Physical exam is notable for subcutaneous emphysema in the clavicular area.

The patient has a Glasgow Coma Scale of 5 and is subsequently intubated.

Chest radiography demonstrates proper tube location and resolution of the pneumothorax.

The patient is transferred to the trauma intensive care unit.

On the unit, a repeat chest radiograph is notable for a recurrent pneumothorax with the chest tube in place.

Needle decompression and chest tube placement are performed, and the patient is stabilized after receiving 2 units of blood and 2 liters of fluid.

He was the front seat unrestrained driver in a head-on collision.


He has also had a nonproductive cough, fever, and malaise for the past 5 days.

His temperature is 38°C (100.4°F), pulse is 125/min, respirations are 32/min, and blood pressure is 85/45 mm Hg.

Physical examination shows distended neck veins.

Auscultation of the chest discloses bilateral basilar rales and muffled heart sounds.

An ECG shows sinus tachycardia, diffuse ST segment elevation, low voltage QRS complexes, and fluctuating R wave amplitude.


He has also had difficulties achieving an erection over the past few weeks.

Physical examination shows a temporal visual field deficit bilaterally.

An MRI of the brain shows an intrasellar mass.


She is currently at 18 weeks gestation and admits to having poor control of her type 1 diabetes before becoming pregnant.

The physical examination shows a pregnant woman with a fundal height of 20 cm (7.9 in).


She does not have urinary or fecal incontinence or any other genitourinary symptoms.

There were no complications with her pregnancies, all of which were full-term vaginal deliveries.

She is sexually active with her husband and no longer uses oral contraceptives.

She has an 11 pack-year history of smoking.

Her vital signs are within normal limits.

The physical examination is unremarkable.

The gynecologic examination reveals descent of the cervix halfway towards the introitus.

On Valsalva and standing, the cervix descents to the plane of the hymen.

The uterus is not enlarged and the ovaries are non-palpable.

Her weight is 79 kg (174 lb) and her height is 155 cm (5 ft).


She has a history of recurrent ovarian cysts.

Menses occur regularly at 28-day intervals.

She was in her aerobics class when the pain started but denies any trauma to the region.

Abdominal examination shows tenderness in the right lower quadrant with guarding.

Pelvic ultrasound shows a large simple cyst on the right ovary.

Right ovarian artery flow is detectable on Doppler, but there is no flow detected in the right ovarian vein.


Physical examination shows nontender cervical and axillary lymphadenopathy.

The spleen is palpated 5 cm below the costal margin.

Her leukocyte count is 12,000/mm3 and platelet count is 217,000/mm3.


She says she visited a physician last year who said she had a pelvic infection, but she was never treated because of insurance issues.

She also complains of scant vaginal bleeding.

She also says her period has been delayed this month.

The pulse is 124/min and the blood pressure is 100/70 mm Hg.

On examination, her abdomen is distended and tender.


He has a history of intravenous heroin use.

Physical examination shows scleral icterus.

A serum study is positive for hepatitis C RNA.

Therapy with interferon-α is initiated in combination with a second drug.


He has not been to the doctor since he was 22 years of age.

He is otherwise healthy and takes no medications.

He reports that over the past three months, he has felt tired and weak despite no changes in diet or exercise.

Physical examination is notable for conjunctival pallor.

A complete blood count reveals a hemoglobin of 9.1 g/dL and hematocrit of 31%.

A stool sample is hemoccult positive and a colonoscopy reveals a fungating hemorrhagic mass in the ascending colon.

Family history is notable for colorectal cancer in his father and paternal uncle, ovarian cancer in his paternal grandmother, and pancreatic cancer in his paternal uncle.


She is a smoker and drinks alcohol occasionally.

Past medical history is insignificant except for chronic knee pain, for which she takes over the counter painkillers.

She states that she has experienced similar pain in the past.

These episodes occur mostly after meals and often subside several hours after she finishes eating.

Due to this reason she mostly avoids eating.

She says she has lost a few pounds in the last couple of months.

Her temperature is 37°C (98.6°F), respiratory rate is 16/min, pulse is 77/min, and blood pressure is 120/89 mm Hg.

A physical abdominal exam is unremarkable, including examination of the abdomen.


One day prior she twisted her right knee and felt a “pop” while chasing after a ball.

She has since felt severe throbbing knee pain and noticed a rapid increase in swelling around her knee.

She is able to bear weight but feels “unstable” on her right leg.

On exam, anterior drawer and Lachman’s tests are positive.

The physician informs her that she has likely injured an important structure in her knee.


He was delivered at 41 weeks' gestation via Caesarian section and the amniotic fluid was meconium-stained.

Physical examination shows increased work of breathing.

Three hours later, the newborn is tachypneic and there is blue-grey discoloration of the lips, fingers, and toes.

X-rays of the abdomen and chest show no abnormalities.

Echocardiography shows elevated pulmonary artery pressure.

He is started on an inhaled medication that increases smooth muscle cGMP, and there is immediate improvement in his tachypnea and oxygenation status.


The investigator determines that inactivating this virus can prevent its spread.

One of the agents studied is a picornavirus that preferentially infects hepatocytes.


She has been trying to conceive with her husband since she stopped taking oral contraceptives 6 months ago; she was happy to tell him last week that she is pregnant.

For the past 2 months, she has had increasing breast tenderness, nausea, 3-kg (6.6-lb) weight gain, and urinary frequency.

Her temperature is 37.2°C (99°F), pulse is 100/min, and blood pressure is 110/60 mm Hg.

Physical examination shows mild, nontender abdominal enlargement.

Transvaginal ultrasonography shows no abnormalities.

She is not sure about the date of her last menstrual period.


He lives in a group home and takes no medications.

During the appointment, he frequently repeats the same information and needs to be reminded why he is at the doctor's office.

His vital signs are within normal limits.

Neurological examination shows no focal deficits.

On mental status examination, he has no long-term memory deficits and is able to count in serial sevens without error.

An MRI of the brain shows atrophy of the anterior thalami and small mamillary bodies.

He says that he is a famous poet and recently had a poem published in a national magazine.


As a member of a research team working on the Hib vaccine, he asks his senior colleague why capsular polysaccharides are conjugated to protein carriers like tetanus toxoid during vaccine development.


The concentration of glutamate in the CA1 region of the hippocampus is measured using magnetic resonance spectroscopy after Schaffer collateral fibers are electrically stimulated.


When asked about the possibility of pregnancy, she mentioned that she uses combination oral contraceptive pills (OCPs) for contraception.

She currently denies any headaches, vision changes, nausea or vomiting, or neck stiffness.

Her physical exam is within normal limits.

She is prescribed rifampin for prophylaxis with specific instructions on when to follow up if symptoms develop.

The physician suggested that her husband should use condoms for contraception as she requires antibiotic therapy.

She was told by her friend that she need to see a physician because she needs to be treated as well, even if she is not having symptoms yet.


She initially thought it was an insect bite, but it has slowly increased in size over the past weeks.

Her temperature is 36.7°C (98°F), pulse is 75/min, and blood pressure is 128/76 mm Hg.

Physical examination shows a 0.8-cm hyperpigmented papule.

When the skin lesion is squeezed, the surface retracts inwards.


Examination shows right-sided anterior cervical lymphadenopathy, bilateral conjunctival injection, erythema of the tongue and lips, and a maculopapular rash involving the hands, feet, perineum, and trunk.


He denies any substance use and states that he was just trying to have a good time.

The patient has a past medical history of psoriasis which is treated with topical steroids.

The patient is very anxious and initially is hesitant to answer questions.

The patient's responses are slightly delayed and he seems to have difficulty processing his thoughts.

The patient tells you he feels very anxious and asks for some medication to calm him down.

His temperature is 99.5°F (37.5°C), blood pressure is 120/75 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air.

On physical exam, you note an anxious young man.

HEENT exam reveals a dry mouth and conjunctival injection.

Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in his upper and lower extremities.

Cardiac exam reveals tachycardia, and pulmonary exam is within normal limits.

He was found at a local celebration acting very strangely and was reported by other patrons of the event.


He has smoked 1 pack of cigarettes daily for the past 45 years.

The patient undergoes emergency laparotomy and is found to have dusky discoloration of the hepatic colonic flexure and an adjacent segment of the transverse colon.


