He is otherwise healthy and has met all developmental milestones.

He is at the 75th percentile for height and the 65th percentile for weight.

The episodes occur every 1–2 months and last for a few hours.

The pain is located in the epigastrium, radiates to his back, and is occasionally associated with mild nausea.

Physical examination shows no abdominal distention, guarding, or rebound tenderness.

His mother is concerned that his condition might be hereditary because his older sister was diagnosed with congenital heart disease.


A chest radiograph is obtained which reveals a boot-shaped heart and absence of a thymus.

An echocardiogram is done which shows pulmonary stenosis with a hypertrophic right ventricular wall, ventricular septal defect, and overriding of the aorta.


He reports that he feels well and has no complaints.

His temperature is 98.6°F (37°C), blood pressure is 135/80 mmHg, pulse is 86/min, and respirations are 17/min.

Results of a lipid panel are: Total cholesterol is 280 mg/dl, triglycerides are 110 mg/dl, HDL cholesterol is 40 mg/dl, and LDL cholesterol is 195 mg/dl.

Her physician considers starting her on atorvastatin.


The patient’s wife says that he had been on a camping trip a few months earlier to study bats but otherwise has not traveled recently.

Past medical history is significant for hypertension, managed medically with hydralazine and enalapril.

The patient’s condition rapidly deteriorates, and he passes away.

An autopsy is performed and a histologic stained section of the brain is shown in the image.


Her physician prescribes high-dose niacin and recommends taking the medication along with aspirin.


The patient reports that he was involved in a severe car accident 30 years ago.

He has never used illicit intravenous drugs.

He takes no medications and has no known allergies.

His father had a history of alcoholism and died of liver cancer.

He has had occasional headaches over the past year, but otherwise feels well.

His temperature is 37.8°C (100°F), pulse is 100/min, and blood pressure is 110/70 mm Hg.

Physical examination shows no abnormalities.

Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 10,000/mm3
Platelet count 146,000/mm3
Serum
Glucose 150 mg/dL
Albumin 3.2 g/dL
Total bilirubin 1.5 mg/dL
Alkaline phosphatase 75 U/L
AST 95 U/L
ALT 73 U/L
HIV negative
Hepatitis B surface antigen negative
Hepatitis C antibody positive
HCV RNA positive
HCV genotype 1
A liver biopsy is performed and shows mononuclear infiltrates that are limited to portal tracts and periportal hepatocyte necrosis.


Physical examination shows conjunctival pallor and an ataxic gait.

Proprioception and sense of vibration are decreased in her toes bilaterally.

Laboratory studies show macrocytic anemia and normal thyroid hormone levels.

Histological evaluation of tissue samples obtained by esophagogastroduodenoscopy reveals atrophic changes of the gastric body and fundus with normal antral mucosa.


Her past medical history is significant for bipolar disorder that is treated with lithium for 3 years.

This negatively affects her sleep, as she has to frequently wake up at night to urinate.

Serum osmolality is 425 mOsm/kg, and urine osmolality is 176 mOsm/kg.


Her medical history is remarkable for iron deficiency, for which she is on ferrous sulfate.

The patient has also experienced intermittent episodes of mild diarrhea, previously diagnosed as lactose intolerance.

These lesions occur intermittently but have worsened over time.

Her height is at the 30th percentile and weight is at the 25th percentile for age and sex.

An immunoglobulin A (IgA) tissue transglutaminase titer is 5 times the upper limit of normal.


He has hypertension, chronic kidney disease, and type 2 diabetes mellitus.

Three months ago, he underwent amputation of his left third toe because of a non-healing ulcer.

He has smoked a pack of cigarettes daily for 48 years.

Current medications include hydrochlorothiazide, metoprolol, and insulin.

His temperature is 39.4°C (102.9°F), pulse is 102/min, blood pressure is 150/94 mm Hg, and respirations are 18/min.

He has had nausea but no vomiting during this time.

Examination shows a 1-cm (0.4-in) round ulcer on the sole of his right foot.

There is costovertebral angle tenderness on the left side.

Laboratory studies show:
Hemoglobin 11.5 g/dL
Leukocyte count 19,000/mm3
Serum
Na+ 140 mEq/L
Cl− 102 mEq/L
K+ 5.0 mEq/L
HCO3− 25 mEq/L
Urea nitrogen 65 mg/dL
Creatinine 2.4 mg/dL
Glucose 240 mg/dL
Urine
Blood 1+
Protein 1+
WBC 100/hpf
Nitrite 2+
WBC casts numerous
Urine and blood samples for culture and sensitivity tests are obtained.


In the early morning of postoperative day 4, the nurse states that the patient is difficult to arouse.

Over the next 3 days, the patient's drainage output is noted to exceed 1 liter per day.

His temperature is 99.5°F (37.5°C), blood pressure is 107/88 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

His skin and mucous membranes are dry on physical exam.

Laboratory values are ordered as seen below.


Her symptoms began on the return flight from a 2-week yoga retreat in India, where she stayed at a resort.

She has a 1-year history of gastroesophageal reflux disease and is allergic to shellfish.

She was mildly nauseous as she boarded the flight, and diarrhea followed immediately after eating the in-flight meal.

Since then, she has had up to five watery stools daily.

Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 115/72 mm Hg.

Abdominal examination shows diffuse tenderness with no guarding or rebound.


A robust clinical trial is performed in a group of 100 subjects comparing the new screening test against the gold standard.


When discussing her infection, the patient says that she uses safe sex practices.

Her history is significant for meningitis and for infection with Streptococcus pneumoniae.

She previously presented with itching, as well as frequent and painful urination.

A vaginal swab was taken and sent to the laboratory to confirm the diagnosis.

Diplococci were seen on Gram stain and were grown on Thayer-Martin agar.

The physician discusses that the reason behind these infections comes from a defect in the innate immune system.


On postoperative day 1, she develops perioral numbness and a tingling sensation, along with paresthesia of the hands and feet.

The physical examination reveals that she is anxious and confused.

Her pulse is 90/min, the blood pressure is 110/80 mm Hg, the respirations are 22/min, and the temperature is 36.7°C (98.0°F).

Latent tetany (carpal spasm) is evident in the right arm.

This is observed when the sphygmomanometer cuff pressure is raised above the systolic blood pressure and held for 3 minutes.


He spends most of his time in the basement playing video games and eating bowls of cereal.

The patient does not smoke or drink alcohol.

The parents report that their son quit doing sports at school because of low energy.

The patient's academic performance has declined recently.

His vital signs are within normal limits.

Examination shows conjunctival pallor, inflammation and fissuring of the corners of the mouth, and concavity of the finger nails.

His mother has Hashimoto's thyroiditis and his father has major depressive disorder.


He has type 2 diabetes mellitus, mitral regurgitation, and atrial fibrillation.

His only other medications are metformin and lisinopril.

His temperature is 37.8°C (100.0°F), pulse is 108/min and irregularly irregular, and blood pressure is 155/89 mm Hg.

Examination of the skin shows large purpura, hemorrhagic bullae, and areas of skin necrosis over his anterior legs, gluteal region, and penis.

Three days ago, he was started on treatment with warfarin.


His teachers have reported hyperactivity during class, difficulties with social interaction, and poor scores on reading and writing assessments.

Molecular analysis shows an increased number of CGG trinucleotide repeats.


She is a known hypertensive but is poorly compliant with medications.

The patient claims to have orthopnea, paroxysmal nocturnal dyspnea, and easy fatigability.

On physical examination, the blood pressure is 80/50 mm Hg.

There is prominent neck vein distention.

An S3 gallop, bibasilar crackles, and grade 3 bipedal edema were also detected.

A 2d echo was performed, which showed a decreased ejection fraction (32%).


2 weeks ago she had a prophylactic ovariectomy because of a family history of ovarian cancer.

She is known to have type 2 diabetes mellitus and stage 1 hypertension, but she does not take her antihypertensives because she is not concerned about her blood pressure.

Also, she has a history of opioid abuse.

She takes metformin 1000 mg and aspirin 81 mg. She has been smoking 1 pack of cigarettes per day for 22 years.

On examination, the patient is dyspneic and acrocyanotic.

Lung auscultation reveals bilateral rales over the lower lobes.

Her vital signs are as follows: blood pressure 155/80 mm Hg, heart rate 101/min, respiratory rate 31/min, and temperature 37.9℃ (100.2℉).

A cardiac examination is significant for S2 accentuation best heard in the second intercostal space at the left sternal border and S3 presence.


She has a past medical history of generalized seizures with her most recent one having occurred 5 days ago.

The patient admits to occasional cocaine use and binge drinking.

The patient has had severe abdominal pain throughout her entire life with occasional episodes of bloody diarrhea.

She has recently lost 7 pounds and has felt generally ill for the past 2 days.

Her temperature is 98.7°F (37.1°C), blood pressure is 107/58 mmHg, pulse is 127/min, respirations are 16/min, and oxygen saturation is 99% on room air.

Physical exam is notable for diffuse abdominal tenderness and guaiac positive stools.

One month ago, the patient was treated for impetigo.


He recalls that he has been told by his primary care physician that he suffers from gastroesophageal reflux disease (GERD).

The gastroenterologist decides to perform an upper endoscopy with biopsy.


Upon discussions with the patient, it is clear that she is not able to understand that sexual intercourse can lead to pregnancy.

The mother states that she wants her daughter to have a bilateral tubal ligation after she recently discovered her looking at pornographic materials.

She states that her daughter is not capable of understanding the repercussions of sexual intercourse, and that she does not want her to be burdened with a child that she would not be able to raise.


He works as a zoologist and was in rural Madagascar studying a rare species of lemur.

His past medical history is notable for hypertension and gout.

He returned from a research trip to Madagascar 2 weeks ago and has since developed a worsening fever with a maximum temperature of 102.2°F (39°C).

He also reports some swelling around his neck and groin.

His temperature is 101.9°F (38.3°C), blood pressure is 145/85 mmHg, pulse is 110/min, and respirations are 22/min.

On exam, he has painful erythematous cervical, axillary, and inguinal lymphadenopathy.

Black hemorrhagic eschars are noted on his fingertips bilaterally.


After reviewing the laboratory tests, the physician decides to write the patient a prescription for miglitol and states that it must be taken with the first bite of the meal.


He works as a dental assistant and is concerned about not being able to work.

He is sexually active with one female partner, and they do not use condoms.

His father has a history of thromboangiitis obliterans.

He has smoked one pack of cigarettes daily for 5 years.

He drinks two to four beers on social occasions.

