She has no history of convulsive disorders and the antepartum course has been unremarkable.

She was compliant with the recommended prenatal care and her last prenatal visit was 2 weeks ago.

She has gained 2 kg (4.4 lb) since her last visit.

She is conscious, but lethargic and complains of a headache that started 2 hours prior to the seizure.

The blood pressure was 160/90 mm Hg, the heart rate was 79/min, the respiratory rate was 14/min, and the temperature was 37.0℃ (98.6℉).

The physical examination shows leg and perineal edema.

The neurologic examination is significant for symmetric upper and lower extremity hyperreflexia and ankle clonus.


The mother and child are refugees from Somalia and arrived in the United States one week ago.

The child was born at 38 weeks gestation with the help of a local midwife.

The mother reports that the child has been chronically tired and subdued since before their arrival in the United States.

The child’s temperature is 98.2°F (36.8°C), blood pressure is 105/60 mmHg, pulse is 90/min, and respirations are 18/min.

Physical examination reveals a listless child with a rotund abdomen and positive fluid wave.

Notable lower extremity edema is present.

They were recently placed in temporary housing.


The patient recently found out she was pregnant after having unprotected intercourse with her husband for the past year.

She is currently taking prenatal vitamins and folate supplements.

She states that she is feeling well and has experienced some nausea and vomiting.

Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 98% on room air.

On physical exam, you notice a gravid uterus 10 cm above the pubic symphysis.

The patient's external genitalia appear within normal limits.


He also has a 2-month history of post-prandial fullness and recurrent nonbilious vomiting.

Abdominal examination shows hepatosplenomegaly and shifting dullness; there is mild tenderness to palpation.

Examination of the skin shows multiple nonblanching maculae.

A CT scan of the abdomen shows mesenteric and retroperitoneal lymph node enlargement and nodular thickening of the omentum.

A photomicrograph of a biopsy specimen from an enlarged mesenteric lymph node is shown.

Immunohistochemical staining of the Ki-67 nuclear antigen shows that the proliferation index of the specimen is > 99%.


His past medical history is significant for abnormal coagulation lab tests before an appendectomy, but his mother cannot recall the exact details.

On presentation, he is found to be in pain with a hot, swollen, erythematous left knee.


He had been treated for urinary tract infections twice in the past 6 months.

Cystoscopy shows pearl-like plaques on the bladder wall.

Biopsy of these lesions shows a focal layer of stratified squamous epithelium with hyperkeratosis.


The vital signs are as follows: blood pressure 125/80 mm Hg; heart rate 100/min; respiratory rate 13/min; and temperature 36.6℃ (97.9℉).

The pelvic examination reveals cervical softening and shortening.

Transvaginal ultrasound shows a cervical length of 12 mm, which is consistent with preterm labor.

A tocolytic and a single dose of betamethasone are administered.


He has a history of hypertension, type 2 diabetes mellitus, and is currently being treated as an outpatient for pneumonia.

His current medications include lisinopril, metformin, and azithromycin.

During the examination, he loses consciousness again.

He has no sign of injury, and he appears well.

Telemetry shows polymorphic ventricular tachycardia with cyclic alteration of the QRS axis, which spontaneously resolves after 30 seconds.


Sensitivity analysis of a sputum culture shows a minimal inhibitory concentration of 1 μg/mL for the causative pathogen.

The plasma clearance of the drug is calculated as 15.0 L/h.

Oral bioavailability of the drug is 75%.

The target plasma concentration is 2 mg/L.


The child has been complaining of difficulty in passing urine and has lower abdominal pain.

On some occasions, he starts crying while passing urine, primarily because of a burning sensation.

A urinalysis is performed, and the results are as follows:
Urine pH 6.2
Urine specific gravity 1.010
Glucose Negative
Ketones Negative
RBCs 1-2/hpf
WBCs 0-1/hpf
Casts 2-3/hpf
The pediatrician believes the boy has a bladder infection with a double-stranded DNA virus.


She reports making multiple mistakes at her office job, has an inability to concentrate, and feels sleepy throughout the day.

She is worried that her sleeping troubles will cause her to get fired.


The parents deny any history of head trauma or infection.

Her kindergarten teacher voiced her concern that the child ‘spaces out’ often and thinks she may have ADHD.

Her blood pressure is 106/74 mm Hg, the heart rate is 69/min, and the respiratory rate is 14/min.

Physical exam demonstrates a happy child who has reached developmental milestones.

Laboratory results are within normal limits.

EEG demonstrates a 3-Hz spike and wave pattern (see image).

The decision is made to start the child on medical therapy.


He has smoked one pack of cigarettes daily for the past 50 years.

His medications include enalapril, atorvastatin, and low-dose aspirin.

His temperature is 37°C (98.6°F), pulse is 70/min, respirations are 18/min, and blood pressure is 100/80 mm Hg.

He reports that he cannot climb more than one flight of stairs without experiencing shortness of breath and dizziness.

Physical examination shows weak peripheral pulses.


He has a 12-year history of hypertension treated with lisinopril.

Results of the testing show decreased concentrations of arginine in vascular endothelial cells.


To test the new therapy, the physician is asked to oversee the operations of testing this new treatment.

The rate of chlamydial infection is exceptionally high in the area, and the local government is wanting to test a new treatment for these infections.

When asking what this would entail, the officials tell the physician that they plan to infect the local prison population with chlamydia and then test the new treatment on these individuals.


She has a history of asthma and has frequent exacerbations despite receiving maximal medical therapy.

Physical examination shows scattered expiratory wheezing.

Laboratory studies show a leukocyte count of 9,800/mm3 (13% eosinophils) and elevated serum concentration of immunoglobulin E. An x-ray of the chest shows thickened bronchial walls and perihilar opacities.

Sputum culture shows scattered septate hyphae that branch at 45 degrees.


Physical exam demonstrates a uterine size greater than expected for her gestational age and taut, shiny skin with scattered striae on her abdomen.

Ultrasound examination of the fetus reveals 2.5 L of amniotic fluid (normal 1.5-2.0 L) with an amniotic fluid index (AFI) of 34 (normal AFI 20-25).


Her past medical history is notable for hypertension, hyperlipidemia, diabetes mellitus, obesity, and a prior myocardial infarction requiring a coronary artery bypass graft 2 years ago.

She takes aspirin, metoprolol, lisinopril, spironolactone, atorvastatin, and insulin.

She is retired and lives a sedentary lifestyle at home.

She reports sudden severe and crushing substernal chest pain that started 1 hour ago.

Before being able to start the physical examination, the patient loses consciousness.

Her temperature is 98.8°F (37.1°C), blood pressure is 109/68 mmHg, pulse is 118/min, and respirations are 24/min.

Her blood pressure is now 88/50 mmHg and pulse is 130/min.

An electrocardiogram demonstrates ST elevations in leads I, aVL, V3, V4, V5, and V6.


Prior to the onset of symptoms, he was seen playing with his mother’s purse containing a bottle of vitamin supplements, which she takes for chronic microcytic anemia.


She has a history of a seizure disorder treated with carbamazepine.

Physical examination shows no abnormalities.

Her last menstrual period was 7 weeks ago.


The first child’s mother reports that he seems to be breastfeeding well and voids at least eight times per day.

His stools are a yellow color, and he does not seem to be straining.

In the office, he can lift his head and chest when in the prone position, and he can track an object with his eyes to the midline.

His hands remain fisted 50% of the time.

In the office, she can roll from supine to prone and can transfer her rattle from hand to hand.

The third child’s father reports that he is starting to explore the world around him.

He has begun taking independent steps at home.

The second child’s parents report that she is doing well at home and seems to enjoy playing with her older brother.

In the office, he seems to recognize the name of several objects, but he cannot follow the direction to “grab the ball.” All three children are assessed as developmentally normal.


The patient has a past medical history of hypertension, atrial fibrillation, diabetes, morbid obesity, gout, and vascular claudication.

On the drive over to the hospital, her symptoms have resolved completely.

Her temperature is 99.0°F (37.2°C), blood pressure is 184/111 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Physical exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in the patient's upper and lower extremities.

The patient's memory is intact and her speech seems normal and fluent.

An initial head CT demonstrates diffuse atrophy which is consistent with previous head CT scans.


The patient works as a farmer and harvests and cans his own foods.

He states that it started yesterday and has been progressively worsening.

Initially, he noticed blurry vision and some trouble speaking and swallowing but thought he was just coming down with a cold.

He then noticed weakness of his facial muscles and shortness of breath.

He has had diarrhea recently and a cough prior to these symptoms of weakness.

His temperature is 97.9°F (36.6°C), blood pressure is 144/94 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 94% on room air.

Physical exam is notable for a man who seems unable to smile with dysarthric speech.

He takes shallow and weak breaths on pulmonary exam.

The patient demonstrates 3/5 strength with diminished reflexes in his upper extremities.


Pelvic speculum examination in the lithotomy position shows a pink structure at the vaginal introitus that protrudes from the anterior vaginal wall when the patient is asked to cough.


She denies any recent travel history, and she works at a nursing home as a caretaker.

She is not currently on any medications.

She reports that diarrhea has been intermittently present for the past month.

The stool is often loose and associated with blood and lower abdominal pain.

Clinical examination shows mild tenderness in the suprapubic region, and there is no organomegaly.

Findings on colonoscopy include patchy erythema and ulceration in the cecum, ascending, descending, and sigmoid colon.

Mucosal biopsy shows colonic crypts with lymphocytic and neutrophilic infiltrates.


His temperature is 95°F (35°C), blood pressure is 50/40 mmHg, and pulse is 80/min, and respirations are controlled at 20/min on lung-protective volume control.

A stat ScvO2 results as 39% with a SaO2 of 100% on 100% oxygen.

His extremities remain cold despite having the ambient room temperature increased to 80°F (26.7°C).

Due to his Glasgow Coma Scale score of 3, an endotracheal airway and large-bore access are secured prior to arrival.

He is aggressively resuscitated with a massive transfusion protocol as the operating room is prepared for an exploratory laparotomy.

An arterial line and central access are obtained.

After a 6:6:1 ratio of red blood cells, plasma, and platelets and the use of continuous phenylephrine infusion, the patient's vital signs remain the same.

Paramedics report extensive blood loss at the scene where he was found.

The surgical team reports no active blood loss.


It is known that her father had dementia.

She has no complaints, but her son states that the patient has impaired memory and poor orientation in space.