Higher mortality was also found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87).

Mortality was studied in relation to age, sex, diagnosis, care pattern, and registration interval.

Standardized mortality ratios (SMRs) were calculated, with the overall SMR being 1.63 (lower when compared with studies that looked at hospitalized individuals).

Men and those in younger age groups showed higher mortality rates (SMRs of 2.24 and 8.82, respectively), and mortality was also higher in the first year following registration (SMR = 2.32).

The authors concluded that the overall mortality of psychiatric patients managed in a community-based setting was higher than expected; however, it was still lower than the mortality described in other psychiatric settings.


The child’s parents died in a car accident 1 month ago.

His grandparents also brought the medications he stopped taking after his parents’ death, including multivitamins, allopurinol, and diazepam.

They say that their grandson has been using these medications for many years; however, they are unable to provide any medical history and claim that their grandson has been behaving strangely, exhibiting facial grimacing, irregular involuntary contractions, and writhing movements for the past few days.

They also note that he has had no teeth since the time they first met him at the age of 2.

An intramuscular medication is administered to calm the boy down prior to drawing blood from him for laboratory tests.

He is in a wheelchair with soft restraints because he has been violent and had been trying to hurt himself that day.


She had to undergo segmental small bowel resection several times because of intestinal obstruction and fistula formation.

She has also noticed that food has recently tasted bland to her.

Examination shows several bullous, erythematous perioral plaques.

There are two well-circumscribed circular patches of hair loss on the scalp.


Her last pregnancy was unremarkable and she gave birth to a healthy rhesus (RhD) positive girl.

Her past medical history is notable for a blood transfusion after a car accident with a complex femur fracture about 3 years ago.

Her temperature is 37.2°C (99°F), pulse is 92/min, and blood pressure is 138/82 mm Hg.

Examination shows that the uterus is at the umbilicus.

Ultrasound examination reveals normal fetal heart rate, movement, and anatomy.


He reports that he emigrated from Mexico 20 years ago and visits his hometown twice a year.

Occasionally, he experiences palpitations, especially during strenuous activities.

In addition to this, he has been experiencing difficulty in digestion and often experiences regurgitation and dysphagia.

The vital signs include: blood pressure 120/75 mm Hg, respiratory rate 19/min, and pulse 100/min.

The physical examination shows jugular vein distention along with pitting edema in the ankles.

Bilateral basilar crackles and an S3 gallop are heard on auscultation of the chest.

An electrocardiogram (ECG) shows no significant findings.


The patient is an immigrant from Spain and works as an office assistant.

She is not aware of any chronic medical conditions and takes a multivitamin daily.

She says that the pain has been slowly worsening over the past 3 days.

Otherwise, she complains of fatigue, a subjective fever, and a sunburn on her face which she attributes to gardening.

Her temperature is 98.7°F (37.1°C), blood pressure is 125/64 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Physical exam reveals bilateral redness over the maxillary prominences.


Over the weekend, he scraped his left thigh when he fell on a muddy field while playing flag football with some friends.

Since that time, he has had progressively worsening redness and pain in his left thigh.

His temperature is 39.4°C (103.0°F), heart rate is 120/min, and blood pressure is 95/60 mm Hg.

Physical exam is significant for a poorly-demarcated area of redness on his left thigh, extending to about a 10 cm radius from a small scrape.

This area is extremely tender to palpation, and palpation elicits an unusual 'crunchy' sensation.

CT scan shows free air in the soft tissue of the left leg.


He has had similar episodes in the past, but the symptoms never lasted this long.

He had a myocardial infarction 4 years ago and currently takes captopril, metoprolol, and atorvastatin.

He denies chest pain, shortness of breath, headaches, and fevers.

His pulse is irregular and cardiac auscultation reveals an irregular heart rhythm.

Laboratory reports show:
Serum glucose 88 mg/dL
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum creatinine 0.8 mg/dL
Blood urea nitrogen 10 mg/dL
Cholesterol, total 170 mg/dL
HDL-cholesterol 40 mg/dL
LDL-cholesterol 80 mg/dL
Triglycerides 170 mg/dL
Hematocrit 38%
Hemoglobin 13 g/dL
Leucocyte count 7,500/mm3
Platelet count 185,000 /mm3
Activated partial thromboplastin time (aPTT) 30 seconds
Prothrombin time (PT) 12 seconds
Cardiac enzymes Negative
An ECG shows the absence of P-waves with an irregular RR complex.

A few hours later, his symptoms subside and he is discharged with an additional anticoagulation drug.


These episodes last for approximately 25 minutes and are accompanied by his neck rotating to the right.

During the last episode, he was able to relieve the stiffness by lightly touching his jaw.

Examination shows a flexed neck rotated to the right.

The neck is rigid with limited range of motion.

His temperature is 37.3°C (99.1°F), pulse is 108/min, and blood pressure is 128/86 mm Hg.

He has received six doses of haloperidol for auditory hallucinations since his admission.


Three days later, while awaiting treatment, he presents to his physician complaining of generalized swelling and is found to have 4+ protein in his urine.

After a physical exam and a series of laboratory tests, the patient undergoes a lymph node biopsy (Image A).


The microbiologist exposes the agar plate to ciprofloxacin, which destroys all of the bacteria except for one surviving colony.


The patient was an alcoholic for several years but abruptly quit drinking 5 days ago.

The patient’s son adds that his father has been having some behavioral problems, as well, and that he was complaining about bugs crawling over his skin this morning even though there were no insects.

The patient’s temperature is 40.0°C (104.0°F), pulse is 130/min, blood pressure is 146/88 mm Hg, and respiratory rate is 24/min.

On physical examination, he is confused, restless, agitated, and lacks orientation to time, place or person.


She also complains of progressively worsening night-time vision.

She has had no fever, chills, or vomiting.

Physical examination shows dry, scaly skin on her extremities and face.


The patient is a known hypertensive for 20 years maintained on amlodipine and telmisartan.

The physician notes that he is also being given a diuretic that blocks the Na+ channels in the cortical collecting tubule.


He is extremely lethargic and is unable to provide an adequate history to his physician.

His wife noted that roughly 3 days ago, her husband mentioned that something bit him, but she cannot remember what exactly.

The vital signs include blood pressure 85/67 mm Hg, pulse rate 107/min, and respiratory rate 35/min.

Upon examination, the man is currently afebrile but is lethargic and pale.

There are some swollen bite marks on his right hand with red streaks extending to his elbow.


She is sexually active with one male partner and does not use condoms.

She also reports a tingling sensation in her legs that is exacerbated by taking a hot shower.

Physical examination shows decreased muscle strength and clonus in both lower extremities.

Patellar reflex is 4+ bilaterally and plantar reflex shows an extensor response on both sides.


They use hospital records to identify 50 people who have been diagnosed with interstitial lung disease.

They also identify a group of 50 people without interstitial lung disease who are matched in age and geographic location to those with the disease.

The participants' exposure to the chemical is assessed by surveys and home visits.


He has a history of major depressive disorder.

His wife found him on the bathroom floor with an empty bottle of medication next to him.

His pulse is 127/min and blood pressure is 90/61 mm Hg.

Examination shows dilated pupils and dry skin.

The abdomen is distended and there is dullness on percussion in the suprapubic region.

An ECG shows tachycardia and a QRS complex width of 130 ms.


This patient is otherwise healthy, and her history does not indicate any health conditions or known allergies.

After this, the patient became irritable and had difficulty breathing, suggesting an allergic reaction, which was immediately treated with epinephrine.

However, due to an unexpected bleeding event, the physician had to order a blood transfusion to replace the blood lost in the surgery.

The physician suspects an immunodeficiency disorder that was not previously diagnosed.


The mother reports that there is no history of serious illness in the family.

On arrival, he is unable to provide history.

The patient appears drowsy and dehydrated.

His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 170/100 mm Hg.

Examination shows several track marks on his forearms and large contusions over his forehead, legs, and back.

The patient is catheterized and tea-colored urine is drained.

Urinalysis shows:
Urine
pH 5.8
Specific gravity 1.045
Blood 3+
Glucose 3+
Proteins 1+
Ketones 1+
RBC none
WBC 0-1/hpf
Urine toxicology is positive for opiates and cocaine.

Intravenous fluids and sodium nitroprusside drip are started.