The patient wonders if the symptoms might be related to a hunting trip he returned from 1 week ago because he remembers seeing a lot of poison oak.

Physical examination shows swelling and erythema of the pulp space of the left index finger; there are multiple 3-mm vesicles.

Laboratory studies show a leukocyte count of 12,000 cells/mm3.


His past medical history is significant for hypertension and GERD.

He takes lisinopril for hypertension and has failed multiple different therapies for his GERD.

On physical exam, he is somewhat tender to palpation over his upper abdomen.

Barium swallow demonstrates a subdiaphragmatic gastroesophageal junction, with herniation of the gastric fundus into the left hemithorax.


Several days prior, he had been swimming in the Gulf coast when he stepped on a sharp rock and cut his right foot.

Three days ago, the patient presented to the emergency room after noticing painful redness spreading along his skin up from his right foot and was subsequently admitted for antibiotic treatment.

Currently, his temperature is 101.8°F (38.8°C), blood pressure is 84/46 mmHg with a mean arterial pressure of 59 mmHg, pulse is 104/min, and respirations are 14/min.

His blood cultures are pending, but Gram stain demonstrated gram-negative bacilli.


The patient has no relevant past medical history, however, the patient admits to being sexually abused by her boyfriend for the past year.

Her current medications include ibuprofen for menstrual cramps.

She states that this has been one of many symptoms she has experienced lately.

At times she has had trouble speaking and has noticed changes in her vision however these episodes occurred over a month ago and have resolved since then.

Two days ago she experienced extreme pain in her face that was exacerbated with brushing her teeth and plucking out facial hairs.

On physical exam it is noted that leftward gaze results in only the ipsilateral eye gazing leftward.

Her vital signs are within normal limits and you note a pale and frightened young lady awaiting further care.

The patient's initial workup is started in the emergency department.


Her brother says she has a problem with alcohol use and that he found an empty bottle of vodka on the counter at her home.

She is unable to personally give a history.

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

She recalls 0 out of 3 words after 5 minutes.

She cannot perform serial sevens and is unable to repeat seven digits forward and five in reverse sequence.

She has difficulty walking without assistance.

Her temperature is 37°C (98.6°F), pulse is 85/min, and blood pressure is 140/95 mm Hg.

Neurologic examination shows horizontal nystagmus on lateral gaze.


She did not disclose her past medical history, but her sexual debut occurred with her boyfriend 3 weeks ago.

She is now complaining of a yellow-green, diffuse, malodorous vaginal discharge that she noticed 1 week ago for the first time.

She also reported mild pelvic and abdominal pain.

cervical motion tenderness was noted during the pelvic examination.

The gynecologist also noticed a pink and inflamed nulliparous cervix with a preponderance of small red punctate spots.

There was a frothy white discharge with a malodorous odor in the vaginal vault.

A wet mount was prepared for a light microscopic examination, which revealed numerous squamous cells and motile organisms.

The gynecologist concluded that this was a sexually-transmitted infection.


Initially, he used to forget his children's names or forget to lock the house door.

During the past year, he has gotten lost twice while returning from the grocery store and was unable to tell passersby his address.

One time, he went to the park with his granddaughter and returned home alone without realizing he had forgotten her.

His daughter says that over the past year, he has withdrawn himself from social gatherings and avoids making conversation.

Short- and long-term memory deficits are present.

He appears indifferent about his memory lapses and says this is normal for someone his age.

On mental status examination, he is oriented only to person.

His daughter has hired a helper to cook and clean his home.


The patient denies having any history of asthma or respiratory symptoms, and does not smoke.

On exam, he is pale and diaphoretic.
His pupils are contracted.

His temperature is 99.8°F (37.7°C), pulse is 65/min, blood pressure is 126/86 mmHg, and respirations are 20/min.

Diffuse wheezes are noted in all lung fields.


Physical examination is notable for frontal bossing and shortened upper and lower extremities.

He is at the 7th percentile for height and 95th percentile for head circumference.

Genetic analysis reveals an activating mutation in a growth factor receptor.

He demonstrates normal intelligence and is able to speak in three-word sentences.

He first sat up without support at twelve months and started walking at 24 months.


Examination of the left breast shows a firm, nontender mass close to the nipple.

Mammography shows an irregular calcified mass.

A core needle biopsy shows invasive ductal carcinoma.


Medical history is notable for hypertension and hyperlipidemia, both managed medically.

He was last seen for follow-up of these conditions 1 month ago.

The patient reports that his bowel habits have changed from every day to every 3 or 4 days.

He also now has to strain to pass stool.

On further questioning, his wife has also noticed that he has seemed fatigued, with little interest in going on their usual afternoon walks.


The patient has a medical history of chronic dermatitis and chronic sinusitis for which he has prescriptions of topical hydrocortisone and fexofenadine.

He smokes one-half pack of cigarettes every day.

On physical examination, the patient appears tired but oriented.

His vital signs include: blood pressure 128/76 mm Hg, heart rate 78/min, and respirations 12/min.

Examination of the skin reveals a 2 x 2 cm round and erythematous, annular plaque on the abdomen 3 cm to the left of the umbilicus.

There are no vesicles, pustules, or papules.

Auscultation of the heart reveals a 1/6 systolic murmur.

Breath sounds are mildly coarse at the bases.

A KOH preparation from the skin scraping confirms the presence of hyphae.


There is no history of abnormal bleeding in the family.

His vital signs are within normal limits.

On examination, he is pressing a gauze against his left nostril while hyperextending his head.

The gauze is stained with blood and upon withdrawal of the gauze blood slowly drips out of his left nostrils.

There is no bleeding from the right nostril.

The remainder of the physical examination shows no abnormalities.


Upon further questioning, she reports decreased appetite, fatigue, constipation, and jaw pain.

Her pulse is 60 bpm and her blood pressure is 130/110 mm Hg.

Biopsy of her thyroid reveals granulomatous inflammation and multinucleate giant cells surrounding fragmented colloid.


You find out that he has recently been fired from his job as a salesperson for months of tardiness and poor performance.

The police tell you that his girlfriend, who was there at the time of the fall, mentioned that the patient has been struggling with alcohol for at least a year.

The patient smells of alcohol and is slurring his words.

Upon physical examination, the patient becomes agitated and starts yelling.

He accuses his ex-boss of being a cocaine addict and says he couldn’t keep up sales percentages compared to someone using cocaine.


Last week she returned from a trip to Africa where she spent several weeks, mostly in rural areas.

Her symptoms began 1 week ago with a severe fever (40℃ (104℉)) for 3 days.

When the fever subsided, she developed a maculopapular rash over the trunk and extremities with painful wrists and fingers.

She also reports abdominal pain, nausea, vomiting, and headaches.

Her temperature is 37.5℃ (99.5℉); pulse is 75/min; respiratory rate is 13/min, and blood pressure is 115/70 mm Hg.

A maculopapular rash is observed over the trunk and limbs.

Both ankles are swollen and painful to active and passive motion.

The abdomen is soft without organomegaly.

Laboratory studies show the following:
Laboratory test
Hemoglobin 11.4 g/d
Mean corpuscular volume 90 µm3
Leukocyte count 4,500/mm3
Segmented neutrophils 70%
Lymphocytes 15%
Platelet count 250,000/mm3
Ring-form trophozoites are absent on the peripheral blood smear.


His past medical history is remarkable for cirrhosis secondary to alcohol abuse and untreated hepatitis C. His current blood pressure is 90/50 mm Hg, heart rate is 128/min, and oxygen saturation in room air is 88%.

Upon examination patient states he feels nauseated as he begins to retch violently and vomit bright red blood.

You begin to review his labs and notice and he has elevated beta-hydroxybutyrate, ammonia, and lactate.

IV fluids are initiated and packed RBCs are ordered.

On further questioning, he states that he is scared to die and wants everything done to save his life.


Prior to admission, her only medications were a multivitamin and an herbal weight-loss preparation.

She does not have pain.
She has nausea but has not vomited.
She appears uncomfortable.

Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 118/78 mm Hg.

Examination shows mild swelling of the right thigh to the ankle; there is no erythema or pitting edema.

The abdomen is soft and shows diffuse tenderness to palpation.

There are five abdominal laparoscopic incisions with no erythema or discharge.

The remainder of the examination shows no abnormalities.

She has been using an incentive spirometer every 6 hours since recovering from her surgery.

She was diagnosed with pancreatic cancer 1 month ago.


His father died of sudden cardiac death at the age of 45 years without a history of hypertension or any chronic cardiac disorder.

His symptoms only lasted for a few seconds and resolved spontaneously.

This is the third time he experienced such an episode.

He says that he recently started having nightmares.

A complete physical examination was normal.

A 12-lead electrocardiogram showed ST-segment elevations in V1, V2, and V3, and the presence of incomplete right bundle branch block (RBBB).

The drug also blocks potassium channels and prolongs action potential duration, but it does not shorten phase 3 repolarization.

The drug also has mild anticholinergic and alpha-blocking activity.

After a complete diagnostic evaluation, Brugada syndrome was diagnosed.

He has prescribed a class I anti-arrhythmic drug, which is a sodium channel blocker that slows phase 0 depolarization in ventricular muscle fibers.


He drinks 10–12 beers daily and has not seen a physician in 15 years.

He describes the vomitus as bloody and containing black specks.

His temperature is 36.7°C (98.1°F), pulse is 122/min, and blood pressure is 85/59 mm Hg.

Physical examination shows decreased radial pulses, delayed capillary refill, multiple spider angiomata, and a distended abdomen.

He is oriented to person but not to place or time.


Past medical history is significant for 2 transient ischemic attacks 6 months prior, characterized by a sudden right-sided weakness and trouble speaking but recovered fully within 30 minutes.

Current medications are sildenafil 100 mg orally as needed.

Patient reports a 30-pack-year smoking history and heavy alcohol use on the weekends.

The patient states that his symptoms started about a week ago and have steadily worsened.

He describes the abdominal pain as mild to moderate, dull, and deeply localized to the umbilical region.

Review of systems is significant for decreased appetite and feeling easily full.

Vitals are temperature 37°C (98.6°F), blood pressure 155/89 mm Hg, pulse 89/min, respirations 16/min, and oxygen saturation 98% on room air.

A pulsatile abdominal mass is felt in the lower umbilical region.

Abdominal ultrasound reveals the presence of an abdominal aortic aneurysm (AAA).

Contrast CT reveals a small, unruptured AAA (diameter 4.1 cm).

High flow supplemental oxygen and fluid resuscitation are initiated.