She is ambulatory and is capable of self-care, but she tends to forget newly introduced information.

Also, she got lost on the way from the home to the local market several times for the past 6 months, and her family is now afraid to let her go anywhere on her own.

The vital signs include: blood pressure is 130/80 mm Hg, heart rate is 62/min, respiratory rate is 11/min, and the temperature is 36.5°C (97.7°F).

The respiratory, cardiologic, and abdominal examinations are unremarkable.

The neurological examination shows equal, round pupils with a normal reaction to light.

The eye movements are normal with no nystagmus and normal oculocephalic reflex.

There is no facial droop, the facial sensation is preserved, and there is no tongue deviation noted.

There is no motor or sensory deficits on the upper and lower extremities.

The patient scores 18 on the Montreal Cognitive Assessment.

She does not have any concomitant chronic conditions nor did she have major cardiovascular events or head trauma.


He describes the pain as the worst pain he has ever felt.

He denies any recent trauma or injury to the knee.

The joint appears red and swollen and is hot to the touch.

On physical examination, his blood pressure is 124/82 mm Hg, respirations are 17/min, pulse is 104/min, and temperature is 39.1°C (102.4°F).

On palpation of the affected joint, there is evidence of tenderness and capsular swelling; the joint is red and warm.

Laboratory studies show increased serum CRP and procalcitonin levels.

There is no family history of joint or connective tissue disorders.


The physical examination is remarkable for scleral icterus and moderate splenomegaly.

The lab test results are as follows:
Laboratory test
Hemoglobin
12.1 g/dL
Mean corpuscular volume (MCV)
85 μm3
Mean corpuscular hemoglobin concentration (MCHC)
47%
Reticulocyte count
3.4 %
White blood cell count
9700/mm3
Platelet count
229,000/mm3
A peripheral blood smear reveals spherocytes.


His father had dementia in his mid-40s, but the details of his condition are unclear.

He has become increasingly irritable, loud, aggressive, and impulsive.

His wife also reports jerky movements of his limbs and trunk for the past few months.

Examination shows irregular movements of the extremities and twitching of the face and tongue.

Mental status examination shows impaired memory.


She drinks a glass of wine every night and does not smoke.

She has a history of hypertension and osteoarthritis.

She has never traveled out of the country.

Her temperature is 37.0°C (98.6°F), pulse is 94/min, and blood pressure is 130/90 mm Hg.

Over the past 8 months, she has had a nonproductive cough, fatigue, and a 9-kg (20-lb) weight loss.

An x-ray of the chest shows a 2.5-cm nodule with irregular borders at the apex of the left lung with no mediastinal or hilar enlargement.


He reports feeling fine with no trouble with his medications.

He exercises regularly and sleeps well without snoring or daytime somnolence.

Today, his pressure is 150/100 mmHg with a pulse of 65/min while on hydrochlorothiazide and ramipril.

His blood pressure measurements in the past have ranged from 160 - 170/80 - 100 mmHg.

Physical exam reveals a II/VI early systolic murmur with split S2 is appreciated at the right upper sternal border.

There is unremarkable carotid, renal, or abdominal bruits.


He is growing along with the 75th percentile and meeting all milestones.

Physical examination shows a poorly rugated scrotum.

The palpation of the scrotum shows only 1 testicle.

A 2nd testicle is palpated in the inguinal canal.

The examination of the penis shows a normal urethral meatus.

The remainder of the physical examination shows no abnormalities.


She is sexually active with 2 male partners and uses an oral contraceptive; she uses condoms inconsistently.

Physical examination shows right costovertebral angle tenderness.

Her last menstrual period was 4 days ago.

Her temperature is 37.8°C (100°F), pulse is 88/min, respirations are 18/min, and blood pressure is 115/70 mm Hg.

Cardiopulmonary examination shows no abnormalities.


She has hypertension for which she takes ramipril.

Dual-energy x-ray absorptiometry at the femoral neck shows a T-score of -2.7 SD.

The physician considers treatment with raloxifene.

Her mother died of breast cancer at the age of 48 years.


She has a history of recurrent fetal loss.

In total, she has had 4 miscarriages between the gestational ages of 8 and 15 weeks.

She has a history of systemic lupus erythematosus and has had several DVTs in the past and a clot in her lung once.

She is asking if there are any treatments she should receive to prevent fetal loss.

She has just learned that she is pregnant and estimates she is approximately 6 weeks pregnant given the timing of her last menstrual cycle.


There is no personal or family history of serious illness.

She is 168 cm (5 ft 5 in) tall and weighs 63 kg (139 lb); BMI is 22.3 kg/m2.

Examination shows normal breast development.

Abdominal examination shows a firm, nontender left inguinal mass.

Pelvic examination shows a blind vaginal pouch.

Ultrasonography does not show a uterus or ovaries.


He is especially concerned about a recent episode in which he noticed a blurring of his vision and headache; he also notes that his “memory is not as good as it used to be,” which his wife confirms.

Physical exam is notable only for pallor and general weakness.

Laboratory studies reveal anemia as well as an elevated erythrocyte sedimentation rate.

Serum protein electrophoresis (SPEP) reveals a sharp, narrow spike of monoclonal IgM; serum IgM concentration is 6.3 g/dL.


She was recently asked to step down from her position as volunteer accountant for a local charity organization because she was no longer able to coordinate her tasks.

She reports that she has become unable to taste or smell her food.

At autopsy, examination of the brain shows generalized cortical atrophy.

A photomicrograph of a section of the brain is shown.


The patient has a past medical history of marijuana use, IV drug use, alcohol use, and asthma.

His current medications include albuterol, fluticasone, and ibuprofen.

The patient went on a long hike this morning, and his girlfriend noticed that his skin had changed color when they were driving home.

Hemoglobin: 10 g/dL
Hematocrit: 32%
Leukocyte count: 5,500 cells/mm^3 with normal differential
Platelet count: 207,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 99 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 17 mg/dL
Glucose: 89 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.1 mg/dL
Bilirubin, total: 11.3 mg/dL
Bilirubin, direct: 7.8 mg/dL

Physical exam is notable for a patient with skin that appears yellow/orange.

His temperature is 97.5°F (36.4°C), blood pressure is 120/75 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air.

Laboratory studies are ordered and are seen below.


Past medical history is significant for sickle cell anemia.

Physical examination is significant for severe tenderness to palpation in the left upper quadrant.

Laboratory findings drawn sometime after admission demonstrate a normal prothrombin time (PT) and elevated partial thromboplastin time (PTT).

The patient is admitted to the hospital for close observation and placed on deep vein thrombosis (DVT) prophylaxis as part of a routine protocol.


He is interested in including maraviroc in his maintenance regimen after seeing advertisements about the medication.

On exam, his temperature is 98.8°F (37.1°C), blood pressure is 116/74 mmHg, pulse is 64/min, and respirations are 12/min.

His viral load is undetectable on his current regimen, and his blood count, electrolytes, and liver function tests have all been within normal limits.

In order to consider maraviroc for therapy, a tropism assay needs to be performed.


The patient is an avid softball player at her high school and denies alcohol, smoking, or illicit drug use.

She reports that the lump seemed to enlarge and became tender just preceding her last 2 menses.

It is otherwise painless, and the patient denies any discharge or skin changes.

On exam, the breasts appear symmetric and normal.

A 3-cm round, mobile mass is palpated in the upper outer quadrant of the left breast.

There is slight tenderness to deep palpation of the mass.

There is no axillary lymphadenopathy on either side.

She has no past medical history but her grandmother, age 72, was just diagnosed with invasive ductal carcinoma of the breast.


The patient has a past medical history of headaches, obesity, polycystic ovarian syndrome, and constipation.

She has had episodic headaches like this in the past and states that her headache today is severe, worse when laying down, and not responding to ibuprofen.

She also reports a transient episode of vision loss and current blurry vision.

She states she has a ringing in her ears as well.

Her temperature is 98.7°F (37.1°C), blood pressure is 149/92 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam is not remarkable and an initial head CT is within normal limits.


She first started having periods at age 13 and her periods have been unremarkable up until they stopped 4 months ago.

Her past medical history is significant for radius and ulnar forearm fractures that she sustained in a car crash 3 months ago.

Otherwise she has been healthy with no previous pregnancies.

Her last period occurred 4 months ago but she has not had sex in the last year and home pregnancy tests have come back negative.

She didn't see the car coming and has had increasing difficulty noticing objects in her peripheral vision.

She also notes having recurrent headaches 5 months ago.

Physical exam reveals galactorrhea and temporal field visual defects.


On physical examination, he appears confused and unable to give a complete history.

His vital signs include a temperature of 37.1°C (98.8°F), pulse of 95/min, and blood pressure of 85/60 mm Hg.

He is noted to have jaundice, palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites.


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

He is currently taking insulin, metformin, lisinopril, and atorvastatin.

The patient was brought in from a nursing home with documentation stating that he has seemed confused for the past day according to the staff.

His temperature is 102°F (38.9°C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Physical exam reveals crackles on pulmonary exam and S4 on cardiac auscultation.


The medical history includes ischemic heart disease diagnosed 2 months ago, and long histories of diabetes and hypertension (30 and 25 years, respectively).

There has been a gradual increase in the degree of weakness.

On examination, the reflexes are hypertonic and the Babinski reflex is positive.


Past medical history is significant for a recent severe sore throat and fever 1 week ago which resolved without treatment.

The patient’s mother says that his symptoms started 3 days ago with a low-grade fever, malaise, and joint pain.

He began to improve over the next 2 days, but this morning, when he woke up, she noticed multiple painful red bumps on his shins.

The vital signs include: temperature 38.0°C (100.4°F), blood pressure 120/70 mm Hg, pulse 85/min, and respiratory rate 15/min.

Physical examination reveals multiple, firm and tender erythematous nodules with indistinct borders, averaging 4 cm in diameter.

Lesions are localized to the anterior surface of the lower legs.

No evidence of drainage, bleeding, abscess formation or ulceration.


Her pregnancy was uncomplicated with the exception of a positive vaginal swab for group B streptococci 3 weeks ago, for which she received one dose of intravenous penicillin.

Physical examination shows labored breathing and thready pulses.

Her temperature is 37.6°C (99.8°F), pulse is 130/min, respirations are 30/min, and blood pressure is 70/30 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 82%.

Speculum examination shows pooling of bright red blood in the cervical canal.