Her previous births have been via uncomplicated caesarean sections, but she wishes to attempt vaginal delivery this time.

Her prenatal care is notable for gestational diabetes controlled with diet and exercise.

The delivery is prolonged, but the patient's pain is controlled with epidural analgesia.

She delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.

The patient loses 500 mL of blood over the next minute, during which her blood pressure decreases from 120/80 mmHg to 90/65 mmHg.

The obstetrician manually removes the placenta, but a red mass protrudes through the vagina attached to the placenta.

Fundal massage is performed, but the placenta does not pass.


He recently moved to the area and has not been to a primary care physician for over 5 years.

He has no history of serious illness, but has intermittent bilateral knee pain for which he takes 650 mg acetaminophen every other day.

He is married with three children and is sexually active with his wife.

During the past 10 years, he has unsuccessfully tried to lose weight.

He has smoked one half pack of cigarettes daily for 15 years.

About 2–3 times per week he has 1–2 glasses of wine with dinner.

He is 160 cm (5 ft 3 in) tall and weighs 93 kg (205 lb); BMI is 36.3 kg/m2.

On abdominal examination, the liver is palpated 2 to 3 cm below the right costal margin.

Laboratory studies show:
Hemoglobin 12.6 g/dL
Platelet count 360,000/mm3
Hemoglobin A1c 6.3%
Serum
Ferritin 194 ng/mL
Total bilirubin 0.7 mg/dL
Alkaline phosphatase 52 U/L
Aspartate aminotransferase 92 U/L
Alanine aminotransferase 144 U/L
Hepatitis B surface antigen Negative
Hepatitis B core IgM antibody Negative
Hepatitis B surface antibody Positive
Hepatitis C antibody Negative
Antinuclear antibody titers 1:20 (N = < 1:60)
Smooth muscle antibody titers Negative
Anti-LKM1 antibody titers Negative
Transabdominal ultrasonography shows a mildly enlarged, diffusely hyperechoic liver.


He was unable to stand up after this collision and reported severe knee pain.

On presentation, he was found to have a mild knee effusion.

Physical exam showed that his knee could be pushed posteriorly at 90 degrees of flexion but it could not be pulled anteriorly in the same position.

During the game, he was about to kick the ball when another player collided with his leg from the front.


He notes that he stopped taking his furosemide two weeks prior, because he ran out of pills.

On exam, his oxygen saturation is 78%, his lungs have crackles throughout, and jugular venous pulsation is located at the earlobe.


He traveled to the Netherlands for 4 days a month ago.

He adds that he is fatigued all the time and has generalized weakness.

He has drenching night sweats and has had 2 episodes of non-bilious vomiting over the past few days.

His symptoms started a few days after he returned home.

Laboratory testing revealed the following:
Hemoglobin 11.2 g/dL
Hematocrit 29%
Leukocyte count 2,950/mm3
Neutrophils  59%
Bands  3%
Eosinophils 1%
Basophils  0%
Lymphocytes 31%
Monocytes  4%
Platelet count  60,000/mm3
Unconjugated bilirubin 12 mg/dL
Alanine aminotransferase 200 IU/L
Aspartate aminotransferase 355 IU/L
The peripheral blood smear showed basophilic ring- and pear-shaped structures inside many red cells and extracellular basophilic rings on Wright-Giemsa staining.

Further evaluation revealed parasitemia and a few schistocytes, poikilocytes, and merozoites in tetrad formation.


Past medical history is negative and family history is irrelevant.

About 10 days ago, she had an episode of unexplained loss of consciousness.

Clinical examination shows a diastolic murmur, which is prominent when she lies on her left side.

Jugular venous distention is present, and chest examination reveals fine crackles that do not clear with coughing.

Chest X-ray shows pulmonary congestion, and 2-dimensional echocardiogram shows a mass in the left atrium attached to the atrial septum.


His past medical history is significant for human immunodeficiency virus (HIV) infection, which was diagnosed last year.

He also experienced a head trauma 5 years ago, which has been complicated by residual seizures.

His only medication is daily phenytoin, which was restarted after he had a seizure 3 months ago.

He reports no recent fevers, night sweats, or weight loss.

On physical examination, multiple non-tender lymph nodes, averaging 2 cm in diameter, are found to be palpable in the anterior and posterior triangles of the neck bilaterally.

The remainder of the physical exam is unremarkable.

Laboratory studies show the following:
Hemoglobin 14 g/dL
Leukocyte count 8000/mm3 with a normal differential
Platelet count 250,000/mm3
Erythrocyte sedimentation rate 40 mm/h
An excisional biopsy of one of the cervical lymph nodes is performed.

The histopathologic analysis is shown in the image.


Her current medications include lisinopril, metformin, insulin, aspirin, atorvastatin, sodium docusate, and loratadine.

She has been waking up every morning with her underwear soaked in urine.

She notices that at work if she does not take regular bathroom breaks her underwear will have some urine in it.

She urinates 5 to 11 times per day but she claims it is a small volume.

Her temperature is 98.2°F (36.8°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Physical exam is notable for decreased pinprick sensation in the lower extremities and a systolic murmur along the right upper sternal border.


He mentions that he has had a ‘heart attack’ 5 years ago.

He also says that he continues to consume alcohol on a regular basis even though his doctor has advised against it.

He says that he finds himself out of breath after taking a few steps, and has to sit down and rest, in order to continue.

He also says that, at night, he has the greatest difficulty in breathing and usually uses at least 3 pillows to sleep comfortably.

He mentions a cough that appears only at night, but which is persistent enough to wake him up from sleep.

He has brought his lab reports which he had recently got done on the suggestions of his family doctor.

An electrocardiogram (ECG) and a chest X-ray are found.


He has a pulse of 195/min, and respirations of 59/min.

He is found to have a nonradiating continuous machine-like murmur at the left upper sternal border.


The girl tells you that she gets nervous around other children, as she cannot tell what they are feeling, when they are joking, or what she has in common with them.

Her teachers describe her as “easily distracted” and “easily upset by change.” When asked about her hobbies and interests, she states that “marine biology” is her only interest and gives you a 15-minute unsolicited explanation of how to identify different penguin species.

Mental status exam is notable for intense eye contact, flat affect, and concrete thought process.


Current medications include intravenous ceftriaxone and oral azithromycin.

Stool cultures grow gram-positive, anaerobic rods.

She is moved to an isolated hospital room.


She was born at 39 weeks via spontaneous vaginal delivery and is meeting all developmental milestones.

Her mother has one brother that occasionally requires blood transfusions.

They are concerned that she becomes lethargic and irritated between meals.

On physical exam, the infant is irritated.

They found that feeding her often with small servings helps.

Today, her blood pressure is 55/33 mm Hg, his heart rate is 120/min, respiratory rate is 40/min, and temperature of 37.0°C (98.6°F).

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

Her blood work shows normocytic anemia with elevated reticulocyte count and decreased haptoglobin.

Sickle cell anemia and other hemoglobinopathies are also ruled out.

Red blood cell osmotic fragility gap is normal.

The physician determined that these findings are related to an enzyme deficiency.


The family lives together in a house built in 1950.

The patient’s parents say he was doing well until a few weeks ago at which time he started to complain of daily abdominal cramps and occasional muscle pains.

His mother also noticed that he has been less active than usual.

The patient’s temperature is 36.8°C (98.2°F), blood pressure is 100/70 mm Hg, pulse is 100/min and respirations are 20/min.

Abdominal exam shows mild diffuse tenderness to palpation and normal bowel sounds.

The patient’s height, weight, and head circumference are normal.

Laboratory results are as follows:
Hemoglobin 7 g/dL
Mean corpuscular volume (MCV) 72
Lead level (capillary blood) 15 mcg/dL
Lead level (venous blood) 60 mcg/dL
Findings on a peripheral blood smear are shown in the image.

The parents deny any complaints of headaches or convulsions.


She works as a school teacher but reports that she has had to miss several days of work due to her symptoms.

She has had intermittent myalgias, arthralgias, fatigue, and skin rashes over the past 10 years that have acutely worsened over the past year.

Her temperature is 99.2°F (37.3°C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 18/min.

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

She has erythematous, raised plaques with keratotic scaling and follicular plugging on her hands.