Morphine sulfate and metoprolol are administered.

Patient’s feet have the following appearance seen in the picture.

On physical examination, the patient is alert and cooperative.


2 weeks later, the patient presents to the outpatient clinic with hoarseness.

During surgery, a young surgeon ligates the inferior thyroid arteries as close to the poles as possible to prevent intraoperative hemorrhage.


He feels increasingly anxious during physical education (PE) class as he has noticed that the size of his penis is significantly smaller when compared to his peers.

Based on the physical examination, he is Tanner stage 1.

The weight and height are 60 kg (132 lb) and 175 cm (5 ft 9 in), respectively.

The cardiopulmonary examination is normal; however, the patient has difficulty identifying coffee grounds by smell.


While on his daily walks he notices a strong cramping pain in his calves that consistently appears after a mile of walking.

To improve his symptoms, cilostazol is prescribed.

He sees his physician and a diagnosis of peripheral artery disease with intermittent claudication is made.


He recently went on vacation to South America but has returned to his job delivering packages.

He has several friends who recently had influenza.

In addition to the fever, he has had malaise, chest pain, and a dry cough.

Hi temperature is 102.8°F (39.3 °C), blood pressure is 137/80 mmHg, pulse is 104/min, respirations are 19/min, and oxygen saturation is 98%.

Chest exam reveals a deep noise found bilaterally in the lung bases.

Chest radiograph reveals a wider area of opacity near the heart and bilateral lung infiltrates.


He smokes 2 packs per day and drinks 2–3 beers every day.

He denies any previous medical problems except for seasonal allergies for which he takes diphenhydramine on occasions.

At the hospital, the vital signs include: temperature 40.0°C (104.0°F), blood pressure 140/80 mm Hg, heart rate 98/min, and respiratory rate 28/min.

On physical exam, he is thin and poorly kept.

Small scars are visible in the decubitus region of both arms.

The lung sounds are equal with bilateral crackles, and heart auscultation reveals a systolic murmur that radiates to the left axilla.

Petechiae are seen on the hard palate and palms of his hands.

A chest X-ray and blood cultures are ordered.


He started experiencing episodic headaches and palpitations 3 months ago; however, he thought that these symptoms were simply related to the stress of moving and starting a new job.

He has continued to experience these intermittent headaches and has also noticed that he sweats profusely during these episodes.

On presentation his temperature is 99.1°F (37.3°C), blood pressure is 163/112 mmHg, pulse is 112/min, and respirations are 15/min.

Physical exam reveals pallor and perspiration but is otherwise unremarkable.


About 90 minutes ago she was on the couch watching television with her husband when she suddenly noticed that she couldn't see the screen normally.

She has never had anything like this happen before.

Her general physical exam is unremarkable.

Her neurologic exam is notable for loss of vision in the right visual field of both eyes with macular sparing, though extraocular movements are intact.

A computed tomography (CT) scan of the head shows no acute intracranial process.


She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted.

She has been breastfeeding the infant but feels the latch has been poor and is unsure how much milk he has been consuming but feels it is not enough.

When asked the mother stated that the baby is currently making stools 2 times per day.

A lactation consult was called for the patient and it was noted that despite proper instruction the observed latch was still poor.


History is significant for liver cirrhosis and alcoholism.

His family has noticed progressive confusion.

On examination, he is jaundiced, lethargic, is oriented to person and place but not date, and has moderate ascites.

His heart rate is 112/min, temperature is 37.1°C (98.7°F), and blood pressure is 110/70 mm Hg.

Neurological examination reveals asterixis, and his stool is guaiac-positive.


He is in good shape and exercises 3 times per week.

He takes no medications and denies smoking cigarettes, drinking alcohol, and illicit drug use.

Prior to starting his run, his heart rate was 70/min, and the blood pressure was 114/74 mm Hg.

Immediately after stopping his run, the heart rate is 130/min, and the blood pressure is 145/75 mm Hg.


No significant past medical history and no current medications.

The patient is not sexually active and denies any alcohol, smoking or drug use.

The patient says that he has been limping with mild pain for the past three weeks, but the pain acutely worsened today.

He describes the pain as severe, non-radiating, sharp and aching in character, and localized to the right hip and knee joints.

The vital signs include: temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 99% on room air.

On physical examination, the patient is alert and cooperative.

The right leg is externally rotated, and there is a limited range of motion in the right hip.

Strength is 4 out of 5 at the right hip joint and 5 out of 5 elsewhere.

No joint erythema, edema or effusion present.

Deep tendon reflexes are 2+ bilaterally.

Plain radiographs of the right hip joint are significant for displacement of the right femoral head inferoposterior off the femoral neck.

The patient denies recent illness, travel, trauma, or similar symptoms in the past.


He used to ride his bicycle for exercise 4 times a week but stopped after he had an accident and injured his left testicle 3 months ago.

For the last 10 years, he drinks one to two beers daily and sometimes more on weekends.

He occasionally takes pantoprazole for heartburn.

He is 171 cm (5 ft 7 in) tall and weighs 87 kg (192 lb); BMI is 30 kg/m2.

Examination shows bilaterally symmetrical, mildly tender gynecomastia.

A nontender 1.5-cm mass is palpated in the left testis; transillumination test is negative.

The remainder of the examination shows no abnormalities.

He has gained 5 kg (11 lb) during this period.


He has hyperlipidemia and was diagnosed with major depressive disorder 3 years ago.

He had not been sexually active for the previous 3 years, since the death of his wife.

Current medications include simvastatin and citalopram.

He first noticed the problem 8 months ago, when he became sexually active with a new girlfriend.

He states that his relationship with his girlfriend is good, but his inability to engage in sexual intercourse has been frustrating.

His temperature is 37.5°C (99.5°F), pulse is 80/min, and blood pressure is 135/82 mm Hg.


The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief.

The patient’s past medical history is otherwise unremarkable, and he has no known drug allergies.

He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea.

In the office, his temperature is 101.8°F (38.8°C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min.

The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses.

His pharynx is erythematous with symmetric swelling of the tonsils.

On lung exam, he has moderate bilateral expiratory wheezing.


His regular medications include inhaled salmeterol and inhaled fluticasone propionate.

He was a chronic smoker but quit smoking 2 years ago.

His temperature is 37.1°C (98.8°F), the pulse rate is 88/min, the blood pressure is 128/86 mm Hg, and the respirations are 30/min.

On physical examination, the use of the accessory muscles of respiration is evident and the arterial saturation of oxygen is 87%.

Auscultation of the chest reveals the presence of bilateral rhonchi with diminished breath sounds in both lungs.


The patient has a past medical history of constipation, anxiety, and substance abuse.

She is not currently taking any medications.

The patient has been trying to get pregnant and was successful recently, but now she is experiencing abdominal pain, contractions, and a bloody vaginal discharge.

According to her last appointment with her primary care provider, she is 10 weeks pregnant.

Her temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for a bloody vaginal discharge and an open cervix.

Upon hearing the news that she is having a spontaneous abortion, the patient becomes angry and aggressive and states that her physician and the medical staff are incompetent, evil, and she is going to sue all of them.

The patient is initially extremely grateful for the care she is receiving and thanks the doctor and the nursing staff for saving her baby.

The patient is left to grieve but upon entering the room again you notice that the patient has new lacerations over her wrists and that some of the medical equipment in the room is broken.


She reports taking high doses of acetaminophen and aspirin over several weeks due to persistent upper back pain.

She denies any previous episodes of hematuria.

The patient’s blood pressure and temperature are normal, but she is found to have proteinuria.

Physical examination is negative for palpable flank masses.


The patient also has been taking metformin for the past 2 years and is severely obese, with a BMI of 41 kg/m2.

The pain developed over time and now limits his mobility.

He states that the pain is worse at the end of the day, though he does have some early-morning stiffness lasting about 20 minutes.

He used to have some success with over-the-counter NSAIDs; however, they no longer help.

Additionally, he states that he has felt increasingly tired during the day, often dozes off during work, and no longer feels refreshed when he wakes up in the morning.

Upon examination, there is no tenderness on palpation or erythema; however, some crepitus is felt.

He has no other complaints but has a family history of rheumatoid arthritis (RA) on his mother’s side.


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

Physical examination shows drooping of the eyelids bilaterally.

He is unable to hold his arms up for longer than 3 minutes.

A CT scan of the chest shows an anterior mediastinal mass with smooth contours.

A photomicrograph of a specimen from the mass is shown.


On physical examination, the patient appears drowsy and lethargic and is minimally responsive to stimuli.

His respiratory rate is 8/min and shallow, blood pressure is 130/90 mm Hg, and pulse is 60/min.

On physical examination, miosis is present, and the pupils appear pinpoint.

The patient is given a drug to improve his symptoms.

The patients’ parents say that a bottle of oxycodone was found at his bedside and was missing 15 pills.


She is a research assistant at the university geology laboratory.

She is originally from Nigeria and visits her family there twice a year; her last trip was 3 months ago.

She has been unable to perform her daily activities.

She has had malaise and bilateral ankle pain during this period.

She noticed her symptoms after returning from a vacation to Arizona.

The remainder of the examination shows no abnormalities.

Her temperature is 37.8°C (100°F), pulse is 100/min, respirations are 24/min, and blood pressure is 112/72 mm Hg.

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

There is no palpable cervical or axillary lymphadenopathy.

Her left eye is notable for ciliary injection and photophobia.

A complete blood count is within the reference range.


His more recent complaints include dysphagia for liquids as well.

The patient states that he has no difficulty initiating swallowing but occasionally food is stuck in his throat.

He does not complain of pain while swallowing but has noticed minor unintentional weight loss.

During the examination, the patient appears ill, malnourished, and slightly pale.

A swallowing study reveals a small outpouching in the posterior neck (see image).

The patient has no history of speech-related pain or nasal regurgitation.


She has had constipation for the past 6 weeks and overall fatigue.

She also had heavy menstrual bleeding; and often feels extremely cold at home.

There is also pain associated with swallowing.

On examination, the thyroid is stony hard, tender and asymmetrically enlarged.

Laboratory studies show a serum T4 level of 4.4 μg/dL and a TSH level of 6.3 mU/L.

A radionuclide thyroid scanning indicates that the nodule has low radioactive iodine uptake.

On the other hand, she has well-controlled asthma and spring allergies.


When she applies compound X to the cells, she finds that the urinary concentration of sodium and the pH decreases while the urinary potassium increases.


The patient has not been able to eat or drink due to the pain and has been irritable.

His vital signs are as follows: T 39.1, HR 110, BP 90/62, RR 18, SpO2 99%.