Laboratory studies show a hemoglobin concentration of 7.6 mg/dL and an undetectable fibrinogen concentration.

The patient successfully underwent combined spinal-epidural anesthesia 1 hour ago.


His past medical history is notable for hyperlipidemia and hypertension.

He drinks socially and has a 20 pack-year smoking history.

His temperature is 99°F (37.2°C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 16/min.

He reports that he recently went on a vacation to South America with his family but just wanted to stay in his hotel all day due to fatigue.

On exam, the patient is appropriately interactive and in no acute distress.

Laboratory analysis reveals the following:

Hemoglobin: 11.0 g/dL
Hematocrit: 36%
Leukocyte count: 3,800/mm^3 with normal differential
Platelet count: 140,000/mm^3

A bone marrow aspiration is ordered but after multiple attempts, they are unable to obtain an adequate bone marrow sample.


Physical examination shows pale conjunctivae.

Laboratory studies show decreased serum hemoglobin levels and increased serum gastrin levels.

Esophagogastroduodenoscopy shows inflammation of the gastric body and fundus.

A photomicrograph of a biopsy specimen taken from the gastric antrum is shown.


You notice an abnormality on his laboratory results caused by his regimen of captopril and triamterene.


Current medications include spironolactone and furosemide.

She used to drink over a pint of vodka daily but quit 2 months ago.

She has been unable to recall her husband's name or their address.

She has had insomnia and daytime sleepiness during this period.

Her temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 102/64 mm Hg.

Examination shows scleral icterus and jaundice.

There are several telangiectasias over the chest and back.

The abdomen is mildly distended and nontender.

There is a flapping tremor of both hands when outstretched and dorsiflexed.

Neurologic examination shows no other focal findings.

She completes the number connection test slower than the age-normalized standard.

One month ago, she underwent a transjugular intrahepatic portal shunt (TIPS) placement.


She is slightly confused and can’t remember when the pain started.

Her daughter states that the pain has been present for approximately one month.

She expresses concern that her mother has been progressively more confused during the past week.

She reports that her mother also has had worsening nausea for several months.

The patient’s vital signs are heart rate 92/min, respiratory rate 13/min, temperature 37.1°C (98.8°F), and blood pressure 120/86 mm Hg.

Upon physical examination, the patient reports pain when the fingers of the left hand are palpated, and small palpable tumors are visible on the fingers.

An X-ray image of the left-hand shows thin bones with brown tumors and osteolysis of the distal phalanges.


Five months ago, she was treated for an episode of thrombophlebitis.

Physical examination shows multiple bruises on her limbs.

Laboratory studies show a platelet count of 900,000/mm3 and elevated levels of serum lactate dehydrogenase and uric acid.

Treatment with a medication is begun that is also used in the treatment of sickle cell disease.


Forty-eight hours later, there is a 14 mm raised, slightly hardened area at the injection site.


He is asymptomatic, but his father died of large intestinal cancer.

A colonoscopy subsequently reveals a polyp in the descending colon but no other abnormalities.

Excisional biopsy of the polyp shows 75% tubular architecture.


He says that his symptoms began an hour after he ate the food.

His temperature is 37°C (98.6°F), respiratory rate is 15/min, pulse is 106/min, and blood pressure is 90/78 mm Hg.

A physical examination is within normal limits except for signs of dehydration.

He was studying for his exams last night when he became hungry and ate some food from the afternoon after heating it for a while.


She describes herself as being “generally healthy” before the cold started.

Medical history includes hypertension and hyperlipidemia.

The patient takes hydrochlorothiazide, lisinopril, and atorvastatin.

She does not smoke and only drinks alcohol occasionally.

During a review of symptoms, she described a month-long trip to St. Louis, Missouri, to visit family.

At the physician’s office, her temperature is 37.0°C (98.6°F), pulse is 82/min, respirations are 20/min, and blood pressure is 130/82 mm Hg.

A focused chest exam reveals mild crepitus on the right side.

A chest X-ray shows a cavitary lesion in the right lung which is confirmed on chest computed tomography (CT).

A lung biopsy is performed to rule out cancer and reveals necrotic granulomatous inflammation with oval yeast in macrophages.


She is at the 10th percentile for height and 25th percentile for weight.

Examination shows a broad chest with widely spaced nipples, a low posterior hairline, forearms angled 20° away from the body when fully extended, and shortened fourth metacarpals bilaterally.


Images and tissue samples are collected from 4 athletes with cartilaginous injury and 4 athletes with bone fractures.

After 8 weeks, the athletes with bone fractures show almost complete resolution, while the athletes with cartilaginous injuries show only minimal signs of healing.

The investigator hypothesizes that this is due to the absence of progenitor cells for matrix regeneration.


She has had 10 male sexual partners in her lifetime and uses condoms inconsistently.

During the past 2 days, she has had urinary incontinence not related to sneezing or laughing.

Last summer, she had weakness and numbness of her right lower extremity that was worse when she was outside; she regained her strength 3 weeks later.

Examination shows an impaired tandem gait.

There is mild spasticity and muscle strength is decreased in both upper extremities.

Deep tendon reflexes are 4+ bilaterally.

Muscle strength in the right lower extremity is mildly decreased.

Sensation to vibration and fine touch is decreased over the upper extremities.


You prescribe triple therapy of omeprazole, clarithromycin, and amoxicillin.

Following an extensive workup, you diagnose her with a duodenal ulcer secondary to H. pylori infection.


Two days ago, she was camping outdoors in Texas with her two young children.

She was awoken in the middle of the night by “something crawling on my hand.” The following morning, she saw a wound on her hand that was initially painless, but over the next several hours she noticed reddening and blistering.

Yesterday, the lesion turned blue with a blackish discoloration at the center.

Her temperature is 38°C (100.4°F), pulse is 83/min, and blood pressure is 128/84 mm Hg.

Physical examination shows a bluish plaque with a central area of necrosis surrounded by a rim of erythema at the dorsum of the right hand.


His symptoms improve significantly after the administration of metoclopramide.


According to bystanders, the cable struck him on his right arm, after which the man slumped to the ground with his arms and legs shaking.

In the emergency department, the man is alert but in severe pain localizing bilaterally in the flanks as well as in his right arm where contact with the power line occurred.

A 6 cm burn is present on the right arm.

His vitals are within normal limits except for mild tachypnea at 21/min.


The patient sees no primary care physician and is currently not taking any medications.

The patient has presented three times this past month with similar complaints.

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

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

On physical exam you note a fatigued appearing gentleman.

Cardiovascular exam reveals an additional heart sound after S2.

Pulmonary exam is notable for bilateral crackles.

Abdominal exam reveals an obese abdomen without pain in any of the quadrants.

Lower extremity pitting edema is noted bilaterally.


He mentions that he has been experiencing intermittent episodes of pain at the same location over the last 3 months and that these episodes usually occur after a heavy meal and subside within 1 or 2 hours.

On physical examination, his temperature is 38.5°C (101.3°F), pulse is 130/min, respirations are 24/min, and blood pressure is 130/84 mm Hg.

On examination of the abdomen, tenderness is present over the right upper quadrant; palpation over the area produces an inspiratory pause.

An urgent bedside ultrasonogram shows a dilated common bile duct stone, but no stone in the common bile duct or in the gallbladder.


The patient recently started college and has presented to the emergency department once before for polysubstance intoxication.

The patient refuses to answer any questions as he suspects that his care team is spying on him.

When the patient is able to be examined, he is somnolent and non-responsive.

He does not comply with any commands, and it is not possible to freely manipulate his extremities due to rigidity.

His temperature is 104°F (40°C), blood pressure is 147/98 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

The patient attempts to assault a nurse, is restrained, and given diphenhydramine and haloperidol.


She gave birth to a healthy baby boy three days prior to presentation.

Since then, she has been feeling sick, and she is concerned that she has been getting worse over time.

On presentation, her temperature is 100.7°F (38.1°C), blood pressure is 115/78 mmHg, pulse is 105/min, and respirations are 14/min.

Physical exam reveals abdominal discomfort with uterine tenderness, and laboratory results show elevated white blood cell count with many plasma cells.


The boy was born at 37 weeks’ gestation and spent 1 night in the neonatal intensive care unit for respiratory distress.

He otherwise has been healthy and started walking independently at 12 months.

On exam, the child demonstrates muscle rigidity and diffuse muscle wasting.

However, his mother reports that he has stopped walking and appears weaker than he was a few months ago.

He also has started having brief convulsive episodes over the past week.

He is unable to stand or sit up straight.

His patellar, Achilles, and brachioradialis reflexes are absent.

Fundoscopic examination is unremarkable.

A urine sample demonstrates metachromic granules.

His parents are both healthy with no medical conditions.


Upon further questioning, the patient is found to have unprotected sex with both men and women with 3-5 partners per month.

On workup, he is found to have an HIV viral load of 15,000 copies/mL with a CD4+ of 170 cells/mm^3.


She has had decreased appetite and a 6-kg (13-lb) weight loss in the past 2 months.

Physical examination shows that on the left medial ankle there is a 2-cm reddish-black nodule with a verrucous surface.

A full-thickness excisional biopsy of the lesion shows S100-protein-positive epithelioid cells.

A subsequent CT scan of the chest, abdomen, and pelvis shows metastases to the liver; a diagnosis of metastatic melanoma is made.

Chemotherapy with aldesleukin is initiated.


Iodine uptake testing shows that the nodule has decreased iodine uptake compared with the rest of the thyroid gland.

A fine-needle aspiration is performed and the physician calls telling the patient that she has a neoplasm of the thyroid.


The patient complains of a headache and chest pain, and he has been vomiting for the last several hours.

Physical exam demonstrates papilledema and a depressed level of consciousness.

To treat this patient's hypertensive emergency, he is started on an IV medication commonly used in this situation.

The agent exerts its effect by releasing nitric oxide as a metabolite, which subsequently activates guanylate cyclase and increases production of cGMP in vascular smooth muscle.


The next morning, she says she is unable to lactate when she tries to breastfeed her child.

The Apgar counts are 9 and 10 at 1 and 5 minutes, respectively.

Thirty minutes after delivery, the mother’s blood pressure drops to 80/60 mm Hg and her pulse is 124/min.

On physical examination, her distal extremities are clammy and cold, and the uterus is boggy.

Aggressive fluid resuscitation is initiated.