She has been on hydroxychloroquine for several years but does not feel that it is adequately controlling her symptoms.

The physician decides to trial the patient on low-dose prednisone to better control her symptoms.

At 2 months of follow-up, she reports that her flares have subsided and she has been able to return to work full-time.


She also says that they both occasionally take sleeping pills to help them fall asleep.

The patient is unable to provide a history due to her breathing difficulties.

The patient’s roommate says that she came home and found her in this state.

Physical examination reveals an obese female, dyspneic with diminished chest wall movements.

The patient’s A-a gradient is calculated to be 10 mm Hg.


The son says she has been very difficult at home and is "losing it".

He seems very frustrated about her diminishing ability to take care of herself the way she used to and no longer thinks he can trust her watching his children.

Today, she appears withdrawn and hesitates to make eye-contact with you.

She lets her son do most of the talking.

At her last visit you noted mild cognitive impairment.


A healthy subject is asked to eat a meal at hour 0, and the pH of stomach contents and rate of stomach acid secretions are measured over the next 4 hours.


She does not have difficulties swallowing, dyspnea, or changes in voice.

Examination shows a 3-cm, hard swelling on the left side of her neck that moves with swallowing.

There is no cervical or axillary lymphadenopathy.

The remainder of the examination shows no abnormalities.

Thyroid functions tests are within the reference range.

Ultrasound of the neck shows an irregular, hypoechogenic mass in the left lobe of the thyroid.

A fine-needle aspiration biopsy is inconclusive.

The surgeon and patient agree that the most appropriate next step is a diagnostic lobectomy and isthmectomy.

Surgery shows a 3.5-cm gray tan thyroid tumor with invasion of surrounding blood vessels, including the veins.


She has no complaints and her past medical history is notable for diabetes and hypertension.

During this visit, the patient undergoes screening procedures per guidelines including a mammogram.

On the screening mammogram a spiculated, irregular mass is found on the left breast.

Further diagnostic mammography and biopsy reveal ductal adenocarcinoma of the breast in the upper outer quadrant of the left breast.


He states that ever since her uncomplicated delivery she has failed to gain weight, has had chronic diarrhea, and has had multiple bacterial and viral infections.

During the course of the workup, an absent thymic shadow is noted and a lymph node biopsy demonstrates the absence of germinal centers.


His hair is tangled and has a dry, brittle texture.

His weight, height, and head size were found to be in the lower percentile ranges on standard growth curves.

Genetic testing reveals that the patient has a connective tissue disorder caused by impaired copper absorption and transport.


There is no personal or family history of serious illness.

She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2.

Examination of the breasts shows a secondary mound formed by the nipple and areola.

Pubic hair is sparse and lightly pigmented.

Abdominal examination shows bilateral firm, nontender inguinal masses.

Pelvic examination shows a blind-ended vaginal pouch.

Ultrasonography does not show a uterus or ovaries.


He was diagnosed with high cholesterol during that episode and was prescribed medication.

He also has a 3-year history of gastritis.

He mentions that the pain started several hours ago and radiates to his left neck and shoulder.

He also mentions that he has some difficulty in breathing.

The blood pressure is 130/80 mm Hg, respirations are 18/min, and the pulse is 110/min.

The physical examination reveals no significant abnormalities.

An ECG shows slight changes in the leads.

His physician talks to him about the benefits of taking low-dose aspirin daily.


She was diagnosed with rheumatoid arthritis 3 years ago and has since been on medication to assist with her pain and to slow down disease progression.

She has no specific complaints at this visit however, she has noticed that she is more tired than usual these days.

At first, she ignored it and attributed it to stress but she feels weaker each week.

She is sometimes out of breath while walking for long distances or when she is involved in strenuous physical activity.

Her temperature is 37.0°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 102/98 mm Hg.

On examination, you notice thinning hair and mildly cool extremities with flattened nail beds.

A complete blood count and iron studies are ordered.


She has congestive heart failure, atrial fibrillation, age-related macular degeneration, type 2 diabetes mellitus, and chronic renal failure.

Current medications include warfarin, metoprolol, insulin, digoxin, ramipril, and spironolactone.

She has also had 3 episodes of vomiting.

She complains of a headache and blurry vision.

Her temperature is 36.7°C (98°F), pulse is 61/min, and blood pressure is 108/74 mm Hg.

The abdomen is soft, and there is diffuse, mild tenderness to palpation.

Three weeks ago, she returned from a cruise trip to the Bahamas.


She had similar episodes in the past, which were often precipitated by food but resolved spontaneously.

During the ultrasound exam, the patient complains of tenderness when the probe presses down on her right upper quadrant.

Her temperature is 38.3°C (101.0°F), heart rate is 96/min, blood pressure is 118/76 mm Hg, and respiratory rate is 16/min.

Physical examination reveals tenderness over the right upper quadrant that is severe enough to make her stop breathing when deeply palpated in the area.

Lab results show:
Leukocyte count 18,000/mm3 with 79% neutrophils
Aspartate aminotransferase 67 IU/L
Alanine aminotransferase 71 IU/L
Serum amylase 46 U/L
Serum Lipase 55 U/L
Serum calcium 8.9 mg/dL
Ultrasonography of the abdomen is shown below.


They recently immigrated from another country, and do not have any previous medical records.

The adolescent girl looks relatively short, but otherwise looks healthy.

She has no complaints except for mild intermittent lower abdominal pain for the past year.

On physical examination, vitals are within normal limits.

There is the presence of axillary hair, breast development, and pubic hair at Tanner stage 5.

You explain to the mother and the patient that you need to perform a complete vaginal examination, however, both of them declined the procedure and would prefer that lab test be performed.


After induction of general anesthesia, preparation of a sterile surgical field, and port placement, the surgeon needs to enter the space posterior to the stomach to access the pancreatic tumor.


His wife says that he has peptic ulcer disease and is being treated with antacids without a good response.

He is unable to give more information about the nature of his pain.

She adds that he vomited repeatedly  in the last couple of hours, his vomitus being brown/red in color.

His temperature is 98.6°F (37°C), respiratory rate is 16/min, pulse is 97/min, and blood pressure is 100/68 mm Hg.

A physical exam reveals a tense abdomen with a board like rigidity and positive rebound tenderness.


His past medical history is significant for an ischemic stroke of the right anterior cerebral artery 1 month ago, status post intravenous (IV) tissue plasminogen activator (tPA) with still some residual neurologic impairment, and long-standing gastroesophageal reflux secondary to a hiatal hernia, managed medically.

The patient reports a 15-pack-year smoking history, but no alcohol or recreational drug use.

He says that he has episodes where he feels his heart is ‘racing and pounding’, lasting 1–2 hours on average.

Initially, he says the episodes would happen 1–2 times per week but now happen almost every day.

This last episode has been constant for the past 2 days.

He denies any seizure, loss of consciousness, dizziness, chest pain, or similar symptoms in the past.

The vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/70 mm Hg, pulse 105/min, and respiratory rate 16/min.

On physical examination, muscle strength in the lower extremities is 4/5 on the left and 5/5 on the right, along with sensory loss on the left, all of which is improved from his previous exam 3 weeks ago.

There is a loss of the left half of the visual field bilaterally which is stable from the previous exam.

Cardiac examination is significant for a new-onset irregular rate and rhythm.

A noncontrast computed tomography (CT) scan shows evidence of an area of infarction in the vicinity of the right anterior cerebral artery showing normal interval change with no evidence of new hemorrhage or expansion of the area of infarction.

An electrocardiogram (ECG) is performed, which is shown in the exhibit (see image below).


They used data in the registry and surveys about peoples’ surgical history to compare the proportion of each population that had undergone a bilateral salpingo-oophorectomy.

To test this hypothesis, they reviewed a database of women who were known to be BRCA-mutation positive and divided the group into those with breast cancer and those without breast cancer.

Based on this data, they reported that women undergoing the procedure had a lower chance of developing breast cancer later in life with an odds ratio of 0.46.


The patient has had pain when urinating and difficulty starting a stream of urine for over 4 months now.

He is bothered because he has to urinate about 9 times every day, including several times when he wakes up at night.

A digital rectal examination revealed multiple hard nodules in the prostate gland.

A CT scan shows a nodule in the right lung that measures 3 cm.