Physical examination is significant for vesicular lesions noted on the tongue, gingiva, and lips, with some vesicles having ruptured and ulcerated, as well as palpable cervical and submandibular lymphadenopathy.


The patient's written advance directive states that he does not wish to be resuscitated in the event of a cardiac arrest.

The patient's wife arrives and demands that "everything" be done to keep him alive because she "can't go on living without him."

The patient's adult son is on his way to the hospital.


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

His current medications are aspirin, simvastatin, metformin, and enalapril.

He has smoked one pack of cigarettes daily for 33 years.

On arrival, his pulse is 136/min and irregular, respirations are 20/min, and blood pressure is 85/55 mm Hg.

He describes it as 7 out of 10 in intensity.

Cardiac examination shows no abnormalities.


Based on clinical suspicion, a CBC, a Coombs test, and a bilirubin panel are obtained to determine the etiology of the gallstone.

These tests reveal a mild normocytic anemia with associated reticulocytosis as well as an increased RDW.

In addition there is an indirect hyperbilirubinemia and the Coombs test results are negative.

To confirm the diagnosis, an osmotic fragility test is performed which shows increased fragility in hypotonic solution.


He reports that his symptoms started after he lifted heavy weights at the gym.

Physical examination shows loss of sensation on the lateral side of the right forearm.

His symptoms do not worsen with axial compression or distraction of the neck.


Serologic tests reveal positive Anti-HBsAg and Anti-HAV IgM antibodies.


He has had hypertension for the past 10 years for which he takes bisoprolol.

His condition started suddenly 30 minutes ago.

On physical examination, the patient appears in severe pain and his left leg is pale and cool.

His temperature is 37.1°C (98.7°F), the blood pressure is 130/80 mm Hg, and the pulse is 100/min and irregular.

The popliteal pulse is weaker on the left side compared to the right side.


He is concerned that she has not undergone puberty yet, while all of her classmates at school have.

The patient herself feels well overall, with no specific complaints.

Examination shows vital signs of T 98.9, HR 71, and BP 137/92.

The physician notes undeveloped breasts and normal external and internal female genitalia in Tanner I stage of development.

Her body mass index is within normal limits, she is in the 40th percentile for height, and she is agreeable and pleasant during the interview.


This mutation results in the sickling of their red blood cells when exposed to inciting factors such as hypoxic conditions.


He has a history of cirrhosis of the liver secondary to alcoholism.

He started becoming more confused a few days ago and it has been getting gradually worse.

His temperature is 98.8°F (37.1°C), blood pressure is 134/90 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Physical exam reveals a distended abdomen that is non-tender.

Neurological exam is notable for a confused patient and asterixis.


She was born at term via vaginal delivery and her delivery was uncomplicated.

Her parents report that she has not eaten anything during this period and that they were unable to calm her down.

Her vital signs are within normal limits.

Examination shows a reddened and swollen 2nd toe of the left foot.

She has not had any trauma.
A photograph of the left foot is shown.


Her past medical history is significant for asthma and eczema.

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

She feels solid food getting stuck in her chest behind the sternum.

She does not have any issues with liquids.

She has no coughing or nasal regurgitation.

She reports occasional heartburn that has lasted for about a year.

Physical examination shows no abnormal findings.

An endoscopic image of the esophagus is shown.

Mucosal biopsy shows eosinophilic infiltration.


They state that approximately one hour after putting their child to sleep, a "hacking" cough was heard from his bedroom.

After entering his room the parents state their child appeared to be in distress, making a high pitched noise with every breath.

Beyond a runny nose for the past few days, the child has been healthy.

Physical exam demonstrates a 2-year-old child in respiratory distress.

He has no toys in his bed or access to any other small objects.


Over the next few months, her symptoms become more severe, as she experiences rapid mental deterioration.

She also starts to have sudden, jerking movements in response to being startled and gait disturbances.

Eventually, she lapses into a coma and dies eight months after the onset of symptoms.


On physical examination, the oral cavity shows mucosal ulceration and atrophy.

Biopsy of the lower lip shows marked lymphocytic infiltration of the minor salivary glands.


He smoked one pack of cigarettes daily for 20 years but quit 5 years ago.

Physical examination shows an increased anteroposterior chest diameter and coarse crackles in the lower lung fields bilaterally.

Treatment with a drug that directly antagonizes the effects of vagal stimulation on the airways is begun.


He had bilateral orchidopexy for cryptorchidism as an infant.

Two days ago, his mother found that he had left the gas on in the kitchen, and he was unable to smell the odor of the gas.

The patient is unable to identify several common odors when presented with them.

As a child, he was consistently in the 40th percentile for height; now he is in the 15th percentile.

Physical examination shows sparse axillary and pubic hair and Tanner stage 1 genitals.


She received appropriate post-exposure prophylaxis in the emergency department and has already received 2 doses of the rabies vaccine.

The same physician has been managing the post-exposure care regimen.

After the physician administers the third dose of the rabies vaccine, the patient asks him if he would like to join her for a movie and dinner.

The physician is interested in going on a date with her.


His fever is low-grade and sputum is often blood-tinged.

He has lost 6.8 kg (15.0 lb) during this period and complains of profound night sweats.

A plain radiograph of the patient’s chest shows consolidation in the apical part of the right lung.

Baseline investigations show the following:
Complete blood count
Hemoglobin 11 g/dL
White blood cells
Total count 16,000/mm3
Differential count
Neutrophils 35%
Lymphocytes 54%
Eosinophils 11%
Erythrocyte sedimentation rate 84 mm
The physician suspects that the patient is suffering from a chronic lung infection.


He informs the physician that he is asthmatic, but does not use inhalers regularly because he does not like using medications.

He is a non-smoker and occasionally drinks alcohol.

The physician asks the nurse to administer nebulized albuterol; however, the boy declines nebulized albuterol because of a history of palpitations that he experienced previously.

On physical examination, the temperature is 37.0°C (98.6°F), the pulse is 120/min, the blood pressure is 114/76 mm Hg, and the respiratory rate is 32/min.

Auscultation of the chest reveals bilateral wheezing.

The physician then prescribes nebulized ipratropium bromide, which results in significant clinical improvement.


Examination of the smaller newborn shows a flattened nose and left-sided clubfoot.

The hematocrit is 42% for the smaller newborn and 71% for the larger newborn.


The patient has a past medical history of asthma, obesity, and a uterine leimyoma which was definitively treated last year.

Her last menstrual period was at the age of 47.

The patient's vital signs and exam are unremarkable.

The patient is started on chemotherapy and ultimately has the mass resected.

She is taking tamoxifen and has regular outpatient follow up appointments to monitor for any recurrence of cancer.

The mass is biopsied and cytology results are diagnostic for invasive ductal adenocarcinoma that is estrogen receptor positive.


She has also had progressive recurring headaches and visual impairment over the last month.

Three days ago, she had a seizure but has not seen a physician.

Her temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/80 mm Hg.

Capillary refill time is more than 3 seconds.


She has pain around her right eye during eye movement.

At the clinic, her blood pressure is 110/70 mm Hg, the pulse is 72/min, respirations are 15/min, and the temperature is 36.5℃ (97.7℉).

On physical examination, illumination of the left eye results in bilateral pupillary constriction while illumination of the right eye results in a mild bilateral pupillary dilation.

Fundoscopic examination shows optic disk swelling in the right eye.

The color vision test shows decreased perception in the right eye.

The remainder of the physical examination shows no abnormalities.


She has not felt like eating or drinking since her symptoms started, and she has not taken any medications.

The vomitus is watery and contains undigested food particles.

She also complains of feeling tired and having the “sniffles”.

Her concern now is that she immediately gets dizzy when she stands up.

Vitals signs include: pulse 120/min, respiratory rate 9/min, and blood pressure 100/70 mm Hg.

Her eyes are sunken, and her tongue appears dry.


He and his wife have been trying to get pregnant for the past two years.

They have used fertility monitors and other aids without success.

The patient has a history of cleft lip and recurrent upper respiratory infections as a child.

He was briefly hospitalized for severe pneumonia when he was 9-years-old.

A hysterosalpingogram in his wife was normal.

His temperature is 98.6°F (37°C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 18/min.

On examination, he is a healthy-appearing male in no acute distress with fully developed reproductive organs.

Notably, cardiac auscultation is silent in the left 5th intercostal space at the midclavicular line.


She has smoked 1 pack of cigarettes daily for the past 30 years.

She has had multiple episodes of upper abdominal pain over the past year.

Physical examination shows a distended abdomen with diffuse tenderness and high-pitched bowel sounds.

An x-ray of the abdomen shows a dilated bowel, multiple air-fluid levels, and branching radiolucencies in the right infra-diaphragmatic region.


Three days after the surgery, he develops fever and redness around the surgical site.

Four days later, the patient continues to have high-grade fever, pain, and purulent discharge.

Physical examination shows purulent discharge from the wound with erythema of the surrounding skin.

Wound culture of the purulent discharge shows gram-positive cocci in clusters.

Treatment with oral dicloxacillin is initiated.


She denies any other symptoms and states that she has not gained any weight.

On exam, you notice a 2 cm nodule on her anterior neck.

Her TSH level is normal and radionucleotide scan reveals a cold nodule.

Fine needle aspiration biopsy (FNAB) reveals follicular architecture suspicious for malignancy.


All pressures are found to be within normal limits, and the cardiology fellow records a pulmonary wedge pressure of 10 mmHg.


He has a history of recurrent ear infections treated with antibiotics since birth.

Over the past 8 months, his mother reports difficulty understanding the boy's speech.

On occasion during this period, she has noticed that he does not respond when called by name and cannot follow 1-step instructions.

His speech is quiet and difficult to understand.

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

Otoscopic examination shows retracted tympanic membranes bilaterally that are immobile on pneumatic otoscopy.

Nasopharyngoscopy shows mild adenoid hypertrophy.

Pure tone audiometry shows a conductive hearing loss of 26 dB on the right side and 28 dB on the left side.


His past medical history is insignificant for any seizure disorders, and he does not take any medications.

He developed nausea, vomiting, and abdominal cramps.

The patient noted facial muscle twitching and developed a tonic-clonic seizure that lasted 3 minutes, 4 hours following the onset of his condition.

His blood pressure is 95/60 mm Hg, heart rate is 104/min, respiratory rate is 10/min, and the temperature is 37.0°C (98.6°F).

On physical examination, the patient’s consciousness is decreased with a Glasgow Coma Scale score of 13.