After administering 4 units of IV fluids and 4 units of whole blood, her vitals stabilize.


One week ago, he had an upper respiratory tract infection.

Examination shows jaundice of the skin and conjunctivae.

The spleen tip is palpated 2 cm below the left costal margin.

His hemoglobin concentration is 9.4 g/dl and his mean corpuscular hemoglobin concentration is 39% Hb/cell.


She has been doing well in school and has no complaints.

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

She is currently sexually active but states that she uses birth control.

She has many friends and states that her mood is typically positive.

Her father died of colon cancer at the age of 68, and her mother was diagnosed with breast cancer at the age of 65.

The patient's last pap smear was 1 year ago.

Her temperature is 98.7°F (37.1°C), blood pressure is 147/108 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam demonstrates a normal S1 and S2, normal breath sounds, and an abdominal exam that is within normal limits.


Her past medical history shows she was hospitalized 10 years ago for an appendectomy and 4 years ago for a fractured ulna following a motor vehicle accident.

She has also had watery diarrhea for several days with no blood or pus in the stools.

She is taking an over-the-counter anti-diarrheal medication, which she cannot remember the name of, and drinking oral rehydration solution, which has helped a little.

Vital signs are pulse is 104/min, blood pressure is 120/80 mm Hg, respiratory rate of 14/min with shallow breathing, and temperature is 36.7°C (98.0°F).

On physical examination, pupils are constricted.

The abdomen is soft but mildly, diffusely tender to palpation with a palpable bladder.

A urinary catheter is placed, and intravenous fluids are started.

Abdominal imaging shows no abnormalities.


He complains of extreme abdominal pain worse in the left upper quadrant which has worsened over the past 30 minutes.

Vital signs on presentation are T 99.0 F, BP 100/60 mmHg, HR 125 bpm, RR 16/min, SpO2 98% on room air.

Exam demonstrates abdominal wall rigidity, involuntary guarding, and tenderness on light percussion.

Bedside sonography shows evidence for hemoperitoneum.

Despite administering more intravenous fluids, repeat vitals are T 98.9 F, BP 82/50 mm hg, HR 180 bpm, RR 20/min, SpO2 97% on room air.


He underwent stenting of the right coronary artery 10 years ago.

He smoked one pack of cigarettes daily for 40 years but quit 2 weeks ago for surgery.

His current medications include metformin, enalapril, aspirin, atorvastatin, and a multivitamin.

His temperature is 37°C (98.6°F), pulse is 102/min, respirations are 20/min, and blood pressure is 130/80 mm Hg.

Five minutes later, he becomes unresponsive.

Directly following the procedure, his temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 110/80 mm Hg.

Pulse oximetry shows an oxygen saturation of 73%.

Surgery is performed under general anesthesia for which the patient is intubated with an endotracheal tube.

He is extubated as soon as he showed signs of alertness.

He is put on a non-rebreather mask with an FiO2 of 100%.

He has type 2 diabetes mellitus, coronary artery disease, and hypertension.

Three minutes later, he is still unresponsive.


He was born vaginally to a 33-year-old woman (gravida 3, para 2) from an uncomplicated pregnancy at 39 weeks.

His mother explains that he can normally stand without help and can walk briefly on his own.

The mother denies any child abuse from her family or child care.

His length and weight are both between the 15th and 25th percentile.

On physical examination, blue-grayish discoloration of the sclerae are noted.

She is concerned about his leg and his inability to stand.

However, he hit his right leg against a chair 2 days ago.

The area became edematous and bruised overtime and the infant became unable to stand or crawl and cries when he puts weight on it.

The patient begins to cry loudly when the physician palpates his leg.

Respiratory, cardiovascular, and abdominal examinations are within normal limits for his age.

There is joint hypermobility and decreased tone in both upper and lower extremities.

The patient’s right calf appears slightly deformed, edematous, and warm to the tough.

The patient’s X-ray shows an incomplete fracture of the right tibial diaphysis.

He has met all developmental milestones and is up to date on all vaccinations.

The patient’s vital signs are as follows: blood pressure 80/40 mm Hg, heart rate 137/min, respiratory rate 25/min, and temperature 36.7°C (97.0°F).


He has no history of serious illness or trauma.

His father has a history of pulmonary embolism.

He has smoked one pack of cigarettes daily since he started college 3 years ago.

He is 173 cm (5 ft 8 in) tall and weighs 92 kg (203 lb); BMI is 30.7 kg/m2.

His temperature is 37°C (98.6°F), pulse is 94/min, respirations are 17/min, and blood pressure is 130/78 mm Hg.

Physical examination shows a tender and mildly swollen left lower leg; dorsiflexion of the left foot causes severe pain in the calf.

Laboratory studies show a platelet count of 184,000/mm3, a prothrombin time of 11 seconds, an activated partial thromboplastin time of 26 seconds, and positive fibrin split products.

Ultrasonography of the left leg shows incompressibility of the popliteal vein with a hyperechoic mass and absent blood flow.

The patient is administered a 5000 IU intravenous bolus of unfractionated heparin followed by a constant infusion.


He has a history of hyperlipidemia, type 2 diabetes mellitus, hypertension, osteoarthritis, and asthma.

Current medications include simvastatin, metformin, lisinopril, albuterol, and ibuprofen.

He does not have chest pain, palpitations, or difficulty breathing.

His pulse is 48/min and blood pressure is 89/50 mm Hg.

He responds slowly to questions but is oriented to person, place, and time.

His lungs are clear to auscultation and bowel sounds are positive with no pulsatile masses or bruits.

Pedal pulses are nonpalpable, distal extremities are cold, and capillary refill time is 4 seconds.

An ECG shows left axis deviation, a Q wave in lead III, a constant PR interval of 0.15 seconds with every third P wave that is nonconducted, and a QRS interval of .09 seconds.


A study is done with a null hypothesis that there is no association between alcohol use and gastro-oesophageal reflux disease (GERD).

The data obtained shows, of the 200 alcoholics who were followed-up, 30 developed GERD; and out of the 400 non-alcoholics, 30 developed GERD.


He has a history of bulimia with laxative abuse several years ago.

He also mentions that he has grossly bloody stool and most of the time an urge to defecate.

He admits having lost about 5 lb in the past month.

His temperature is 37° C (98.6° F), respiratory rate is 15/min, pulse is 77/min, and blood pressure is 105/86 mm Hg.

On physical examination, a mild conjunctival pallor is evident, and the rectum is erythematous, indurated, and tender.

Colonoscopy demonstrates continuous mucosal lesions throughout the rectum to the hepatic flexure of the colon.


He has been evaluated by several practitioners, who have all prescribed antimicrobial therapy, including ciprofloxacin, with no improvement and leading to emotional distress and sleep disturbances.

Additionally to this health issue, you have also been following him for recurrent abdominal pain, periods of constipation and diarrhea, and fatigability, with all test results within the normal range thus far.

The physical examination is unremarkable, except for a mildly tender prostate, without masses or nodules.

There are no testicular masses, hernias, or hemorrhoids.


The patient undergoes an exploratory laparotomy, during which, it is discovered that his splenic artery was damaged at its origin from the celiac trunk.

The surgeon ligates the splenic artery at its origin.


The child was born to a gravida 2, para 0 mother with known hepatitis B.

The mother made it to all of her prenatal appointments and took the recommended dose of folic acid since conception.

She gave up smoking when she discovered she was pregnant.

The infant’s heart rate is 150/min, respiratory rate is 48/min, temperature is 37.5°C (99.5°F), and blood pressure is 80/52 mm Hg.

APGAR testing exhibits a score of 7 and 8 at 1 and 5 minutes, respectively.

No neural tube defects are present on inspection or palpation of the spine.

There is strong flexion in all 4 extremities.

Sensory and deep tendon reflexes are without any abnormalities.

Which of the following is the best course of action for the newborn child?


The patient is otherwise healthy and is currently taking metformin and albuterol.

He states that 2 weeks ago, he had a fever, chills, and a cough, which his primary doctor treated with acetaminophen, ibuprofen, and rest.

Since then, the patient’s symptoms have resolved with the exception of a chronic cough and a small amount of clear sputum that is occasionally laced with blood.

The patient denies chest pain, shortness of breath, fever, or chills.

His temperature is 98.3°F (36.8°C), blood pressure is 129/75 mmHg, pulse is 84/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam is notable for bilateral clear breath sounds, absence of lymphadenopathy on HEENT exam, and a normal oropharynx.


The urge to urinate occurs suddenly, and he often is unable to make it to the bathroom before leaking urine.

He has no incontinence with coughing or laughing.

Digital rectal examination shows no abnormalities.

Ultrasonography shows a normal post-void residual volume.


Her depression has improved, and she has stopped taking her sertraline 2 months ago.

Other than ibuprofen as needed, she is not currently taking any additional medications.

She last took ibuprofen 2 hours ago but did not feel any improvement in the pain.

She has been nauseous and unable to get out of bed and is currently laying in the dark with the lights off.


He has a past medical history of asthma, and his only medication is an albuterol inhaler.

He fainted when he realized his finger had been cut off.

The patient's current blood pressure is 122/78 mmHg.

The teacher immediately transported the patient to the emergency department and he arrived within 20 minutes.

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


Menses had previously occurred at irregular 15–45 day intervals with moderate to heavy flow.

She started having sexual intercourse with her boyfriend about 3 months ago.

Six months ago she had a manic episode, which was treated with risperidone.

She is very conscious of her weight and appearance.

She is 171 cm (5 ft 6 in) tall and weighs 79 kg (174 lb); BMI is 27.02 kg/m2.

Her temperature is 37°C (98.6°F), pulse is 60/min, and blood pressure is 116/70 mm Hg.

Pelvic examination shows a normal vagina and cervix.

Serum hormone studies show:
Prolactin 16 ng/mL
Thyroid-stimulating hormone 3.8 μU/mL
Follicle-stimulating hormone 6 mIU/mL
Luteinizing hormone 5.1 mIU/mL
Progesterone 0.8 ng/mL (follicular N <3; luteal N >3–5)
Testosterone 2.2 nmol/L (N <3.5)
A urine pregnancy test is negative.

Her mother has PCOS and her father has diabetes mellitus.


She is a student who exercises and eats a well-balanced diet every day.

There is no family history of hypertension or other metabolic syndromes.

She is concerned about her health especially after her colleagues noticed that her face gets red at times while at work.