An ultrasound scan of his urinary bladder and prostate shows residual urine of > 200 mL and heterogeneous findings of the prostate gland.

Follow-up 9 months later shows his prostate cancer is well controlled with goserelin.

Biopsy reveals grade 2 prostate adenocarcinoma.


The patient admitted to having trouble sleeping from a young age but became more aware of how much this is affecting his health after attending a sleep conference earlier this year.

He has no past medical or psychiatric condition and is not known to use any recreational drugs.

He is worried that his health has suffered because of this, and he is also concerned that he will not be able to pay his bills if he were to get sick.

The patient arrived for his appointment an hour early because he was afraid he might miss it.

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

Physical examination reveals an irritable middle age man who is tense and somewhat inattentive during the interview.


She is at the 30th percentile for height and 15th percentile for weight.

Echocardiography shows a defect in the membranous portion of the interventricular septum and a moderately decreased left ventricular ejection fraction.


He has bronchial asthma and hypertension.

He has smoked one pack of cigarettes daily for 41 years.

Current medications include an albuterol inhaler and enalapril.

His temperature is 37.6°C (99.7°F), pulse is 88/min, respirations are 20/min, and blood pressure is 136/89 mm Hg.

Three weeks ago, he had a fever and a cough for 6 days after he returned from a trip to Southeast Asia.

He has had a 4-kg (9-lb) weight loss over the past 3 months.

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

Cardiac examination shows no abnormalities.


He reports that he has a 15-year history of hypertension treated with hydrochlorothiazide.

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

Neurological examination shows decreased sensation to light pinprick and temperature on the right side of the face and body.

Motor strength is 5/5 and deep tendon reflexes are 2+ bilaterally.


The patient’s mother denies any other symptoms and says he is otherwise healthy.

Physical examination shows multiple petechiae and bruising on the torso and extremities bilaterally.

The remainder of the physical exam is unremarkable.


There is decreased sensation to pinprick on the thumb, index finger, middle finger, and radial half of the ring finger of the left hand.

The tingling pain is aggravated by tapping over the swelling.

Physical examination shows a transilluminating, rubbery, fixed, non-tender mass over the lateral volar aspect of the left wrist.


The swelling started several weeks ago but is not always present.

Physical examination shows an 8-cm, soft, cystic nontender right-sided scrotal mass that transilluminates.

The mass does not increase in size on coughing and it is possible to palpate normal tissue above the mass.

There are no bowel sounds in the mass, and it does not reduce when the patient is in a supine position.

Examination of the testis shows no abnormalities.


While evaluating him per your institution's trauma guidelines, you discover pain upon palpation of his right lower extremity which is much larger than his left counterpart.

The patient admits to decreased sensation over his right lower extremity and cannot move his leg.

There are no palpable dorsalis pedis or posterior tibial pulses on this extremity, and it is colder and paler in comparison to his left side.

Measured compartment pressure of his distal right leg is 35 mm Hg.


He has not received any childhood vaccinations because his parents believe that they are dangerous.


He is visibly intoxicated, and hospital records indicate a long history of alcohol substance abuse treated with antabuse (disulfiram).

Vital signs include T 98.4, HR 89, BP 154/92, and RR 20.

EGD is notable for mild esophagitis, and a longitudinal esophageal tear at the gastroesophageal junction, with no active bleeding.


He is asked by the surgeon to disinfect the patient’s skin with a chlorhexidine-isopropyl alcohol solution before the procedure.

Recent studies have shown that this solution substantially reduces the risk of surgical site infections compared with a povidone-iodine preparation without alcohol in clean-contaminated surgery.


Relevant social history includes participation in school wrestling.

Other than the pruritic rash, a review of systems is negative.

On physical examination, there is an erythematous, well-demarcated patch on his left thigh, over his pubic region, and throughout the perineum.


She was born at 38 weeks gestation to a 25-year-old woman via an uncomplicated spontaneous vaginal delivery.

The mother reports that prenatal screening revealed no developmental abnormalities and that the baby has been gaining weight, feeding, stooling, and urinating appropriately.

The mother has a history of polycystic ovarian syndrome and is curious about the development of her daughter's ovaries.

Physical exam of the infant is unremarkable.


His father had gallstones, for which he underwent a cholecystectomy at the age of 26 years.

Examination shows pallor of the mucosal membranes, mild scleral icterus, a swollen, red tongue, and several mouth ulcers.

There is darkening of the skin over the dorsal surfaces of the fingers, toes, and creases of the palms and soles.

One year ago, a peripheral blood smear performed during workup of fatigue revealed erythrocytes without central pallor.

His spleen is enlarged and palpable 3 cm below the left costal margin.

Laboratory studies show a hemoglobin concentration of 9.1 gm/dL, mean corpuscular volume of 104 μm3, and a reticulocyte count of 9%.


This further increased glucose-dependent insulin production.


His asthmatic symptoms are usually well controlled with regular high-dose inhaled triamcinolone, but over the last week or so he has developed a nocturnal cough and mild wheezing despite good compliance with controller medications.

A review of several spirometry reports suggest of bronchial asthma with a partial irreversible airway obstruction.


His temperature is 38°C (100.4°F) and respirations are 32/min.

Crackles are heard over the right upper and the entire left lung fields.

Sputum culture confirms infection with Streptococcus pneumoniae.

Despite appropriate therapy, the patient dies.

A photomicrograph of a section of the lung obtained during the autopsy is shown.


The patient was born prematurely at 36 weeks estimated gestational age via vacuum-assisted vaginal delivery.

Tearfully, the patient’s mother describes witnessing her child fall from the changing table.

Her vital signs include: blood pressure of 94/60 mm Hg, pulse 200/min, and respiratory rate 70/min.

Physical examination reveals a subconjunctival hemorrhage in the left eye and multiple bruises on the chest and back.


The measured outcomes include progression to pyelonephritis, positive urine culture on day 7 after initiation of treatment, and likelihood of re-presenting to the emergency room for another UTI within 90 days.

Of 200 consecutive women who present to the emergency room for such a UTI, 50 are randomized to each of the following: nitrofurantoin 100 mg every 12 hours for 5 days, nitrofurantoin 100 mg every 12 hours for 7 days, cefpodoxime 100 mg every 12 hours for 5 days, and cefpodoxime 100 mg every 12 hours for 7 days.


Specifically, he reports that he has been experiencing pain and swelling of the anterior portion of his neck near the midline.

Otherwise, he says that he has been getting tired easily and feels cold often.

Physical exam reveals a painful diffusely enlarged thyroid gland with many small nodules.

A biopsy is obtained showing diffuse cellular hyperplasia with areas of focal colloid hyperplasia.

Given these findings, the patient is started on appropriate therapy, and the neck mass becomes smaller over time.


He admits to using illicit intravenous drugs in the past.

He does not have any immunization records because he moved from Africa to the US at the age of 18.

He is also worried about his skin looking yellow.

He does not have any other complaints and denies fever and headache.

His vital signs are as follows: heart rate 72/min, respiratory rate 14/min, temperature 37.9°C (100.2°F), and blood pressure 100/74 mm Hg.

Physical examination is not significant except for mild diffuse abdominal tenderness.

His blood is drawn for routine tests and shows an alanine aminotransferase level (ALT) of 2,000 IU/L.


Past medical history is positive for systemic lupus erythematosus.

She also has a history of one spontaneous abortion at 12 weeks gestation.

She recently had an unfortunate sporting incident resulting in large bruises along both legs and lower thighs.

An X-ray after the event was negative for fracture.

Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 119/80 mm Hg, and temperature is 37.0°C (98.6°F).

On physical examination, her left leg appears pink and slightly swollen.

A Doppler ultrasound reveals a thrombus in the left popliteal vein.


She states that she feels as though her “lungs are falling apart,” noting that her lung function has been steadily deteriorating.

She further states that she has visited a number of other physicians who prescribed several different types of inhalers, but she feels that they have not helped her control her asthma exacerbations.

She has experienced 4 episodes of pneumonia in the last 3 years and often suffers from “random” bouts of excessive coughing and wheezing.

When asked if her coughing episodes produce sputum, she states, “Yes, the stuff is greenish with specks of red in it.” She also states that her coughing and wheezing episodes are associated with fever, malaise, and occasional expectoration of brown mucous plugs.

