shows small, pale red blood cells with basophilic stippling.


All participants were interviewed about their prenatal consumption of folic acid using standardized questionnaires.

The study ultimately found that folic acid supplementation was associated with lower rates of ASD in offspring (OR = 0.3, p < 0.01).

The researchers retrospectively surveyed 200 mothers with children diagnosed with ASD during the first 4 years of life and 200 mothers with healthy children.

A 94% response rate was obtained from the surveys.


For one of the subjects, he notices that the subject is eliminating 0.5 mg of the drug every 4 hours.

His duty as a member of the team is to collect serum samples of the subjects every 4 hours and send them for analysis of serum drug levels.

He is also supposed to collect, document and analyze the data.


She has felt weaker lately and has lost some weight.

Her BUN at her last visit 4 months ago was 45 mg/dL, and her creatinine was 2.0 mg/dL.


He has had 2 children from a previous marriage and has been tested for causes of male infertility.

She has had prior abdominal surgery as well as a family history of endocrine abnormalities.

Based on this history, a panel of tests are obtained and treatment is started.

This treatment will be administered intermittently one week before her normal menstrual cycle.


Renal ultrasound shows bilateral dilation of the renal pelvis.

A voiding cystourethrography shows retrograde flow of contrast into the ureters during micturition.


He had recently lost his job and his house was about to begin foreclosure.

His adult children were concerned for his well being and called the police requesting a welfare check.

A review of his medical records reveals that he was previously in good health.

He was found unresponsive in his gurague.

There were several empty bottles of vodka around him and one half empty container of antifreeze.

On physical exam his speech is slurred and he has difficulty following commands.

Upon arrival to the ED he regains consciousness.

His blood pressure is 135/85 mmHg, heart rate 120/min, respiratory rate 22/min, and temperature 36.5°C (97.7°F).

His abdomen is diffusely tender to palpation with no rebound tenderness.

Initial laboratory tests show an elevated serum creatinine (Cr) of 1.9 mg/dL, and blood urea nitrogen (BUN) of 29 mg/dL.


Treatment with oral antibiotics and topical combination therapy with benzoyl peroxide and retinoid has not completely resolved her symptoms.

Examination shows oily skin with numerous comedones, pustules, and scarring over the face and upper back.

Long-term therapy is started with combined oral contraceptive pills.


She presented with a lump in her neck 2 weeks ago.

On examination, a thyroid nodule was present; the nodule was fixed, immobile, and non-tender.

Ultrasound showed a hypoechoic nodule with a size of 2 cm.

Histological examination of a fine needle biopsy was performed and cytological examination reported a likely suspicion of neoplasia.

CT scan is performed to check for any lesions in the bones and/or lungs, common metastatic sites in this condition.

Treatment with radioiodine therapy is planned after near-total thyroidectomy.


He recently returned from a tour of the world where he visited Thailand, Ethiopia, and Brazil.

Otherwise his past medical history is unremarkable.

He also says his right eyelid has been painlessly swelling and is starting to block his vision from that eye.

On presentation, his temperature is 102°F (38.8°C), blood pressure is 126/81 mmHg, pulse is 125/min, and respirations are 13/min.

Physical exam reveals a nontender swelling of the right eyelid, lymphadenopathy, and an indurated red patch with surrounding erythema and local swelling on his left leg.


Her chart demonstrates no other medical problems and vaccinations/boosters up to date.

On arrival to the emergency department, her vitals are T: 36 deg C, HR: 110 bpm, BP: 100/60, RR: 12, SaO2: 99%.

A FAST and abdominal CT are promptly obtained which are demonstrated in Figures A and B, respectively.

Bystanders call paramedics and she is subsequently taken to the nearest hospital.

The splenectomy is successfully performed with removal of the damaged spleen (Figure C).

The patient is diagnosed with a Grade V splenic laceration and is immediately brought to the OR for emergent splenectomy.


It is believed that, in addition to the commonly found ΔF508 mutation, a novel mutation in this gene is found in a particular population under study.