She has even started to use blankets to cover her feet, even on the warmest days in the summer, even though her hands feel warm to the touch.

On examination, her blood pressure is 145/92 mm Hg, respirations are 19/min, pulse is 64/min, and temperature is 36.7°C (98.0°F).

An echocardiogram is ordered for investigation.


There is clubbing present in the fingers bilaterally.

Cardiopulmonary examination shows fine inspiratory crackles bilaterally.

Pulmonary function tests (PFTs) show FVC is 78% of expected and FEV1/FVC ratio is 92%.

Following an orchiectomy, he was placed on chemotherapy.

He was recently diagnosed with stage 3 embryonal carcinoma testicular cancer.


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

Prior to admission, his medications were insulin, metoprolol, and losartan.

The abdomen is soft on physical examination, and there is tenderness to palpation of the left lower quadrant.

On admission, a complete blood count showed a hemoglobin concentration of 15.5 g/dL and a leukocyte count of 14,000/mm3.

Urinalysis showed 2+ proteinuria, and serum studies showed a blood glucose of 145 mg/dL and a creatinine concentration of 1.2 mg/dL.

Today, his temperature is 37.7°C (99.9°F), pulse is 97/min, respirations are 12/min, and blood pressure is 135/87 mm Hg.

The remainder of the examination shows no abnormalities.

Therapy with intravenous ketoprofen, piperacillin, and tazobactam was begun, and the patient was placed on bowel rest.

A CT scan of the abdomen confirmed the diagnosis.


While talking about inflammasomes, he describes the process via an example: products of cellular stress are detected by NLRP3, which includes NOD-, LRR-, and pyrin domain-containing 3; the latter interacts with apoptosis-associated speck-like protein containing CARD (ASC) via the pyrin domain, which leads to the formation of a protein speck that consists of multimers of ASC dimers.


The location of the ribosome within the cell can vary and provides a clue to the function of the particular cell.


The patient's current medications that she can recall include sumatriptan and naproxen.

She has been admitted to the hospital several times recently for panic attacks and suicide attempts.

She states that the pain started 1 hour ago after rugby practice.

Typically, she takes a special medication for bad headaches, but this time she took 2 doses and noticed no improvement in her symptoms.

Two hours later, the patient demonstrates slurring of her speech.

On physical exam there is drooping of the left side of her mouth, and her left upper extremity demonstrates 2/5 strength.

Her temperature is 99.2°F (37.3°C), blood pressure is 129/65 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air.

The patient is given dihydroergotamine, IV fluids, and is started on 100% oxygen.


Her last pap smear at age 22 showed no intraepithelial lesions nor malignancy of the cervical cells.

Menses occur at regular 28-day intervals and last 4 days.

Her last menstrual period was 2 weeks ago.

She is sexually active with one male partner.

Her father died of colon cancer at the age of 75 years and her mother was diagnosed with breast cancer at the age of 40 years.

She mentions that she is planning a backpacking trip through Europe in 2 months.

Her routine immunizations are all up-to-date.

Her temperature is 36.9°C (98.5°F) and her blood pressure is 94/58 mm Hg.

Pelvic and speculum examination show no abnormalities.


The patient has a past medical history of asthma and cocaine use.

His current medications include albuterol and ibuprofen.

The patient suddenly becomes short of breath with notable bilateral wheezing with poor air movement.

His temperature is 99.5°F (37.5°C), blood pressure is 70/35 mmHg, pulse is 150/min, respirations are 19/min, and oxygen saturation is 98% on room air.

On initial trauma evaluation, his airway is intact and he is breathing spontaneously.

The patient's dorsalis pedis and radial pulses are palpable bilaterally.

Head to toe examination reveals instability of the pelvis when downwards force is applied.

The patient's vitals are measured again and his temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air.

His blood pressure is 60/35 mmHg and pulse is 160/min.

The patient is started on IV fluids and norepinephrine, and a pelvic binder is placed.

A blood transfusion is started, and the patient is given hydromorphone.

The patient is treated appropriately, intubated, stabilized, and transferred to the surgical intensive care unit.


Per chart review he finds that a prior cesarian birth is associated with a statistically significant increased risk of placenta accreta.

The relative risk associated with this finding is 1.23.


He has no family history available as he was adopted.

He does not have any significant past medical history.

Although he has had gum bleeding in the past, it has never been this severe.

His physical exam is within normal limits.

Screening lab work is ordered with the following values:
Platelet count 330,000/mm3
Bleeding time 6 mins
Prothrombin time 12 sec
Activated partial thromboplastin time 42 sec
Factor VIII activity decreased
Ristocetin cofactor assay decreased
He is subsequently referred to a hematologist for further work-up and treatment.


The rest of her past medical history is unremarkable.

She has been smoking 1 pack of cigarettes daily for 30 years.

Her mother had a fracture of the wrist when she was in her late 60s.

The physical examination shows no abnormal findings.

Dual-energy X-ray absorptiometry (DEXA scan) shows a T-score of -3.2 standard deviations (SDs) in the hip.

The patient is educated regarding her risk of falls.

Exercise regimen and smoking cessation assistance are provided.


She has a history of recurrent painful ulcers on her vulva, but she currently does not have them.

Her current medications include acyclovir, folic acid, and a multivitamin.

The contractions last 40 seconds, occur every 2 minutes, and are increasing in intensity.

Her temperature is 36.9°C (98.4°F), heart rate is 88/min, and blood pressure is 126/76 mm Hg.

The cervix is dilated to 5 cm, 70% effaced, and the station of the head is -2.

A fetal ultrasound shows no abnormalities.

Her first child was delivered by lower segment transverse cesarean section because of a non-reassuring fetal heart rate.


The patient lives in a homeless shelter and has not seen a doctor in the last 20 years.

He has been drinking 5-8 drinks of alcohol per day for the last 20 years.

Family history is non-significant, and the patient does not take any medications.

He reports using extra pillows at night to sleep and two nighttime awakenings to catch his breath in the last month.

His temperature is 37.1°C (98.9°F), blood pressure is 135/115 mm Hg, pulse is 85/min, and respiratory rate is 24/min.

Physical examination reveals 2+ bilateral pitting edema.

Chest auscultation reveals bibasilar crackles.


The patient has no past medical history and takes no prescription medications.

He does not drink alcohol or smoke cigarettes.

On examination, the physician notices 2 clean puncture wounds with localized cellulitis.

The patient’s vitals are currently within normal limits.

Sensorimotor evaluation of the hand is without deficits.


Her family has been displaced several times over the last few years.

Nutrition and housing were frequently inadequate.

At the physician’s clinic, the boy appears irritated and drowsy.

Physical examination shows pitting edema over the ankles and feet and around his eyes.

Abdominal examination is positive for ascites and hepatomegaly.

Oral examination shows several missing teeth.


Since his 18-month visit, the parents have become concerned that his speech does not seem to be developing appropriately.

The parents report that the patient’s vocabulary is still limited to fewer than 10 words, and he is still only using single words to describe things.

At times the patient seems hyperactive and can be difficult to redirect.

On exam, his temperature is 98.4°F (36.9°C), blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 14/min.

The rest of the exam is unremarkable, except that the patient’s face appears to be abnormally long and narrow.

The patient is further referred to a geneticist, as he is believed to have a trinucleotide repeat disorder.

The parents say that his motor milestones do not seem to be affected, as the patient is very physically active and can run and kick a ball.


He had always been a quiet boy, who needed some time on his own, but he used to meet with friends at least once a week.

He used to smoke marijuana occasionally but quit 1 year ago.

The mother reports that over the past 7 months her son has become increasingly withdrawn; he has not answered any phone calls or visited his family and friends.

The patient says that he cannot leave the house because aliens are watching him and “stealing his thoughts”.

On mental status examination, it is impossible to follow the patient's sequence of thoughts.

His vital signs are within normal limits.

Physical examination shows no abnormalities.


Her medical history is significant for systemic lupus erythematosus.

She takes ibuprofen and hydroxychloroquine.

She states that she first noticed the swelling 6 weeks ago.

Initially, the swelling was minimal, but now she is finding it difficult to walk and she can’t fit into any of her shoes.

Two days later the patient returns to clinic complaining of blood in her urine.

Her temperature is 99°F (37.2°C), blood pressure is 153/86 mmHg, and pulse is 88 beats/min.

Pitting edema to bilateral knees is noted on physical examination.

A urinalysis reveals moderate erythrocytes but is negative for leukocyte esterase, nitrites, or crystals.

Diffuse oozing of the bladder mucosa with neovascularization is seen on cystoscopy.

The patient is started on an immunosuppressant.


Medical history is significant for essential hypertension.

She has worked from home as a web graphic designer for 20 years.

Questions about her social life reveal that she is very shy with few friends, and she often makes excuses to avoid parties and social gatherings.

She has no complaints and offers very little information voluntarily.

She answers each question with soft, short sentences and avoids eye contact.

She appears timid, anxious and admits that this is one of the very few times she has left the house in the last several years.

Despite this, she expresses a strong desire to be in a relationship.

Today, her blood pressure is 125/85 mm Hg, heart rate is 95/min, respiratory rate is 18/min, and temperature is 37.0°C (98.6°F).

On physical examination, her heart has a regular rhythm and her lungs are clear to auscultation bilaterally.

She takes hydrochlorothiazide and a daily vitamin.


The boy has no past medical history and takes no medications.

On exam, the boy is lethargic but responsive.

He appears to be grasping at his ears and swaying from side-to-side when attempting to ambulate.

His temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 28/min.

The boy had seemingly opened several different pill bottles that were in a cabinet in his parent’s bathroom.

The mother has brought the empty bottles to the emergency room, and they include aspirin, metoprolol, acetaminophen, levothyroxine, and lorazepam.


Past medical history is significant for peptic ulcer disease diagnosed 2 years ago for which he is not compliant with his medications.

He reports a 10-pack-year smoking history and occasionally alcohol use.

His vital signs include: temperature 37.1°C (98.7°F), blood pressure 142/91 mm Hg, pulse 98/min.


She is 13 weeks pregnant based on the date of her last menstrual period.

She is dizzy and weak, and is unable to move around the house and perform her daily tasks.

Initially, she had only light spotting, but later on in the day the bleeding increased.

The blood pressure is 90/60 mm Hg, the temperature is 37.8°C (100°F), the pulse is 125/min, and the respiratory rate is 14/min.