The vital signs include: blood pressure 122/70 mm Hg, pulse 66/min, respiratory rate 26/min, and temperature 37.0°C (98.6°F).

On physical exam, the patient appears frail-looking and in moderate respiratory distress.

Auscultation reveals inspiratory crackles in the right lung base and coarse breath sounds in the bilateral upper lung lobes.

Chest radiograph, as shown below, reveals atelectasis in the right lung base.

There are also branched radiodensities that the radiologist notes as being “glove-finger shadows” (noted by the arrow in the image).

Serum immunoglobulin E (IgE) levels are elevated.


The past medical history is unobtainable due to a language barrier (the patient recently immigrated from abroad), but his wife says her husband had a motor vehicle accident when he was a teenager that required surgery.

There is no history of headaches, vomiting, or loss of consciousness.

He is transferred to the ICU after a few hours in the ED because of dyspnea, cyanosis, and near-collapse.

There are no signs of a meningeal infection.

The Blood pressure was 70/30 mm Hg at the time of transfer.

A chest X-ray at the time of admission showed interstitial infiltrates without homogeneous opacities.

The initial laboratory results reveal metabolic acidosis, leukopenia with a count of 2,000/mm³, thrombocytopenia (15,000/mm³), and a coagulation profile suggestive of disseminated coagulation.

A gram stain from an autopsy specimen of the lungs revealed gram-positive, lancet-shaped diplococci occurring singly or in chains.

Despite ventilatory support, administration of intravenous fluids, antibiotics, and vasopressor agents, the patient died the next day.

A peripheral smear was performed and is shown below.


She had a similar episode of facial swelling after a bicycle accident 1 year ago, which resolved within 48 hours without treatment.

The patient also manifests symptoms of redness and swelling of the face and lips without pruritus.

Her symptoms began following a tooth extraction earlier in the morning.

Examination shows a nontender facial edema, erythema of the oral mucosa, and an enlarged tongue.

The abdomen is soft, and there is tenderness to palpation over the lower quadrants.

An abdominal ultrasound shows segmental thickening of the intestinal wall.


To evaluate his pulmonary function, lung and thoracic compliance are measured at different system pressures.

A graph of the relationship between his lung volume and transpulmonary pressure is shown.


His serum glucose concentration is 88 mg/dL and his serum ammonia concentration is 850 μmol/L (N<90).

Urinalysis shows an increased orotic acid to creatinine ratio.


Menses occur at irregular 30- to 45-day intervals; her last menstrual period was 5 weeks ago.

Her temperature is 38°C (100.4°F), heart rate is 102/min, and blood pressure is 128/84 mm Hg.

Physical examination shows hyperreflexia.

Ultrasonography shows a 6-cm hypoechoic adnexal mass.


The patient has smoked a pack of cigarettes daily for the last 40 years and binge drinks alcohol after work and on the weekends.

He underwent an appendectomy when he was 14 years old.

Neither of his parents had any significant medical history.

His temperature is 37.7°C (100°F), blood pressure is 135/75 mm Hg, pulse is 102/min, respiratory rate is 20/min, and BMI is 25 kg/m2.

The pain is so severe that it woke him up.

On examination, his right first metatarsophalangeal joint is very tender, swollen, warm, and red in color.

Range of motion cannot be assessed due to extreme tenderness.

Laboratory test
Complete blood count:
Hemoglobin 11.5 g/dL
Leukocytes 16,000/mm3
Platelets 150,000/mm3
ESR 50 mm/hr
Synovial fluid is aspirated from the joint.

The findings are:
Appearance Cloudy, dense yellow
WBC 30,000 cells/µL
Culture Negative
Needle-shaped birefringent crystals are observed in the joint aspirate.


He was recently admitted to the hospital with fever, shortness of breath, and cough, and was found to have Pneumocystic jirovecii pneumonia and a new diagnosis of HIV.

His CD4 count is 175, viral load is pending.

As part of routine laboratory studies given his new diagnosis, an RPR was found to be positive with a titer of 1:64, and this is confirmed with a positive FTA-ABS.

His neurological examination is normal, and he has no symptoms.

He is unsure when or how he acquired HIV or syphilis.


He has not noticed any major changes in his health over the last year but says that unfortunately, he stopped exercising because he has been stressed by work.

His past medical history is significant for obesity, hypertension, diabetes, hypercholesterolemia, and hyperlipidemia.

He is taking a number of drugs but does not remember what they are.

A panel of metabolic and lipid tests are ordered and show worsening of his metabolic parameters.

Based on these findings, his physician prescribes a drug that leads to a large decrease in triglycerides with a much smaller increase in high-density lipoproteins and decrease in low-density lipoproteins.


She wishes to become pregnant within the next several months.

A thorough history reveals that the patient suffers from phenylketonuria (PKU).

She recalls being instructed by prior physicians to follow a diet that avoids certain foods; however, she admits to not being complaint with these recommendations.

Laboratory testing reveals a plasma phenylalanine level of 20.2 mg/dL (normal range <2 mg/dL).


He is having difficulty seeing properly and is extremely worried about losing his vision.

Further history reveals that he has had progressive lower back pain for over 2 months now.

The pain is usually at its worst in the morning, but it remains throughout the day.

It gets better with movement, however, so he tends to do some light exercises every day.

He also has heel pain and feels significant pressure while walking.

Laboratory analysis reveals increased ESR and CRP serum levels.


The remainder of her history is unremarkable and she takes no regular medications.

There is no history of smoking or drug use, however, she does consume 5 alcoholic drinks per week.

While usually occurring late at night, she has also had similar pains during the day at random times, most recently while sitting at her desk in her office and at other times while doing the dishes at home.

The pain lasts 10–15 minutes and resolves spontaneously.

She is unable to identify any common preceding event to pain onset.

Examination reveals: pulse 70/min, respirations 16/min, and blood pressure 120/70 mm Hg.


His vital signs are as follows: T 39.1 C, HR 82, BP 122/76, RR 14, and SpO2 99%.

Physical examination is significant for splenomegaly, tonsillar exudate, and posterior auricular lymphadenopathy.

Laboratory work-up shows an elevated lymphocyte count, atypical lymphocytes on a peripheral blood smear, and a positive heterophile antibody screen.


He drinks 9 glasses of water per day and takes his medication regularly.

He has hypertension, for which he has been taking hydrochlorothiazide for the past 6 months.

He is 168 cm (5 ft 6 in) tall and weighs 90 kg (198 lb); BMI is 32 kg/m2.

Over the past 2 days, he has also been feeling weak and tired.

When standing up after sitting for a while, he feels dizzy.

He says he has to go to the bathroom more often than usual, and that he is urinating “a normal amount” each time.

His temperature is 36.5°C (97.7°F), blood pressure is 106/54 mm Hg, and pulse is 92/min.

Physical examination shows whitening of the tongue.

Skin that is pinched on the back of the hand retracts after 5 seconds.

On mental status examination, his speech is slowed; he is oriented to person, place, and time.


Her only complaint is difficulty losing weight.

In addition to a standard physical exam, the physician orders a glucose tolerance test.

The woman's fasting blood glucose level is 120 mg/dL and two-hour post 75g glucose load blood glucose level is 190 mg/dL.

The physician informs the patient that she is "pre-diabetic" or at risk of developing diabetes and recommends lifestyle modification with follow-up in 6 months.


On further questioning, he admits having hematuria.

A chest X-ray reveals bilateral focal pulmonary consolidation.

Urinalysis shows RBC casts and 400 mL of urine is excreted in 24 hours.


He is a veteran who returned from a deployment to Afghanistan 2 years ago.

He is worried he may lose his job due to poor performance.

He feels constantly tired but attributes his fatigue to waking up early most mornings and being unable to fall back asleep.

His wife has noticed that he has been speaking more slowly than usual and his appetite has decreased.

He used to enjoy dance classes with her but has not been as interested in this recently.


She first started seeing double after a long day at her work as a radiation technologist.

She has a history of type I diabetes mellitus and her most recent hemoglobin A1c was 7.4%.

Her family history is notable for Sjogren’s syndrome in her mother and hypertension, hyperlipidemia, and carotid dissection in her father.

Since then, her vision has appeared to worsen in the evenings.

She has also felt worsening fatigue despite no change in her work hours or sleep habits.