His lung sounds are normal, cardiac sounds are decreased, and no murmurs are present.

Abdominal palpation reveals epigastric tenderness.

Neurological examination shows rapid downbeating nystagmus, facial muscle twitching, and symmetrically decreased sensation to all the sensory modalities on both the upper and lower extremities.

Further discussion reveals that the patient was using sodium fluoroacetate as a pesticide, which is known to form fluorocitrate in the cells of aerobic organisms.

His wife reports that 30 min following the onset of her husband’s condition, which started approximately 6 hours ago, he treated his garden bed with pesticides against mice.


Social history is significant for alcohol abuse.

90 minutes ago, the patient was found by a neighbor unarousable on the couch with multiple empty bottles of medication on the floor next to her.

Physical examination reveals an awake female with a fluctuating level of consciousness, not oriented to time or place.


He has metastatic colon cancer and has received three cycles of chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin; his last chemotherapy session was 2.5 months ago.

His medications include a fluticasone-salmeterol inhaler and a tiotropium bromide inhaler.

He has smoked one pack of cigarettes daily for 48 years.

The cough is productive of small amounts of green phlegm.

His temperature is 39.1°C (103.1°F), pulse is 112/min, respirations are 32/min, and blood pressure is 88/69 mm Hg.

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

Pulmonary examination shows diffuse crackles and rhonchi.

An x-ray of the chest shows a left upper-lobe infiltrate of the lung.

Endotracheal aspirate Gram stain shows gram-negative rods.

He has chronic obstructive pulmonary disease and has been treated with antibiotics and prednisolone for acute exacerbations three times in the past year.

Two sets of blood cultures are obtained.

Two large bore cannulas are inserted and intravenous fluids are administered.


Over the last 7 months, he has claimed to hear voices telling him that he must prepare for the end of the world.

He used to be a straight A student but started failing exams recently due to his erratic behavior.

Furthermore, there are periods of time where he does not sleep for several days and redecorates the entire apartment.

During those times he spends huge amounts of money on online shopping.

These periods usually last for about 2 weeks and happen every other month.

On physical exam, he appears unkept and irritated.

He seems to respond to invisible stimuli, and he jumps from topic to topic without clear focus.


He had a left basal ganglia hemorrhage 12 years ago and a right middle cerebral artery infarction 4 years ago.

Current medications are amlodipine, aspirin, clopidogrel, metformin, sitagliptin, and valsartan.

He lives with his son and can feed himself and change his clothes.

The patient’s son says he has difficulty remembering recent events and names.

He says the patient’s symptoms have progressively worsened over the last several years but became acutely worse just recently.

Also, yesterday, the patient complained that he could not see out of his right eye, but today he can.

When asked about these concerns, the patient seems to have no insight into the problem and reports feeling well.

His vitals include: blood pressure 137/82 mm Hg, pulse 78/min, respiratory rate 16/min, temperature 37.0°C (98.6°F).

On physical examination, the patient is alert and oriented.

He is unable to perform simple arithmetic calculations and the mini-mental status exam is inconclusive.

Muscle strength is 4/5 on the right side.

The tone is also slightly reduced on the right side with exaggerated reflexes.

His medical history is significant for diabetes mellitus type 2 and hypertension.

There is no history of urinary or fecal incontinence.


She is currently unemployed and lives in a low-income neighborhood with her 3 children.

Current medications include dolutegravir, tenofovir, and emtricitabine.

For the past 3 years, her HIV RNA viral load was undetectable, but last week, her viral load was 8,391 copies/mL (N < 50).

On questioning, she says that she misses her medications every other day.


He has a history of peripheral arterial disease, type 2 diabetes mellitus, hypertension, hypercholesterolemia, and gout.

The patient has smoked 1 pack of cigarettes daily for the past 50 years.

His current medications include aspirin, metformin, enalapril, simvastatin, and febuxostat.

His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 122/76 mm Hg.

He feels well but reports occasional episodes of weakness and numbness in his left hand.

Cardiac examination shows no murmurs, rubs, or gallops.

Auscultation of the right side of the neck shows a bruit.

There is a right-sided reducible inguinal hernia.

Neurological examination shows no abnormalities.

A complete blood count and serum concentrations of electrolytes, creatinine, and glucose are within the reference ranges.

An electrocardiogram shows signs of mild left ventricular hypertrophy.

An x-ray of the chest shows no abnormalities.


She has a history of regular menstruation every 4 weeks that lasts about 4 days with mild to moderate bleeding, but she missed her last period 2 weeks ago.

She has a 6-year history of hyperthyroidism that is well-controlled with daily methimazole.

She is currently asymptomatic and has no complaints or concerns.

A blood specimen is taken and confirms the diagnosis.

Additionally, her thyroid-stimulating hormone (TSH) is 2.0 μU/mL.


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

He drinks 3 alcoholic drinks every day and has a 44 pack-year smoking history.

The patient states that he has gradually worsening back pain that seems to have worsened after moving furniture the other day.

He also states that while he walks, he feels numbness and weakness in his legs.

The only time the patient states his back pain is improved is when he is riding his bike or pushing a cart at the grocery store.

His temperature is 99.5°F (37.5°C), blood pressure is 157/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Physical exam is notable for a non-tender spine with normal mobility in all 4 directions.

Radiography of the spine and basic labs are ordered.


She has experienced 7 similar episodes, each lasting 2–5 days in the previous 2 years.

She has also had intermittent abdominal cramps and recurrent episodes of foul-smelling greasy diarrhea in the past year.

She is at the 55th percentile for height and 35th percentile for weight.

Her temperature is 38.9°C (102°F), pulse is 100/min, respirations are 24/min, and blood pressure is 110/60 mm Hg.

Physical examination shows an erythematous oropharynx without exudate and tenderness over the frontoethmoidal sinuses.

The abdomen is distended, nontender, and tympanitic to percussion.

Stool microscopy shows pear-shaped multi-flagellated organisms.


Past medical history is significant for a recent sore throat which caused him to miss several days at school.

The patient’s vaccination status is unknown.

On physical examination, the patient is pale and ill-looking.

There are pink rings present on the torso and inner surfaces of the limbs.

Cardiac exam is significant for a holosystolic murmur heard best over the apex of the heart.


He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression.

His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram.

He has no complaints except for a dry cough.

His vitals signs are stable, with blood pressure 126/79 mmHg.

Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL.

The remainder of his physical exam is unremarkable.


He was born at 40 weeks' gestation at 2514 g (5.54 lb) to a 28-year-old woman, gravida 3, para 2, by an uncomplicated cesarean section.

The mother did not receive prenatal care.

Examination shows hyperreflexia, tremors, and an excessive startle response.

Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

The infant's temperature is 38.0°C (100.4°F), pulse is 170/min, and blood pressure is 71/39 mm Hg.


A month ago, she returned from a camping trip to Sri Lanka.

During this time, she has also noticed that her gums bleed while brushing her teeth.

There are a few scattered petechiae over the trunk and back.

Her temperature is 39.3°C (102.8°F), pulse is 104/min, respirations are 24/min, and blood pressure is 135/88 mm Hg.

Examination shows pallor and mild scleral icterus.

Test of the stool for occult blood is positive.

Laboratory studies show:
Hemoglobin 8.2 g/dL
Leukocyte count 10,000/mm3
Platelet count 18,000/mm3
INR 1.0
Coomb's test negative
Fibrin split products negative
Serum
Urea 20 mg/dL
Creatinine 1.1 mg/dL
Bilirubin
Total 3.0 mg/dL
Direct 0.8 mg/dL
Alanine aminotransferase 20 U/L
Aspartate aminotransferase 16 U/L
Lactate dehydrogenase 900 U/L
Urine
Protein 1+
WBCs occasional
RBCs 50–60/hpf
Bacteria nil
A photograph of the peripheral blood smear is shown.

Physical and neurologic examinations show no other abnormalities.


On arrival, he is oriented to person but not to place or time.

His temperature is 37.3°C (99.1°F), pulse is 116/min, respirations are 18/min, and blood pressure is 79/42 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 97%.

Examination shows multiple abrasions over the arms and thorax.

There is a 1-cm (0.4-in) entry wound with minimal bleeding on the right side of the chest in the 6th intercostal space at the midclavicular line.

Cardiopulmonary examination shows no abnormalities.

Abdominal examination shows diffuse mild tenderness to palpation with no guarding or rebound.

A focused assessment with sonography shows no obvious free fluid in the pericardium; assessment of the abdomen is equivocal.

An x-ray of the chest shows mild opacification of the right lower lobe.

Two large-bore cannulas are inserted and intravenous fluid resuscitation is begun.

The patient is intubated and mechanical ventilation is begun.

He sustained a gunshot wound in an altercation outside of a bar.


This mutation results in a rare disease characterized by muscle cramping and stiffening that is usually most severe after exercise or strenuous activity and is typically relieved after affected individuals rest for a few minutes.


He has had type 2 diabetes for 27 years and essential hypertension for 19 years.

He has smoked 20–30 cigarettes per day for the past 35 years.

His symptoms started 20 minutes ago while shaving.

He also feels nauseated, lightheaded and short of breath.

His temperature is 36.9°C (98.4°F), the blood pressure is 115/72 mm Hg and the pulse is 107/min.

The patient is admitted to a unit with continuous cardiac monitoring.

Aspirin, clopidogrel, sublingual nitroglycerin, and morphine are given immediately and the patient now rates the pain as 4–5 out of 10.

Family history is irrelevant.
ECG is shown in the image.


He underwent appendectomy at the age of 39.

He takes a topical corticosteroid, ramipril, metformin, and ibuprofen daily.

He is 176 cm (5 ft 9 in) tall and weighs 108 kg (240 lb); BMI is 35.4 kg/m2.

His last bowel movement was yesterday and he has not passed flatus since then.

His temperature is 36.8°C (98.4°F), respirations are 15/min, pulse is 90/min, and blood pressure is 112/67 mm Hg.

Examination shows thick, scaly, plaques over both elbows and knees.

Abdominal examination shows three well-healed laparoscopic scars.

The abdomen is distended and there are frequent, high-pitched bowel sounds on auscultation.

Digital rectal examination shows an empty rectum.

Laboratory studies show:
Hematocrit 44%
Leukocyte count 9,000/mm3
Platelet count 225,000/mm3
Serum
Na+ 139 mEq/L
K+ 4.1 mEq/L
Cl− 101 mEq/L
HCO3− 26 mEq/L
Glucose 95 mg/dL
Creatinine 1.1 mg/dL
Alkaline phosphatase 78 U/L
Aspartate aminotransferase (AST, GOT) 19 U/L
Alanine aminotransferase (ALT, GPT) 14 U/L
γ-Glutamyltransferase (GGT) 52 U/L (N=5–50 U/L)
Hemoglobin A1C 6.4%
Abdominal ultrasound shows nonpropulsive peristalsis of the small bowel.