On pelvic examination, the vagina contains blood and the cervical os is open.

She also complains of cervical motion and adnexal tenderness on examination.

An ultrasound shows an intrauterine gestational sac low in the uterine cavity.

No fetal movement or cardiac activity are observed.

Slight downward migration of the gestational sac is observed with no change in the fetal status.

A saline infusion is started, and blood and urine specimens are sent for analysis.

Thus far, she has used six sanitary pads.

She is advised to rest for a couple of hours, after which the scan is repeated.


She went camping with her new boyfriend 3 weeks ago but does not recall any tick bites.

Examination of the right knee shows swelling, warmth, and tenderness on passive movement.

There is a tender pustule on the sole of the left foot.

Arthrocentesis of the right knee joint yields 8 mL of cloudy fluid with a leukocyte count of 45,000/mm3 (90% segmented neutrophils with intracellular organisms).


He is currently on cimetidine for his condition and reports that his GERD initially improved.

However, following his recent move to Michigan, he is experiencing more frequent episodes of chest pain (4-5 times a week).

The pain is described as burning in quality and is concentrated around his epigastric region following food ingestion.

It does not radiate anywhere and is alleviated when he takes antacids.

A physical examination demonstrates a healthy male with unremarkable findings.

He is subsequently prescribed a new medication for control of his symptoms.


He has no history of major medical illness.

He had a sore throat and cough 2 weeks ago that resolved spontaneously.

Physical examination shows moderate periorbital edema and 2+ pitting edema of the lower extremities bilaterally.

A kidney biopsy specimen shows effacement of the podocytes on electron microscopy.


Results: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to non-contrast CT abdomen The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method.

The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (p < 0.001).

Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (p = 0.50).

By 7 days, the average pain score was 2.0 in each group (p = 0.84).

Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups.

Methods: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal non-contrast CT.

Subsequent management, including additional imaging, was at the discretion of the physician.

We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure.

Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analog scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy.

Related adverse events were infrequent (incidence, 0.4%) and similar across groups.

Conclusions: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations.


She has no history of serious medical illness.

She also complains of dyspnea on exertion and has had a 4.5-kg (10-lb) weight loss in the past 2 months despite normal appetite.

Cardiac examination shows an irregularly irregular rhythm and a grade 3/6, low pitched, rumbling, mid-diastolic murmur heard best over the apex.

Diffuse wheezing and bilateral rales are present in the lung bases.

A transthoracic echocardiogram shows a left-ventricular ejection fraction of 40% and a mass in the left atrium.


Her left leg was amputated below the knee after a motorcycle accident 25 years ago.

She is currently waiting for a new prosthesis and walks with crutches.

Current medications include captopril, glyburide, and ibuprofen.

The pain is recurrent and occurs when she exerts herself or when she is outside during cold weather.

She also experiences shortness of breath and palpitations during these episodes.

The symptoms resolve spontaneously when she stops or sits down for a while.

Over the past few days, the episodes have increased in frequency.

Her pulse is 88/min, respirations are 20/min, and blood pressure is 144/90 mm Hg.

Cardiac examination shows no abnormalities.

An x-ray of the chest shows no abnormalities.

An ECG shows a normal sinus rhythm without any signs of ischemia.

Serum cardiac markers are within the reference range.


She was diagnosed with asymptomatic bacteriuria at her last appointment 2 weeks ago, and was treated with amoxicillin.

She has no concurrent diseases and no complaints.

Her vital signs are as follows: blood pressure 110/80 mm Hg, heart rate 82/min, respiratory rate 11/min, and temperature 36.6℃ (97.7℉).

The physical examination reveals no abnormalities.

On gynecologic examination, the cervix is soft and non-tender with no discharge from the external os.

The uterus is enlarged to the umbilicus and the fetal heart rate is normal.


On physical examination in the delivery room, the pediatrician notes that the baby has upslanting palpebral fissures, epicanthal folds, a flat facial profile, small ears, a single palmar crease, and hypotonia.


Her headache is diffuse, dull in character, moderate in intensity, and is worse in the morning.

It is not associated with fever and sensitivity to light or sound.

She experiences occasional nausea but no vomiting.

She did not have similar headaches in the past.

Her blood pressure is 140/90 mm Hg; pulse, 60/min, and body mass index is 33.5 kg/m2.

The neurological examination reveals normal extraocular movements.

A magnetic resonance imaging of the brain reveals a solitary lesion in the left temporal region with predominant hemorrhage.

Refer to the image below of the MRI of the brain.


She has smoked 2 packs of cigarettes daily for 10 years and is actively trying to quit smoking.

During this time, she has had a 5-kg (11-lb) weight gain.

She reports trouble concentrating at her job as a preschool teacher and has missed work several times in recent weeks due to generalized fatigue.

A drug is prescribed that will treat the patient's mood disturbance and support smoking cessation.


A few days ago, she began to notice an eruption of small red bumps that cover her torso, back, and buttocks.

The patient first thought she had acne, but became worried when the rash continued to itch.

Physical exam is notable for red papules and pustules scattered across the trunk, abdomen, back, and buttocks, while sparing the limbs.

Closer examination indicates inflammation of the hair follicles.

Culture yields motile, gram-negative rods that are non-lactose fermenting and oxidase positive.


Her past medical history is notable for asthma and takes albuterol as needed.

She does not smoke but drinks alcohol socially.

Her family history is notable for cystic fibrosis in her paternal uncle and interstitial lung disease in her paternal grandfather.

Her temperature is 101°F (38.3°C), blood pressure is 115/75 mmHg, pulse is 110/min, and respirations are 21/min.

Rales are noted in the right lower lung, and a chest radiograph demonstrates focal consolidation in the right lower lung lobe.

After initiating the appropriate treatment, she agrees to take part in a study assessing the immune response to lung infections.

A protein is identified in her serum that is thought to be elevated in response to her condition.

An amino acid sequence at the carboxy terminus of the protein is isolated and a fluorescent marker is added to the sequence.

This labeled sequence is subsequently added to a gel containing a protein isolated from the cell surface of the patient’s own neutrophils and macrophages and subsequently labeled with another fluorescent marker.

The sequence binds strongly to this protein as evidenced by increased fluorescence in the gel.


On arrival, the police found his body to be cold and stiff.

His body was discovered 7 hours later by a group of campers who promptly called the police.


The patient mentions her friend who is a medical student told her that her symptoms are suggestive of a parvovirus B19 infection which may adversely affect her baby.

Physical examination reveals a mild lace-like rash and arthritis.


He reports drinking 2 glasses of whiskey earlier that day, after a stressful day at work.

Current medications include hydrochlorothiazide and atorvastatin.

He has smoked one pack of cigarettes daily for the past 20 years.

His pulse is 102/min, and blood pressure is 135/88 mm Hg.

Cardiopulmonary examination shows normal heart sounds.

An ECG obtained on arrival at the emergency department shows ST-segment elevations in the anterior leads.

15 minutes later, the patient's chest pain has resolved and a repeat ECG shows no abnormalities.


He has asthma and has been hospitalized multiple times.

His mother has type 2 diabetes mellitus.

Overnight, he has another episode of decreased consciousness.

Serum studies show a glucose concentration of 22 mg/dL and a potassium concentration of 2.4 mEq/L.

Serum studies taken during the episode show a glucose concentration of 19 mg/dL, an insulin concentration of 108 mIU/L (N=2.6–24.9), and a C-peptide concentration of 0.3 ng/mL (N = 0.8–3.1).

A dextrose infusion is administered, after which his glucose concentration normalizes and his symptoms improve.

He is admitted to the hospital for further observation.


The medical history is significant for arterial hypertension and poorly controlled type 2 diabetes mellitus for 8 years, and depression for 3 years.

She is prescribed amlodipine, valsartan, atorvastatin, metformin, and amitriptyline.

She reports that she has not urinated for the past 2 days and that the urine leakage occurs during both day and night and is not associated with physical exertion.

Her weight is 75 kg (165 lb) and her height is 166 cm (5 ft 40 in).

Her vital signs are as follows: blood pressure, 120/80 mm Hg; heart rate, 91/min; respiratory rate, 13/min; and temperature, 36.4℃ (97.5℉).

The physical examination reveals lower abdominal tenderness with a distended urinary bladder that is palpated in the suprapubic region.

The neurological examination shows decreased Achilles reflexes bilaterally, and diminished fine touch and vibratory sensation.

On gynecologic examination, the cervix was normally positioned, mobile, and without any visible lesions.

Bulging of the posterior vaginal wall was noted.

An ultrasound examination showed an overdistended urinary bladder with no structural abnormalities.


The patient states that this weekend he had a barbecue.

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

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

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

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

The patient states that it feels, "electrical."


She adds that she is having difficulty swallowing.

She denies trouble with her breathing but endorses 5–10 lb of unintentional weight loss over the past few months.

On physical exam, the patient’s fingernails appear flat and mild conjunctival pallor is noted.

An upper barium esophagram shows an upper esophageal web.


The patient has a past medical history of diabetes diagnosed 20 years ago and osteoarthritis.

Her medications include metformin, glimepiride, and ibuprofen as needed for pain.

The patient’s only complaint is that she feels her vision has been getting more blurry over the past year.

Fundoscopic examination of this patient reveals narrowing of retinal arteries and microaneurysms.


The patient's immunizations are up-to-date.

The episodes of lesions started at the age of 2 months and multiple treatment options have been attempted without success.

He has also had several episodes of respiratory tract infections, enlarged lymph nodes, and recurrent fevers since birth.

He is at the 5th percentile for length and 10th percentile for weight.

He appears ill. His temperature is 38°C (100.4°F), pulse is 100/min, and blood pressure is 100/60 mm Hg.

Examination shows several raised, erythematous lesions of different sizes over the face, neck, groins, and extremities; some secrete pus.

Cervical and axillary lymph nodes are enlarged bilaterally.

The remainder of the examination shows no abnormalities.


Over the weekend he "strained his shoulder" during a pick-up basketball game and reports an acute exacerbation of his pain symptoms.

On exam, he complains of pain to palpation just below the acromion.

You suspect he has torn his supraspinatus.


She has hypercholesterolemia and hypertension.

Her mother died of metastatic breast cancer 15 years ago, at the age of 65 years.

Current medications include atorvastatin, labetalol, and aspirin.

She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.8 kg/m2.

The pain is worse after standing a lot at work and when she climbs stairs.