Her temperature is 98.9°F (37.2°C), blood pressure is 105/70 mmHg, pulse is 75/min, and respirations are 16/min.

On examination, her pupils are equally round and reactive to light.

Mild ptosis is noted bilaterally but worse on the left.

A visual acuity test reveals no abnormalities.


Six months prior, she had a cerebral stroke with left hemiparesis, from which she has almost completely recovered with physiotherapy.

She has a history of hypertension and atrial fibrillation (AF).

She takes metoprolol, amlodipine, warfarin, and atorvastatin.

She has a minor limp and weakness in her left arm and leg.

Blood pressure is 125/70 mm Hg, pulse is 75/min with an irregular rhythm.

Heart exam shows no abnormalities other than irregular beats.

She has no significant ischemic, valvular, or structural heart disease.


He is found to be delayed in reaching normal childhood cognitive and social milestones, which is consistent with observations at previous check-ups.

Physically, he is also found to be significantly overweight with hypogonadism.

Notably, the boy was limp when he was born and did not have a normal motor response to stimuli.

Elevated levels of a gastrointestinal hormone are associated with the cause of this patient's weight gain.


A study from Brazil demonstrated 76.7% accuracy, 67.9% sensitivity, 84.4% specificity, 79.1% positive predictive value, and 75% negative predictive value when using 5-mm skin elevation as a threshold, or cut-off, point for the screening test (following intradermal injection).

One of the key strategies for the detection of TB is the use of tuberculin skin testing as a globally pertinent screening method, due to its low cost and technical simplicity.


He admits to smoking cigarettes since his early teenage years.

Moderate icterus is evident during physical examination, the abdomen is distended and dull to percussion, and there is periumbilical tenderness.

While in the county hospital, he did not develop fever, and his vital signs were stable for the 48 hours he spent at there.

Initial laboratory tests are given below:
Total bilirubin 7 mg/dL
Direct bilirubin 6.4 mg/dL
AST 100
ALT 40
Alkaline phosphatase 480 IU/L
Glucose 160 mg/dL
The patient’s medical history is relevant for hypertension and diabetes mellitus.


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

She has been breastfeeding exclusively and feels that he has been feeding well.


She had an uncomplicated vaginal delivery 10 years ago and a cesarean section 4 years ago.

She drinks at least 6 glasses of water a day but may drink more on days she goes for a long run.

She also has a large coffee in the morning and another coffee mid-day if she “needs to focus.” The patient denies tobacco, alcohol, and other recreational drug use.

Pelvic examination and speculum examination are unremarkable.

At first, she would notice leakage only during athletic exercise, but now the incontinence occurs even when she laughs or coughs.

The patient states that she goes to the bathroom more frequently to try to prevent “wetting myself.” She wakes up once a night to urinate.

The patient has bipolar syndrome and takes lithium.

When that patient is asked to Valsalva, leakage of urine is observed.

A urinalysis, including specific gravity, is within normal limits.

A beta-human chorionic gonadotropin is negative.


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

She was at a party when she suddenly fell to the floor.

Her friends state that she was not responsive and was acting oddly.

After the episode, the patient seemed confused and had no memory of the event.

Physical exam reveals a girl who seems confused and responds to questions slowly.

Her temperature is 98.6°F (37.0°C), blood pressure is 117/69 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 99% on room air.

Her gait is stable, and she demonstrates 5/5 strength in her upper and lower extremities.


The past medical history is unremarkable.

Her symptoms began following a company picnic a few days ago.

Initially, she was unable to tolerate any solids or liquids by mouth, but now has been able to drink sips of water.

She had a mild headache, which was relieved with acetaminophen.

The blood pressure is 120/60 mm Hg and the heart rate is 60/min.

On examination, the mucous membranes are dry and the eyes are slightly sunken.


The patient is breast fed and takes no medications.

His mother notes that the symptoms started shortly after birth and have been progressively worsening.

His labs are within normal limits with the exception of his liver function tests as follows:

ALT: 8 U/ L
AST: 10 U/L
Alkaline phosphatase: 50 U/L
Albumin: 3.7 g/dL
Total protein: 6.7 g/dL
Bilirubin, total: 29.4 mg/dL
Bilirubin, unconjugated: 29.2 mg/dL
Bilirubin, conjugated: 0.2 mg/dL

The boy is taken immediately for treatment.


He has Crohn disease and underwent a small bowel resection 5 years ago.

He currently takes mesalamine and a multivitamin.

He reports alternating episodes of decreased urine output followed by a temporary increase in urine output for the past 2 days.

His vital signs are within normal limits.

Examination shows right costovertebral angle tenderness.

Urinalysis shows 70 RBC/hpf and envelope-shaped crystals.

A CT scan of the abdomen shows a 6-mm stone in the proximal right ureter and two 4-mm stones in the left kidney.

In the past year, he has had two urinary tract infections.


His mother says that he has had dry, scaly skin since he was 6 months old.

She says it is worse in winter and better in summer.

There is no associated itching, redness, or discharge.

Examination reveals generalized fine scales with coarse skin all over the body, except in the skin creases of the neck and in the cubital and popliteal fossae (see image).

There are multiple papular elevations at the base of hair follicles and darkening of the palmar and plantar creases.


Her current pregnancy was achieved by means of in vitro fertilization due to azoospermia in her partner.

Prenatal course has been uncomplicated with regular prenatal visits.

Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate; her other child was delivered vaginally.

She has had abnormal Pap smears due to HPV in the past.

Speculum examination shows a tender, bruised cervix, with a closed cervical os.

Her pulse is 82/min, respirations are 18/min, and blood pressure is 134/76 mm Hg.

The abdomen is nontender, the uterus is consistent with 24 weeks' gestation, and the fetus is in a cephalic presentation.

Fetal heart rate is 166/min and CTG shows a reassuring fetal heart rate tracing.

Ultrasound shows a uniformly echogenic placenta located at the fundal end of the posterior uterine wall.

After a period of having avoided sexual intercourse during her early pregnancy, she resumed sexual activity with her partner at week 22 of gestation.

There are traces of blood on the vulva and the introitus.


He has diabetes and takes insulin but stopped taking it when he began to feel poorly two days ago.

His parents say that the boy was doing well until two days ago when he told them that he was feeling unwell.

He appears severely dehydrated, showing signs of fatigue, and poor skin turgor.

His temperature is 37°C (98.6°F), respirations are shallow and rapid with a rate of 33/min, pulse is 107/min, and blood pressure is 101/68 mm Hg.

Blood is drawn for labs and the results are given below:
Serum:
  pH: 7.21
  pCO2: 32 mm HG
  HCO 3-: 15.2 mEq/L
Sodium: 122 mEq/L
Potassium: 5.8 mEq/L
Urinalysis is positive for ketone bodies.


The patient’s past medical history is significant for a heart murmur that is being followed by his outpatient cardiologist.

The patient works as a carpenter and reports being monogamous with his wife.

He denies any history of intravenous drug use or recent travel.

He reports that one hour ago he was climbing the stairs in his home when he suddenly developed excruciating chest pain.

He describes the pain as ripping and radiating to the back.

In the emergency department, the patient’s temperature is 99.4°F (37.4°C), blood pressure is 94/56 mmHg, pulse is 121/min, and respirations are 14/min.

On physical exam, the patient appears to be in moderate distress and is clutching his chest.

His breath sounds are equal and full bilaterally and has weak distal pulses.


Three times now in the last month the child has begun screaming and crying in the middle of the night.

When the parents rush to the child's room, they find her crying inconsolably.

They try to ask her what is wrong, but she does not respond and persists crying for approximately 20 minutes, after which she goes back to sleeping comfortably.

Upon awaking the following morning, she has no recollection of the night's events.


This morning, she started a course of ceftriaxone for treatment of pyelonephritis.


She underwent a laparoscopic cholecystectomy 4 years ago.

She lives with her daughter and reports frequent fights with her at home.

Her current medications include sertraline, insulin, enalapril, sodium bicarbonate, and sevelamer.

The pain is 8 out of 10 in intensity and radiates down the legs.

Her temperature is 37.3°C (99.1°F), pulse is 102/min, respirations are 15/min, and blood pressure is 132/94 mm Hg.

There is severe tenderness on palpation over the L2 vertebra; range of motion is limited.