She additionally reports bloody diarrhea and tenesmus.


During the past 3 months, the patient has had several upper respiratory tract infections and poor weight gain.

Physical examination shows crackles over both lung fields and enlargement of the tonsils and cervical lymph nodes.

His serum IgA, IgE, and IgG titers are decreased.

An x-ray of the chest shows bilateral interstitial infiltrates.

Methenamine silver staining of bronchial lavage fluid shows disc-shaped cysts.


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

He reports that he gets tired easily compared to his baseline and feels dizzy when he exerts himself (e.g., when he walks long distances).

A physical examination demonstrates moderate hepatomegaly and lymphadenopathy.

Leukocyte count and differential:
Leukocyte count: 11,500/mm^3
Segmented neutrophils: 40%
Bands: 3%
Eosinophils: 1%
Basophils: 0%
Lymphocytes: 50%
Monocytes: 8%

Hemoglobin: 11.2 g/dL
Platelet count: 120,000/mm^3
Mean corpuscular hemoglobin concentration: 31%
Mean corpuscular volume: 80 µm^3
Reticulocyte count: 3%
Lactate dehydrogenase: 45 U/L

A subsequent flow cytometry test demonstrates CD20+ cells.


His past medical history is significant for Alzheimer disease though he is still relatively functional at baseline.

He has also been taking warfarin over the last 3 months after he suffered a deep venous thrombosis.

On presentation, he is found to be somnolent and physical exam reveals ataxia and nystagmus.

After determining the cause of this patient's symptoms, his physicians begin monitoring his international normalized ratio, because they are concerned that it will start trending down.

After he was transported to the ED, his family found that the pills his grandson takes for seizures were missing.


She returned from a vacation to northern Brazil 4 days ago.

She took the appropriate medications and immunizations prior to her visit.

There is no family history of serious illness.

Her temperature is 39.4°C (103°F), pulse is 110/min and blood pressure is 94/54 mm Hg.

Examination shows jaundice of the conjunctivae and skin.

The abdomen is soft and nontender; the spleen is palpated 2 to 3 cm below the left costal margin.


She has no history of serious illnesses and is on no medications.

There has been no recent contact with any animals or pets.

Last week she noted several painless red papules on her left thigh when she was on a summer trip to Madagascar.

The temperature is 38.6℃ (101.5℉), the pulse is 78/min, the respiration rate is 12/min, and the blood pressure is 110/65 mm Hg.

Swelling of the left inguinal area was noted; however, there were no skin changes.

Several large, tense, and tender lymph nodes with a boggy consistency were palpated in the inguinal region.

The right inguinal area is normal on physical exam.

There was no lymphadenopathy in other areas.

No abnormalities existed in the lungs, heart, and abdomen.

Microscopic examination of pus from the inguinal lymph nodes revealed gram-negative Coccobacilli.

Serum anti-F1 titers show a 4-fold rise.


She has coronary artery disease, hypertension, and type 2 diabetes mellitus; she has had trouble adhering to her medication regimen.

Examination shows 20/50 vision in the left eye and no perception of light in the right eye.

Direct pupillary reflex is present in the left eye, but absent in the right eye.

Intraocular pressure is 16 mm Hg in the left eye and 18 mm Hg in the right eye.

Fundoscopic examination of the right eye shows a pale, white retina with a bright red area within the macula.


She returned from a business trip from Europe 3 days ago.

She has smoked a pack of cigarettes daily for 10 years.

Her only medication is an oral contraceptive.

The left lower leg is swollen, erythematous, and tender to palpation.

Her temperature is 38.0°C (100.4°F), pulse is 115/min and regular, and blood pressure is 155/85 mm Hg.

Examination shows decreased muscle strength on the entire right side.

Deep tendon reflexes are 4+ on the right.


They tell you that she has diabetes but do not know anything more about her condition.

On physical examination, the patient is breathing heavily and gives irrelevant responses to questions.

The skin and mucous membranes appear dry.

The woman’s vital signs include: pulse 110/min, respiratory rate 24/min, temperature 36.7°C (98.0°F), and blood pressure 90/60 mm Hg.

Examination of the abdomen reveals mild diffuse tenderness to palpation.

Deep tendon reflexes in the extremities are 1+ bilaterally.

Laboratory studies show:
Finger stick glucose 630 mg/dL
Arterial blood gas analysis:
pH 7.1
PO2 90 mm Hg
PCO2 33 mm Hg
HCO3 8 mEq/L
Serum:
Sodium 135 mEq/L
Potassium 3.1 mEq/L
Chloride 136 mEq/L
Blood urea nitrogen 20 mg/dL
Serum creatinine 1.2 mg/dL
Urine examination shows:
Glucose Positive
Ketones Positive
Leukocytes Negative
Nitrite Negative
RBCs Negative
Casts Negative
The patient is immediately started on a bolus of intravenous (IV) 0.9% sodium chloride (NaCl).


He has a history of hypothyroidism, schizoaffective disorder, type 2 diabetes mellitus, dyslipidemia, and hypertension for which he takes medication.

Ten days ago, he was started on a new drug.

According to the father, the patient was unable to get out of bed that morning and has become increasingly confused over the past several hours.

His rectal temperature is 32°C (89.6°F), pulse is 54/min, respirations are 8/min, and blood pressure is 122/80 mm Hg.

Examination shows weakness in the lower extremities with absent deep tendon reflexes.

Deep tendon reflexes are 1+ in the upper extremities.

The pupils are dilated and poorly reactive to light.

The father also noticed it was “pretty cold” in his son's apartment because all of the windows were left open overnight.

Throughout the examination, the patient attempts to remove his clothing.


Investigations show her hemoglobin level to be 8.6 gm/dL and serum creatinine of 4.6 mg/dL.

The serum is negative for antinuclear antibodies (ANA) and positive for C3 nephritic factor.

The renal biopsy demonstrates hypercellular glomerulus with electron dense deposits along the glomerular basement membrane.


He does not take any medications despite being diagnosed with hypertension 10 years ago.

For the past several months, he has had shortness of breath on exertion and while lying down on the bed, frequent headaches, and swelling of his feet.

His pulse is 90/min, respirations are 20/min, blood pressure is 150/110 mm Hg, and temperature is 37.0°C (98.6°F).

Physical examination shows an overweight male in acute distress with audible wheezes.

Crackles are heard bilaterally and are loudest at the lung bases.


Methods:
In this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA.

Patients who were immunocompromised or had a history of recurrent infections were excluded.

Patients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants.

Plaque volume was determined by ultrasound.

Results:
At baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all).

All outcome variables were approximately normally distributed.

She notices that the standard error surrounding measurements in the pulmharkimab 150 mg/day group is generally greater than the standard errors for the placebo and pulmharkimab 75 mg/day groups.

Which of the following statements is the best explanation for the increased standard error in the pulmharkimab 150 mg/day group?"

"Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma
Introduction:
Active asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors.

It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease.

This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression.

All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence.

Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms.

Analyses were performed from baseline to month 12.

A total of 215 participants (18%) were lost to follow-up.

At 12-month follow-up, the groups contained the following numbers of participants:
Pulmharkimab 75 mg/d: 388 participants
Pulmharkimab 150 mg/d: 202 participants
Placebo: 395 participants
Table 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes.

Models were adjusted for sociodemographic variables and medical comorbidities.

Pulmharkimab 75 mg/d, (Mean +/- 2 SE) Pulmharkimab 150 mg/d, (Mean +/- 2 SE) Placebo, (Mean +/- 2 SE) P-value
Plaque volume (mm3), change from baseline 6.6 ± 2.8 1.2 ± 4.7 15.8 ± 2.9 < 0.01
LDL-C levels, change from baseline -9.4 ± 3.6 -11.2 ± 14.3 -8.4 ± 3.9 0.28
FEV1/FVC ratio, change from baseline 0.29 ± 2.21 0.34 ± 5.54 -0.22 ± 3.21 0.27
ACQ scores, change from baseline 0.31 ± 1.22 0.46 ± 3.25 0.12 ± 1.33 0.43
Conclusion:
Pulmharkimab may be effective in reducing plaque volume but does not lead to improved asthma control in patients with a history of myocardial infarction and comorbid asthma.


Physical examination shows bright red rectal bleeding.

His temperature is 37.6°C (99.6°F), pulse is 115/min, respirations are 24/min, and blood pressure is 86/60 mm Hg.

Colonoscopy shows profuse diverticular bleeding; endoscopic hemostasis is performed.

After initiating fluid resuscitation, the patient becomes hemodynamically stable.


The patient was found unconscious by the paramedics and regained consciousness briefly during the ambulance ride.

His is unresponsive to verbal commands and physical touch.

Upon arrival at the hospital, the patient’s vitals show: pulse 110/min, respiratory rate 12/min, blood pressure 100/70 mm Hg, and oxygen saturation of 96%.

Physical examination reveals an unresponsive man with multiple bruises across the chest and along the upper arms with a laceration on the forehead.

An urgent noncontrast CT of the head is performed and shown in the image.

The patient is prepared for emergency neurosurgery.


She is sexually active and inconsistently uses condoms.

The patient has no past medical history.

Physical examination of the genitalia is normal.

She denies having a fever but has experienced intermittent chills.

Urinalysis shows positive leukocyte esterase and nitrites.

The urine culture demonstrates gram-negative rods that form pink colonies on MacConkey agar.

She is treated with an antibiotic and her symptoms quickly improve.


He has smoked a pack of cigarettes daily for 45 years.

His medications include warfarin, enalapril, and amiodarone.

His pulse is 85/min and irregularly irregular.

Physical examination shows enlarged fingertips and markedly curved nails.

A CT scan of the chest shows clustered air spaces and reticular opacities in the basal parts of the lung.


The patient’s mother mentions that he has been diagnosed with major depressive disorder 3 years ago for which he was taking a medication that resulted in only a slight improvement in his symptoms.

She says he still found it difficult to concentrate on his studies and did not participate in any social events in college.

He didn’t have many friends and was often found sitting alone in his room.

He has also threatened to take his life on several occasions, but she did not think he was serious.

While recording his vital signs, the patient goes into a coma.

His ECG shows a QT interval of 450 milliseconds.