Over the past 2 months, she has been taking over-the-counter ibuprofen as needed for the joint pain.

Her temperature is 37°C (98.6°F), pulse is 88/min, and blood pressure is 114/68 mm Hg.

Examination of the left knee shows tenderness on palpation of the anteromedial joint line; there is crepitus and pain with full flexion and extension.

Serum uric acid concentration is 8.0 mg/dL and erythrocyte sedimentation rate is 15 mm/h.


He has a history of a variety of bacterial infections since birth.

Physical examination reveals light-colored skin with silver-colored hair.

Study of the boy’s neutrophils reveals that they contain large cytoplasmic vacuoles.

Genetic studies show a mutation in the LYST gene.

The pediatrician suspects an immunodeficiency disorder and decides to order several tests.


He returns to the emergency department one week later with difficulty breathing.

His temperature is 101°F (38.3°C), blood pressure is 150/80 mmHg, pulse is 80/min, and respirations are 22/min.

An ulcer with associated erythema and purulence is noted on his foot.

His temperature is 98°F (37°C), blood pressure is 100/70 mmHg, pulse is 130/min, respirations are 27/min, and oxygen saturation is 92% on room air.

His amputated foot stump is erythematous and edematous but not tender to palpation.

An electrocardiogram reveals sinus tachycardia.

He is given appropriate prophylaxis for tetanus and discharged 5 hospital days later on antibiotics.

He requests something to help calm his breathing down.

Based on his radiography, he is diagnosed with osteomyelitis and admitted to the hospital for partial amputation of his right foot.


He has a history of hypertension treated with hydrochlorothiazide and nephrolithiasis.

Four months ago, he had an episode of severe joint pain involving his left knee that lasted several days and resolved with over-the-counter analgesics.

Examination shows erythema, swelling, warmth, and tenderness of the right metatarsophalangeal joint; range of movement is limited by pain.

Arthrocentesis yields cloudy fluid with a leukocyte count of 18,500/mm3 (80% segmented neutrophils).

Polarized light microscopy of the synovial fluid is shown.


Past medical history is significant for hypertension for which he takes labetalol.

20 minutes after being stung by a bee on the left arm.

While being questioned, the patient becomes obtunded.

His vital signs include: temperature 37.0°C (98.6°F); blood pressure 85/55 mm Hg; pulse 110/min; respiratory rate 31/min; and oxygen saturation 90% on room air.

On physical examination, an area of severe edema and erythema is noted on the extensor surface of the left forearm, and there is severe angioedema of the face and neck.

The patient is intubated, and aggressive fluid resuscitation and intramuscular epinephrine are administered.


He is on an experimental drug (drug X) that is used to reduce the action of testosterone by blocking the androgen receptor.

The patient has no significant complaints, except for excessive sweating at times.

On physical examination, a small area of tissue around his nipples is enlarged bilaterally.

Since the initiation of therapy, the growth of the cancerous tissue has slowed.

This medication is known to be excreted by the kidneys at the current dose that he is taking.


Suddenly, he is unable to move his arms and legs in addition to experiencing difficulty chewing, swallowing, moving his face, and speaking.

He was started on IV fluids and received a head CT, which was negative.

It was decided that he would be watched for one day before being discharged, after a negative work-up.


He works at a community center and volunteers at a local homeless shelter.

Two months later, he has numbness and burning over both feet and an unsteady gait.

A tuberculin skin test shows an induration of 14 mm.

Physical examination shows decreased sensation to light touch extending from the soles of the feet to the mid-shin bilaterally.

Treatment with an antimycobacterial drug is initiated.


He reports pain with climbing stairs and with extended walks of greater than 100 yards.

The pain worsens with activity throughout the day and is alleviated by periods of rest.

He states that he has minimal morning stiffness, lasting approximately 5-10 minutes after waking up most days.

Physical examination reveals tenderness to palpation of the bony structures on the medial aspect of the bilateral knees as well as crepitus and a decreased range of motion, limited at the extremes of flexion and extension.

Both knee joints are cool to touch and exhibit bony enlargement upon palpation of the medial joint line.


She had a 4-day history of diarrhea and vomiting that subsided two days ago.

One month ago, she had a 3-day episode of high fever, followed by a rash with bright red discoloration over her cheeks for two days before subsiding without treatment.

Her vital signs are within normal limits.

Examination shows petechiae on her trunk and extremities.

Abdominal examination shows diffuse abdominal tenderness with hyperactive bowel sounds.

Laboratory studies show:
Hemoglobin 8 g/dL
Mean corpuscular volume 82 fL
Leukocyte count 17,000/mm3
Platelet count 49,000/mm3
Prothrombin time 12 seconds
Partial thromboplastin time 34 seconds
Serum
Urea nitrogen 42 mg/dL
Creatinine 1.4 mg/dL
Bilirubin
Total 3 mg/dL
Indirect 2.8 mg/dL
Lactate dehydrogenase 300 U/L
Urine
Blood 2+
Protein 2+
A peripheral blood smear shows schistocytes.

The remainder of the exam shows no abnormalities.


He has no history of any serious illnesses and takes no medications.

A diagnostic workup including endoscopy and biopsy shows gastric adenocarcinoma.

Before further workup and staging, the biopsy results are discussed with the patient.

He refuses any type of life-prolonging treatment, including chemotherapy, radiation, or surgery, but he requests appropriate palliative care without any significant burden of healthcare costs.


Vital signs include: blood pressure is 130/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.8°C (98.2°F).

Her physical examination is within normal limits.

The woman’s complete blood count shows an absolute increase in the cells shown in the first image.


The patient has a past medical history of constipation which is treated with fiber supplements.

The patient states she has pain in the right side of her abdomen which started yesterday and has been worsening.

She has experienced a few episodes of vomiting and diarrhea during this time.

Her temperature is 99.5°F (37.5°C), blood pressure is 110/68 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air.

On physical exam, you note a young woman who appears to be in pain.

Cardiopulmonary exam is within normal limits.

Abdominal exam is notable for right lower quadrant pain that is reproducible when the left lower quadrant is palpated.


She is gravida 2 para 0 with a history of the same complaints in her last pregnancy which ended with a stillbirth at the 31st week.

Her older sister had preeclampsia in both of her pregnancies.

Currently, the patient is responsive but lethargic.

The vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 15/min, and temperature 36.4°C (97.5°F).

The physical examination shows jaundice, right upper quadrant tenderness, and 2+ pitting edema of the lower extremities.


He has had several similar episodes since birth, all of which resolved spontaneously.

He has a 5-year history of poorly controlled type II diabetes mellitus and was started on glipizide one week ago.

He predominantly eats fast food, although he tried a new Lebanese restaurant about one month ago.

Prior to the episode, he felt well without any upper respiratory or gastrointestinal symptoms.


Examination shows erythema with scaling on both cheeks that spares the nasolabial folds and two 1-cm ulcers in the oral cavity.


On exam, you note an elevated JVP and 2+ pitting edema of bilateral lower extremities.


He feels well and has no history of serious illness.

He has smoked one pack of cigarettes daily for the past 25 years and drinks two to three glasses of wine weekly.


There is no personal or family history of serious illness.

Menses occur at irregular 35- to 50-day intervals and last 3–7 days.

Her last menstrual period was 5 weeks ago.

She has had an unintentional 10-kg (22-lb) weight gain over this period.

She also reports decreased sexual desire and increased hair growth on her face and arms.

Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg.

Physical examination shows central obesity, increased pigmented hair over the chin and upper lip, and purple stretch marks on the abdomen.

She has a prominent hump of fat over the base of the dorsum of her neck and decreased proximal muscle tone and strength.


He has a history of diet-controlled type 2 diabetes mellitus.

He has smoked one-half pack of cigarettes daily for 15 years and reports occasionally using marijuana.

His temperature is 38.7°C (101.1°F), pulse is 85/min, respirations are 25/min, and blood pressure is 110/65 mm Hg.


He works as a foreman in a factory that produces industrial solvents.

The patient is unable to stand with his feet together without support.

There is a coarse tremor of the hands when he is asked to grab a pen.

Rapid alternating movements of the hands is impaired.

He is alert and oriented to time, place, and person.

His temperature is 36.7°C (98.1°F), pulse is 88/min, and blood pressure is 108/70 mm Hg.

Muscle strength and tone are normal in all extremities.

Sensation to pain, vibration, and position is intact bilaterally.

Mental status examination shows no abnormalities.


She has no history of serious illness.
Immunizations are up-to-date.

The mother reports that she had her first menstrual period 1 week ago.

Physical examination shows Tanner stage 3 breast development and pubic hair.


The patient has a past medical history of hypertension and peripheral vascular disease.

He was released from the hospital 1 week ago for an appropriately managed ST-elevation myocardial infarction (STEMI); however, he has not filled any of his prescriptions and did not attend his follow up appointment as scheduled.

Physical exam is notable for jugular venous distention and bilateral lower extremity pitting edema.

His temperature is 97.5°F (36.4°C), blood pressure is 167/118 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air.

Echocardiography demonstrates an ejection fraction of 55%.


He had smoked 2 packs of cigarettes daily for 30 years but quit 1 year ago.

He has had frequent episodes of a productive cough over the past 3 years.

Pulse oximetry on room air shows an oxygen saturation of 91%.

Chest auscultation reveals diffuse wheezes and coarse crackles.

A chest x-ray shows increased lung lucency bilaterally and flattening of the diaphragm.


She has obtained a tissue sample from a normal thyroid gland for histopathologic examination.

It shows follicles lined by a single layer of cube-like cells with large central nuclei.


She feels well but asks for advice about smoking cessation.

She has smoked one pack of cigarettes daily for 7 years.

She has tried to quit several times without success.

During the previous attempts, she has been extremely nervous and also gained weight.

She has also tried nicotine lozenges but stopped taking them because of severe headaches and insomnia.

She is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2.

Physical and neurologic examinations show no other abnormalities.


He has no history of any serious illnesses and takes no medications.

His vital signs are within normal limits.

At discharge from the hospital, he is given complete instructions for a strict gluten-free diet.


His personal history is significant for a myocardial infarction 6 years ago that required revascularization and hypertension.

His medication consists of simvastatin and lisinopril.

In the ED, he has a blood pressure of 100/80 mm Hg, a pulse of 88/min, a respiratory rate of 28/min, and a temperature of 36.5°C (97.7°F).