Sixty similar but healthy individuals are recruited into the control group.

Educational status is considered to be an important variable, as it would affect the awareness of the disease and its risk factors among the participants.

Based on the level of education, 2 groups are formed: low educational status and high educational status.

A chi-square test is performed to test the significance of the relationship, and an odds ratio of 2.1 was computed for the association between low education and the risk of MI, with a confidence interval of 0.9–9.7.


She is asymptomatic and has no history of serious illness.

Her only medication is a prenatal vitamin.

Her temperature is 37.2°C (99°F) and blood pressure is 108/60 mm Hg.

Pelvic examination shows a uterus consistent in size with a 16-week gestation.

A quadruple screening test shows maternal serum AFP of 3 times the median and normal levels of serum β-hCG, estriol, and inhibin A.


He works as a long-haul truck driver, and he informs you that he recently returned to the east coast from a trip to Utah.

His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus type 2, and acute lymphoblastic leukemia from when he was a child.

He currently smokes 2 packs of cigarettes/day, drinks a 6-pack of beer/day, and he denies any illicit drug use.

He says this started abruptly about 6 hours ago.

He says that he has not noticed that anything that makes his pain better or worse.

The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 98/min, and respiratory rate 23/min.

His physical examination shows minimal bibasilar rales, but otherwise clear lungs on auscultation, normal heart sounds, and a benign abdominal physical examination.


Specifically, she says that she was gardening 8 hours prior to presentation when she sustained a laceration over her distal interphalangeal (DIP) joints.

Since then, they have become red and swollen.

She has also had pain in her proximal interphalangeal (PIP) joints and metacarpophalangeal (MCP) joints for several years and reports that this pain is worse in the morning but improves over the day.

The cells that are present in this patient's DIP joints and PIP joints are analyzed and compared.


The patient is otherwise healthy and is not currently taking any medications.

She states it is 10/10 in intensity and states that it is associated with chewing.

She describes it as a dull pain over the sides of her head.

Her temperature is 97.0°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Physical exam is notable for pain and tenderness over the mandibular and temporal region that is worsened when the patient opens and closes their mouth.


He has asthma well controlled with an albuterol inhaler.

His father died of lung cancer at 62 years of age.

He has smoked one pack of cigarettes daily for 14 years.

His temperature is 37.4°C (99.3°F), pulse is 98/min, respirations are 19/min, and blood pressure is 122/76 mm Hg.

Examination shows reduced breath sounds over the left lung base.

Cardiac examination shows no abnormalities.

There is a clean, dry surgical incision over the midline of the abdomen.

His hemoglobin concentration is 12.9 g/dL, leukocyte count is 10,600/mm3, and platelet count is 230,000/mm3.

An x-ray of the chest in supine position is shown.


He has type 2 diabetes mellitus, hypertension, and hypercholesterolemia.

His current medications include metformin, enalapril, and atorvastatin.

He has smoked one pack of cigarettes daily for 35 years.

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

He had difficulty putting on his shirt and shoes before coming to the hospital.

His temperature is 37°C (98.6°F), pulse is 99/min and blood pressure is 170/100 mm Hg.

Examination shows equal and reactive pupils.

There is drooping of the left side of the face.

Muscle strength is decreased in the left upper and lower extremities.

Plantar reflex shows an extensor response on the left side.

There is a bruit on the right side of the neck.

A complete blood count, coagulation profile, and serum concentrations of glucose and electrolytes are within the reference range.


After 3 weeks, the patient presents with complaints of fever and significantly increased cough for 3 days.

His Mantoux test is 2 mm × 3 mm, and his chest radiograph is normal.

His CD4+ T cell count is 90/μL and HIV RNA is 30,000 copies/mL.

He is started on a 4-drug regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol in appropriate doses.

There is no respiratory distress but generalized lymphadenopathy is present.

His chest radiograph shows pulmonary infiltrates and mediastinal lymphadenopathy, sputum smear is negative, Mantoux test is 12 mm × 14 mm, CD4+ T cell count is 370/μL, and HIV RNA is 2,900 copies/mL.

He becomes sputum smear-negative after 4 weeks and reports significant improvement in symptoms.

After another 4 weeks, the physician removes pyrazinamide from the antitubercular regimen and adds antiretroviral therapy (dolutegravir/tenofovir/emtricitabine).

His sputum smear and culture confirm the diagnosis of pulmonary tuberculosis due to Mycobacterium tuberculosis.


On physical examination, there is erythema, tenderness and enlargement of the thyroid gland that is worse on the left.

Pain is worsened during neck hyperextension and relieved during neck flexion.

His vital signs include: body temperature 39.0°C (102.2°F), heart rate 120/min, and respiratory rate 18/min and regular.

Thyroid function tests are within normal limits.

An ultrasound of the thyroid gland reveals a unifocal perithyroidal hypoechoic space.


He states that he does not experience dysuria.

On physical exam there is no costovertebral angle tenderness.


The patient’s mother says he started complaining of pain in his abdomen after he got back from school yesterday and vomited 3 times during the night.

This morning, he seemed confused so she rushed him to the ER.

She has also noticed that he has been urinating frequently and drinking a lot of water recently, and he has lost 6 kg (13.2 lb) over the past 20 days.

His vital signs include: blood pressure 100/50 mm Hg, heart rate 110/min, respiratory rate 27/min, and temperature 35.6°C (96.0°F).

On physical examination, he is disoriented to time and place and is taking deep and labored breaths.

There is diffuse tenderness to palpation in the abdomen with guarding.

Laboratory tests are significant for a pH of 7.19 and a blood glucose level of 754 mg/dL.

The doctor explains to his mother that her son has developed a life-threatening complication of a disease characterized by decreased levels of a hormone.


She reports nausea and vomiting and is unable to tolerate oral intake.

Her temperature is 38.1°C (100.6°F), the pulse is 92/min, the respirations are 18/min, and the blood pressure is 132/85 mm Hg.

Physical examination shows yellowish discoloration of her sclera.

Her abdomen is tender in the right upper quadrant.

There is no abdominal distention or organomegaly.

The laboratory tests show the following results:
Hemoglobin 13 g/dL
Leukocyte count 16,000/mm3
Urea nitrogen 25 mg/dL
Creatinine 2 mg/dL
Alkaline phosphatase 432 U/L
Alanine aminotransferase 196 U/L
Aspartate transaminase 207 U/L
Bilirubin
Total 3.8 mg/dL
Direct 2.7 mg/dL
Lipase 82 U/L
Ultrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder.

Her temperature is 39.1°C (102.4°F), the pulse is 105/min, the respirations are 22/min, and the blood pressure is 112/82 mm Hg.

Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole are initiated.

After 12 hours, the patient appears acutely ill and is not oriented to time.


The physician suspects that the patient may have elevated aldosterone levels and wants to initiate a trial of an aldosterone receptor antagonist.

The patient is very concerned about side effects, particularly impotence and gynecomastia, as he had a friend who took a similar medication and had these side-effects.


She says she was previously well and denies any history of similar symptoms.

No significant past medical history or current medications.

She reports that, at onset, she felt as if she was going to die and says her heart beating has been beating really fast.

There was also profuse sweating, and she says she feels short of breath.

She could not recall how long the event lasted but can remember that the symptoms did go away on their own by the time she arrived at the emergency department.

Her vitals rapidly returned to normal while giving her medical history and she begins to look and act more calm.

Her electrocardiogram and initial cardiac enzymes are normal.


He has no medical conditions and does not take any medications.

He does not drink alcohol or use recreational drugs.

He was recently kicked off of the school's football team after missing too many practices.

He has also been avoiding his family and friends because he is not in the mood to see them, but he admits that he is lonely.

He has not left his room for 2 days, which prompted his father to bring him to the physician.

He says he wants to use his father's licensed firearm to “end his misery” over the weekend when his parents are at church.

While the father is in the waiting room, a mental status examination is conducted, which shows a constricted affect.

He says that he would be better off dead and refuses to be treated.


The parents report that 2 weeks ago, his daycare group visited an animal shelter, after which he developed a rash on the left hand.

Physical examination shows three linear crusts on an erythematous background on the dorsum of the left hand.

There is tender left-sided axillary and cervical lymphadenopathy.

Histopathologic examination of an axillary lymph node shows necrotizing granulomas.


There is no other history of serious illness.

He had a sudden pruritic papular rash on his right thigh when he was in the southwestern USA hiking in northern Arizona and New Mexico.

The next day he developed severely painful inguinal swelling on the same side; however, he did not see a physician and controlled the pain with painkillers.

The temperature is 39.5℃ (103.1℉), the pulse is 105/min, the respiration rate is 32/min, and the blood pressure is 95/45 mm Hg.

Rales are heard in the lower lobe of the left lung on auscultation.

The right inguinal lymph nodes are enlarged with a spongy consistency and an underlying hard core.

The surrounding area is edematous without overlying erythema or cellulitis.

A computerized tomography (CT) scan is shown in the picture.


The patient has no known medical problems and takes no medications.

He smokes one pack of cigarettes per day and uses intravenous street drugs.

The lesions are non-pruritic and have been present for the last 3 weeks.

He reports feeling fatigued and malaise for the past few months.

His heart rate is 82/min, the respiratory rate is 14/min, the temperature is 36.7°C (98.1°F), and the blood pressure is 126/80 mm Hg.

Auscultation of the heart is without murmurs.

Lungs are clear to auscultation bilaterally.

Three 2-3 mm, dome-shaped, hardened papules are noted on the left thigh.

Central umbilication can be observed in each papule.

There is a non-tender cervical lymphadenopathy present.


However, rather than engaging in homosexual behavior, he holds rallies against gay rights and regularly criticizes gay people.


The patient has a past medical history of diabetes, hypertension, and atrial fibrillation and is currently taking warfarin, insulin, lisinopril, and metoprolol.

The patient’s brother recently died from a heart attack and he has switched to an all vegetarian diet in order to improve his health.

His temperature is 98.6°F (37.0°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

The patient’s physical exam is unremarkable.

His laboratory values are ordered as seen below.


She was in her normal excellent state of health prior to this event.

Two weeks ago, she had an upper respiratory infection (URI) but has since recovered.

On physical exam, the patient appears to have altered mental status and her skin is dry, hot, and erythematous.

She is complaining of severe bilateral flank pain and generalized myalgia.

At the hospital, her temperature is 40.3°C (104.5°F), blood pressure is 85/55 mm Hg, pulse is 105/min, and respiratory rate is 24/min.

Catheterization produces 200 mL of tea-colored urine.