On physical examination, he has jugular vein distention, displaced point of maximal impulse (PMI), an S4-gallop, a holosystolic murmur, and 2+ pitting edema up to the mid calf.

After 6-hours of continued therapy, his blood pressure remains low, and his serum creatinine is found to be 1.9 mg/dL.

He is started on furosemide, carvedilol, and oxygen therapy.


Her family and past medical history are unremarkable.

She has also noticed a decrease in urination.

Her temperature is 38.2°C (100.7°F), blood pressure is 118/76 mm Hg, heart rate is 74/min, and respiratory rate is 15/min.

Upon physical examination, her mucous membranes are moist and she has no abdominal tenderness.


She states that while she used to be able to go for short walks, she is no longer able to do so.

Now, even simple tasks like getting ready in the morning have become burdensome for her.

When she gets tired, sitting down helps to alleviate her symptoms.

Her blood pressure is 136/92 mm Hg and heart rate is 76/min.

On physical examination, she has regular heart sounds but does have 1+ pitting edema to her bilateral lower extremities.


Family history is notable for migrainous headaches in her mother and brother.

The pain typically occurs in waves of several individual episodes lasting about one second.

It is bilateral, but rarely occurs on both sides simultaneously.

Touching her face or brushing her teeth can trigger an attack.

Four months ago, she had an episode of weakness in her right arm that lasted for about a week.

There is decreased sensation in the V2 and V3 distribution of her face bilaterally.

Muscle strength is 3/5 in the left upper extremity and 5/5 in the right upper extremity.

There is spasticity of the lower extremities with sustained clonus.


Her previous pregnancy was uncomplicated and she gave birth to a healthy boy.

The father's blood group is B, Rh-positive.


His family history is significant for type 2 diabetes mellitus in his mother and cousin.

His weight is 112 kg ( 246.9 lb), height 187 cm (6 ft 1 in), blood pressure: 150/90 mm Hg, heart rate: 89/min, respiratory rate: 14/min, and temperature: 36.7℃ (98.4℉).

The physical examination is significant for dry skin, a pustular rash over the patient’s shoulders and back, an accentuated second heart sound (S2) best heard in the second intercostal space at the right sternal border, and distal loss of vibration sensitivity in both feet.

A fundoscopic examination shows small red dots in the superficial retinal layers suggestive of microaneurysms.


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

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

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

He does not engage in any physical or strenuous activity.

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

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

Strength of the patient's upper extremity is 4/5.


His medications include amlodipine, metformin, glimepiride, and a fluticasone/salmeterol inhaler.

The patient has been living at his upstate cabin for the past 5 weeks but denies other recent travel.

He denies smoking tobacco or illicit drug use.

The patient reports that about 4 weeks ago he developed a “nagging” headache.

He thought he had a cold, so he tried over the counter ibuprofen that provided only mild and temporary relief.

Recently, he also started feeling dizzy and nauseous, which only resolves when he steps outside to shovel the snow.

The patient’s temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 72/min, and respirations are 16/min with an oxygen saturation of 98% on room air.

The patient is currently asymptomatic while sitting in the office, and physical examination is unremarkable.

The patient’s medical history is significant for hypertension, type II diabetes mellitus, and asthma.


Since then, she has been compliant with her medications and currently has no significant complaints.

At that time, she was acutely severely manic and was brought to the emergency department by her concerned boyfriend.

A week after discharge, the patient forgot to take her medication for a few days and quickly began to manifest manic symptoms again which required brought her to the emergency department again.

She was started on lithium, and after subsequent improvement, she was discharged.


The patient has no significant past medical history but was recently treated with ciprofloxacin for an uncomplicated urinary tract infection.

She also notes irregular periods, with a last menstrual period 6 weeks ago.

She is a college student who has had 3 sexual partners in the last year with inconsistent use of barrier protection.

She states that her symptoms have progressed and she now feels feverish as well.

She also notes an episode of nonbloody diarrhea 2 days ago and has been increasingly nauseous.

While being evaluated in the emergency room, she vomits three times.

Her temperature is 100.5°C (38.1°F), blood pressure is 102/68 mmHg, pulse is 97/min, and respirations are 14/min.

On exam, the patient is noticeably uncomfortable.

There is marked tenderness to palpation in the suprapubic region and right lower quadrant, with voluntary guarding but no rebound.

Pelvic exam shows moderate purulent discharge in the vaginal vault, cervical motion tenderness, and a tender adnexal mass on the right side.


His pulse is 100/min, and blood pressure is 90/60 mm Hg.

Further evaluation shows a systemic vascular resistance of 35 mm Hg × min/L with an end-systolic volume of 80 mL.


She has a past medical history of uterine fibroids.

She takes mifepristone daily to reduce the size of the fibroids.

She complains of vomiting and complete hearing loss in her left ear.

The patient believes she had an ear infection in the same ear but never sought out treatment.

The patient appears pale and in mild distress.

Her blood pressure is 114/72 mm Hg, the heart rate is 68/min, the respiratory rate is 12/min, and the temperature is 36.8°C (98.2°F).

Otoscopy reveals a suppurative, erythematous, bulging tympanic membrane.

The tympanic membrane is observed to be immobile as confirmed by the pneumatoscope.

Pure-tone audiometry testing reveals hearing loss across all frequencies in the left ear.

Lungs are clear to auscultation bilaterally.

MRI of the brain does not reveal a tumor or abscess.


Her medical history is significant for obesity, hypertension, inflammatory bowel disease, and extensive alcohol use.

She takes a number of medications but does not remember what they are.

This pain started acutely, and she describes the pain as sharp.

On physical exam, her right first MTP joint appears warm, swollen, erythematous, and exquisitely painful to the touch.

One month later on follow-up, she is found to have pancytopenia.

After resolution of this acute episode, the patient is started on a drug to prevent recurrence of the symptoms.


5 days ago, he had a burning sensation in his chest and discomfort in his left shoulder.

The patient now describes discomfort in his chest and left shoulder, somewhat similar in nature to what initially brought him into the hospital.

A pulse of 86/min, respiratory rate of 16/min, and a blood pressure of 146/90 mm Hg are observed.

Auscultation of the chest reveals no abnormal findings.

The patient’s ECG is difficult to interpret.

Upon initial presentation to the hospital’s emergency department, he was diagnosed with an ST-elevation myocardial infarction and treated with alteplase.

He has been under close observation since then.


Her only medication is an oral contraceptive pill.

She fell on an outstretched hand while playing basketball.

She ignored it initially as she thought it was just a bruise, but the pain and swelling worsened throughout the day.

The analgesic spray she used did not provide adequate relief.

Her temperature is 37.1°C (99°F), pulse is 88/min, and blood pressure is 118/72 mm Hg.

Examination shows a swollen and tender left wrist; range of motion is limited.

The anatomical snuffbox is tender to palpation.

The grip strength of the left hand is decreased.

The thumb can be opposed towards the other fingers.

X-rays of the wrist shows no abnormalities.

There is no family history of serious illness.


He was diagnosed with ulcerative colitis 7 years ago.

At the time of diagnosis, a pANCA test was also positive.

Physical examination shows scleral icterus and multiple scratch marks on the trunk and extremities.

Serum studies show a total bilirubin concentration of 3.2 mg/dL, direct bilirubin concentration of 2.5 mg/dL, and alkaline phosphatase level of 450 U/L.

Magnetic resonance cholangiopancreatography shows focal areas of intrahepatic bile duct strictures alternating with areas of dilation.


Her past medical history is notable for mild intermittent asthma, gout, and obesity.

She uses an albuterol inhaler as needed and takes allopurinol.

She has had 5 sexual partners in the past year and uses the pull-out method for contraception.

She has a 10-pack-year smoking history and drinks 10-12 alcoholic beverages per week.

She first noticed the lesion 3 days ago.

The patient describes the lesion as painful and swollen.

On exam, she has an ulcerated, tender, and purulent ulcer on the left labia majora.

The patient has mild unilateral painful inguinal lymphadenopathy.


The patient reports no smoking or alcohol use but mentions that he had tried cocaine and heroin in his 20s and 30s.

He mentions that lately, he has been feeling increasingly restless and is unable to control feelings of nervousness pertaining to all his daily tasks.

He noticed that these feelings were more prominent in the last 2 months but have been present on and off for the last year.

On many occasions, his mind will be racing with thoughts that keep him up at night.

During these moments, he finds his heart racing and feels light-headed and dizzy to the point of blacking out.

He has also been experiencing back and neck pain with increased muscle tension in these areas.


She has systemic lupus erythematosus and hypertension.

Prior to hospitalization, her medications included nifedipine and prednisolone.

Her pulse is 112/min and blood pressure is 90/64 mm Hg.

The abdomen is soft and non-tender, and the laparoscopic incisions have no discharge.

Her serum cortisol and serum ACTH are decreased.


The patient has attended many prenatal appointments and followed her physician's advice about screening for diseases, laboratory testing, diet, and exercise.

She has no history of a serious illness.

Her first child was delivered via normal vaginal delivery.

Her vital signs are within normal limits.

Cervical examination shows 100% effacement and 10 cm dilation.

Her pregnancy has been uncomplicated.
A cardiotocograph is shown.


She has a past medical history of Hashimoto’s thyroiditis.

On peripheral blood smear, you notice neutrophils with 7 lobes and large oval-shaped red blood cells.

On physical exam, you notice the patient has decreased position sense and a loss in vibratory sensation in her lower extremities.


He has a medical history significant for chronic obstructive pulmonary disease and osteoarthritis.

He smoked 2 and a half packs per day, and had done so for the past 26 years.

After ceasing tobacco use for 1 year, he has recently begun smoking again.

On physical examination, the patient appears disoriented and is only somewhat comprehensible.

The blood pressure is 138/88 mm Hg, the respiratory rate is 12/min, the heart rate is 76/min, and the pulse oximetry is 87% on room air.

The pupils are equal, round, and reactive to light with extraocular movements intact.

The auscultation of the heart is absent of murmur, rubs, or gallops.

The auscultation of the lungs demonstrate audible rales in the bases bilaterally.

He takes albuterol, ipratropium and aspirin.


He admits that he has noticed himself flirting with some of the female co-workers at his new workplace.

When he goes on a dinner date with his wife after work one evening, he accuses her of giving their waiter flirtatious looks and asks her whether she has been cheating on him or trying to spend time with other men.