Urine dipstick is positive for blood, but urinalysis is negative for RBCs or WBCs.

Her father has chronic kidney disease (CKD), bilateral hearing loss, and vision problems.


His heart rate is 76/min, respiratory rate is 14/min, temperature is 36.0°C (96.8°F), and blood pressure is 110/86 mm Hg.

Physical examination show signs suggestive of liver cirrhosis.


Her family history is negative for malignancies and inherited disorders.

She is the result of a pregnancy complicated by numerous miscarriages in the 1960s, for which her mother received diethylstilbestrol.

During a pelvic examination, you notice a polypoid mass on the anterior wall of the vagina.

The bimanual examination is negative for adnexal masses.

You suspect the presence of carcinoma and, therefore, send tissue samples to pathology, which confirmed the presence of malignant cells.


He was diagnosed with generalized anxiety disorder 6 months ago, which is being treated with citalopram.

He comments that his symptoms have improved since initiating the prescribed therapy; however, in the past 2 months, he has been unable to have sexual intercourse due to weak tumescence and low libido.

His blood pressure is 122/74 mm Hg, heart rate is 75/min, and respiratory rate is 16/min.

Physical examination reveals regular heart and lung sounds.


Two months ago, he had herpes zoster that was treated with acyclovir.

During this period, the patient has had recurrent episodes of high-grade fever, night sweats, and feelings of fatigue.

Temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure 130/80 mm Hg.

Physical examination shows generalized painless lymphadenopathy.

The liver and the spleen are palpated 2–3 cm below the right and the left costal margin, respectively.

Laboratory studies show:
Hematocrit 42%
Leukocyte count 15,000/mm3
Segmented neutrophils 46%
Eosinophils 1%
Lymphocytes 50%
Monocytes 3%
Platelet count 120,000/mm3
Blood smear shows mature lymphocytes that rupture easily and appear as artifacts on a blood smear.

Flow cytometry shows lymphocytes expressing CD5, CD19, CD20, and CD23.


His past medical history is notable for hypertension, diabetes mellitus, and hyperlipidemia.

He takes enalapril, metformin, and atorvastatin.

He has a 20-pack-year smoking history and is an avid hiker.

He developed severe, crushing, substernal chest pain 10 hours ago while he was hiking in the Adirondack mountains.

He is diaphoretic and intermittently conscious.

His temperature is 100°F (37.8°C), blood pressure is 102/60 mmHg, pulse is 130/min, and respirations are 28/min.

Bilateral rales are heard on pulmonary auscultation.

An electrocardiogram demonstrates ST elevations in leads I and aVL.

An autopsy is performed demonstrating ischemia in the left atrium and posterior left ventricle.

He was with 2 friends at the time who gave him aspirin before carrying him 5 miles to a town to get phone service, where they then called emergency medical services.

Despite appropriate management, the patient expires.


Twenty years ago, he had a painless ulcer on his penis that resolved without treatment.

Examination shows small pupils that constrict with accommodation but do not react to light.

Sensation to pinprick and light touch is decreased over the distal lower extremities.

Patellar reflexes are absent bilaterally.


She denies any similar symptoms in the past.

Upon physical examination, scleral icterus is present, and significant hepatosplenomegaly is noted.

Laboratory findings are significant for elevated serum levels of bilirubin, aminotransferases, alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGTP), immunoglobulins, as well as cholesterol (especially HDL fraction).

The erythrocyte sedimentation rate is also elevated.

Anti-mitochondrial antibodies are found.

A liver biopsy is performed, and the histopathologic examination shows bile duct injury, cholestasis, and granuloma formation.


He was at a college party exhibiting belligerent behavior when he suddenly passed out and fell to the ground.

The patient is covered with emesis and responds incoherently to questions.

As the patient begins to wake up he continues vomiting.

Thirty minutes later the patient presents with muscle rigidity and is no longer responding coherently to questions.

His temperature is 100°F (37.8°C), blood pressure is 107/48 mmHg, pulse is 125/min, respirations are 19/min, and oxygen saturation is 99% on room air.

His temperature is 103°F (39.4°C), blood pressure is 127/68 mmHg, pulse is 125/min, respirations are 18/min, and oxygen saturation is 98% on room air.

The patient is started on IV fluids, analgesics, and anti-emetics and begins to feel better.

The patient's basic laboratory studies are drawn and he is started on IV fluids, given lorazepam, and placed under a cooling blanket.

Despite these initial measures, his symptoms persist.


He is an active member of his school's gymnastics team.

The pain is exacerbated by jogging and climbing up stairs.

Knee extension against resistance causes pain in the anterior proximal tibia.

His vital signs are within normal limits.

Examination of the right knee shows a tender swelling at the proximal tibia; range of motion is full.

The remainder of the examinations shows no abnormalities.

X-ray of the right knee shows anterior tibial soft tissue swelling with fragmentation of the tibial tuberosity.

He has no history of trauma to the knee.


She underwent an abdominal hysterectomy 16 years ago for multiple fibroids of the uterus.

She has smoked one pack of cigarettes daily for 17 years.

She has right-sided chest pain that increases on inspiration and has had a productive cough for the last 12 hours.

Her temperature is 39°C (102.2°F), pulse is 98/min, respirations are 18/min, and blood pressure is 128/82 mm Hg.

Inspiratory crackles are heard at the right lung base.

There is a healing surgical incision below the right ribcage.

She had an episode of hypotension after the operation that resolved with intravenous fluid therapy.

The remainder of the examination shows no abnormalities.


The patient says he moved to Nevada 6 months ago because of a new job where he works outdoors; however, he worked indoors in an office before.

The patient’s rash is shown in the exhibit.

His vital signs include: blood pressure 100/60 mm Hg, pulse 64/min, respiratory rate 18/min.


Her maternal uncle had similar symptoms.

Cardiac examination shows wide splitting of S2.

The second component of S2 is loud and best heard at the 2nd left intercostal space.


You suspect that this patient has experienced a loss of polyanions in his glomerular basement membranes.


She first noticed her symptoms after she got off a rollercoaster ride 2 months ago.

Physical examination shows weakness when extending the right wrist against resistance.


Her past medical history is significant for chlamydia.

She is currently sexually active and does not use contraception.

Her menstrual periods occur regularly every 30 days.

She states that she was in a kickboxing class when she suddenly developed left-sided abdominal pain.

The patient’s temperature is 99°F (37.2°C), blood pressure is 110/68 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% on room air.

On physical exam, there is left-sided, lower abdominal tenderness and guarding.

Pelvic examination is notable for clear mucous in the vaginal introitus and tenderness of the left adnexa.

A pelvic ultrasound with Doppler reveals a large amount of fluid in the rectouterine pouch.

Her last menstrual period ended 2 days ago.


He reports a history of myocardial infarction 4 years ago, but he has no supporting documentation.

At the moment, his only medication is aspirin.

He also stated that he used to have ‘high blood sugars’ when checked in the hospital 4 years ago, but he did not follow up regarding this issue.

He has a 24-pack-year history of smoking and consumes alcohol occasionally.

He works as a farmer and noticed that it became much harder for him to work in the last few days because of fatigue and syncope.

The vital signs include: blood pressure 150/90 mm Hg, heart rate 83/min, respiratory rate 16/min, and temperature 36.5℃ (97.7℉).

On physical examination, the patient is pale and acrocyanotic.

There is a visible jugular vein distention and bilateral lower leg pitting edema.

The pulmonary auscultation is significant for occasional bilateral wheezes.

Cardiac auscultation is significant for a decreased S1, S3 gallop, and grade 3/6 systolic murmur best heard at the left sternal border in the 4th left intercostal space.

Abdominal percussion and palpation are suggestive of ascites.

The hepatic margin is 3 cm below the right costal margin.


She does not drink, smoke, or use illicit drugs.

She says that the accumulation of things in her kitchen and dining room makes regular use of these spaces incredibly difficult.

Her behavior started when she was in high school.

She feels anxious when she tries to discard her possessions and her husband tries to clean and organize the home.

This behavior frustrates her because most of the items she saves have little emotional or monetary value.

She now feels that her behavior is “taking over” her life.

Her temperature is 36°C (96.8°F), pulse is 90/min, respirations are 12/min, and blood pressure is 116/80 mm Hg.

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

She reports that there has been no improvement despite attending cognitive behavioral therapy sessions for the past 6 months.


She has a history of hypertension and recurrent renal stones for which she takes lisinopril and hydrochlorothiazide.

She was admitted to the hospital earlier in the year after falling in her front yard and sustaining a distal radius fracture and vertebral compression fracture.

She reports a 3-month history of gradually worsening pain in her shoulders and hips that is worse in her right hip.

Her temperature is 98.5°F (36.9°C), blood pressure is 145/85 mmHg, pulse is 100/min, and respirations are 20/min.

On exam, she is well-appearing with mild tenderness to palpation in her shoulders and hips.

She has mild pain with hip flexion and shoulder abduction.

She has full range of motion in her bilateral upper and lower extremities.


She denies recent use of any medication.

Though this has been stressful for the whole family, the daughter has been hearing voices and having intrusive thoughts ever since.

These voices have conversations about her and how she should have been the one to die and they encourage her to kill herself.

She has not been able to concentrate at work or at school.

She has no other history of medical or psychiatric illness.

Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 36.9°C (98.4°F).

On physical exam, she appears gaunt and anxious.

Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally.

The patient’s father died from lung cancer 1 week ago.


She has smoked 10 cigarettes per day for the past 15 years.

She adds that she has lost weight over the last 7 weeks, despite a good appetite, and is anxious most of the time with difficulty sleeping at night.

Her blood pressure is 100/55 mmHg, temperature is 36.5°C (97.7°F), and pulse is irregular with a rate of 140–150/min.

On physical examination she is thin, frail, and appears anxious.

Her palms are sweaty and there are fine tremors on extension of both hands.

Examination of the eyes reveals bilateral exophthalmos.

An electrocardiogram is obtained and shown in the picture.


The patient reports consuming undercooked ground beef four days prior to the onset of the symptoms.


She does not have any sick contacts, and her medical history is significant only for diabetes well-controlled on metformin.

She says that she recently returned from traveling abroad and had been administered an antibiotic during her travels for an unknown infection.

She also complains of some weakness and back/leg pain.

On presentation, her temperature is 98.6°F (37°C), blood pressure is 119/78 mmHg, pulse is 62/min, and respirations are 25/min.

An EKG is obtained showing flattening of the T wave.

After further testing, the physician prescribes a thiazide for this patient.