Neurologic examination shows no focal findings.

Laboratory studies show:
Hemoglobin 10.1 g/dL
Leukocyte count 8,700/mm3
Platelet count 130,000/mm3
Serum
Na+ 136 mEq/L
Cl- 101 mEq/L
K+ 5.1 mEq/L
Calcium 8.2 mg/dL
Urea nitrogen 33 mg/dL
Glucose 190 mg/dL
Creatinine 3.8 mg/dL
An x-ray of the spine shows a wedge compression fracture of the L2 vertebra.


Three months ago, he was diagnosed with hypertension and started on a new medication.

Physical examination shows 2+ edema in both lower extremities.

Laboratory studies are within the reference ranges.


A subset of normal human cells with an elevated intracellular concentration of bisphosphoglycerate mutase is harvested and isolated.


On arrival, she is stable and says that she hit a car at an intersection that "came out of nowhere".

She states that she had similar close encounters with other cars these past few weeks but was able to avoid collisions with those.

She has also had intermittent headaches over the last month and has noticed that her shirts have been getting wet unexpectedly.

Blood tests reveal an abnormal elevation of a circulating substance.


Over-the-counter pain medications have failed to reduce her symptoms.

An MRI of the brain shows isolated dilation of the left lateral ventricle.


The girl was born at 39 weeks gestation via spontaneous vaginal delivery at home with minimal prenatal or postnatal care.

This is her first visit to a physician of any type.

They are concerned about lethargy and easy bruising.

Her mother reports that she has been eating less for the past few days.

She normally nurses four-five times a day, but ate less yesterday and this morning.

The daughter’s pulse is 97/min, respirations are 35/min, temperature is 35.8°C (96.4°F), and blood pressure is 71/46 mm Hg.

Physical examination shows diffuse petechiae and bruising.

The family is carefully questioned and child abuse is ruled out.


He has not received any routine childhood vaccinations.

He has also had a fever and sore throat for 4 days.

Examination shows a flushed face except around his mouth.

A diffuse, papular, erythematous rash that blanches with pressure is seen over the trunk.

Pharyngeal erythema and a red beefy tongue are noted.

His leukocyte count is 11,200/mm3 (75% segmented neutrophils, 22% lymphocytes).


He has a past medical history of asthma, and his current medications include albuterol and fluticasone.

The patient states that his symptoms started last night and have persisted to this morning.

His temperature is 102°F (38.9°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.

On physical exam, the patient seems uncomfortable.

He requests that the lights in the room stay turned off during the physical exam.

The patient's cardiac exam demonstrates a normal rate and rhythm, and his pulmonary exam is clear to auscultation bilaterally.

Musculoskeletal exam reveals diminished mobility of the neck in all four directions, with flexion of the neck causing the patient discomfort.

Lumbar puncture is performed and results are seen below.


He has had asthma for more than 20 years.

His only medication is a high-dose combination salmeterol/fluticasone inhaler.

His temperature is 37.1°C (98.8°F), pulse is 74/min, respirations are 14/min, and blood pressure is 125/65 mm Hg.

Indirect mirror examination of the posterior oropharynx, larynx, and hypopharynx shows no abnormalities.

A photograph of his oral mucosa is shown.


She has multiple sclerosis and a chronic indwelling bladder catheter for neurogenic bladder dysfunction.

Physical examination shows marked tenderness in the right costovertebral area.

Urine cultures grow a non-lactose fermenting, oxidase-positive, gram-negative rod.

One week ago, she was discharged from the hospital after treatment for a multiple sclerosis flare.


He reports that the fever lasts for 7 to 10 days, then subsides completely for about a week before returning again.

Physical examination shows nontender cervical and supraclavicular lymphadenopathy.

An x-ray of the chest shows bilateral mediastinal masses.

Resection of a cervical lymph node is performed.

A photomicrograph of the resected specimen is shown.


There is no personal history of serious illness.

During this period, she has had increased urinary frequency and fatigue.

She also reports two episodes of non-bloody vomiting.

Her last menstrual period was 6 weeks ago.

Physical examination shows bilateral breast tenderness.

The remainder of the examination shows no abnormalities.


He has Down syndrome.
His vaccinations are up-to-date.

Vomiting occurs almost immediately after most feeds.

Each time, he becomes irritable while feeding and refuses to finish the bottle.

He appears agitated and cries during the examination.

He was born at 37 weeks' gestation and weighed 3300 g (7 lb 4 oz); he currently weighs 4000 g (8 lb 13 oz).

His temperature is 37.2°C (99°F), pulse is 156/min, respirations are 32/min, and blood pressure is 100/49 mm Hg.

Examination shows upward slanting of the eyelids, a broad and flat nasal bridge, and a single transverse palmar crease on both hands.

A 2.5-cm (1-inch) epigastric mass is palpated.

Cardiac examination shows no abnormalities.

Arterial blood gas analysis is within normal limits.


She is known to have an allergy to cephalosporins.

She was born at 39 weeks gestation via spontaneous vaginal delivery.

She has met all of her developmental milestones and most of her vaccines.

Her vital signs are as follows: blood pressure 105/60 mm Hg, heart rate 98/min, respiratory rate 18/min, and temperature 37.0°C (98.6°F).

Her mother describes photophobia, bilateral lacrimation, eye itching, and eyelid swelling for the last week.

The physical examination is mostly normal except for her eye exam as presented in the image below.


His blood pressure is 110/65 mm Hg, temperature is 39.5°C (103.1°F), pulse is 98/min, and respiratory rate is 14/min.

Physical examination including examination of the central venous catheter site shows no source of infection.

Broad-spectrum antibiotics are initiated.

He was initially diagnosed with t(9;22)-positive acute T cell lymphoblastic leukemia following workup for fatigue and pancytopenia.


He has smoked one pack of cigarettes daily for 20 years and drinks four beers daily.

The patient is a known user of intravenous heroin.

There are several track marks on both forearms.

He also reports headaches and numbness in both hands.

Over the past 4 months, he has had intermittent lower back pain after waking up.

He also has recurrent episodes of gout in the metatarsophalangeal joint of his right big toe.

Examination of the neck shows warmth, erythema, and limited range of motion.

Gentle palpation over the midcervical spinal processes causes severe pain.

He appears acutely ill. His temperature is 39°C (102.2°F), pulse is 110/min, and blood pressure is 140/85 mm Hg.

Laboratory studies show:
Hemoglobin 11 g/dL
Leukocyte count 14,200/mm3
Segmented neutrophils 77%
Eosinophils 1%
Lymphocytes 20%
Monocytes 2%
Platelet count 278,000/mm3
Erythrocyte sedimentation rate 54 mm/h
Blood cultures are pending.

An x-ray of the cervical spine shows no abnormalities.

An MRI of the spine shows signs of inflammation.


She was born at 39 weeks gestation via spontaneous vaginal delivery and is breastfed exclusively.

Over the past week, she has been projectile vomiting after most feedings.

Initially, the vomiting would occur just once or twice a day, but now it occurs after every feed.

However, her appetite hasn’t decreased, and she seeks milk right after each episode of vomiting.

On physical exam, the vital signs include: temperature 37.5°C (99.5°F), blood pressure 85/55 mm Hg, respiratory rate 28/min, and heart rate 150/min.

On examination, she appears to be mildly dehydrated, listless, and irritable.

Her abdomen is soft and nontender with a palpable olive-shaped mass in the epigastric region.


The girl has been HIV-positive since birth and is being treated with HAART.

She has also developed shallow erythematous ulcers inside of her mouth.

There is no history of chills, rigors, or headaches.

On general examination, the girl appears ill. Diffuse inspiratory crackles are heard on chest auscultation with normal heart sounds.

No lymphadenopathy or hepatosplenomegaly is noted on physical examination.

A blood sample is drawn, which shows a CD4 count of 100/mm3 and a viral load of 25,050/mL.


The patient lives in a nursing home and has Alzheimer dementia at baseline.

His nurse noticed that he was more confused than usual and was somnolent for the past 12 hours.

The patient’s nurse also noticed that he was soiling his diapers more frequently with copious amounts of urine.

The patient has lost 15 pounds since his last physician appointment 3 weeks ago.

Laboratory values are ordered as seen below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 12.2 mg/dL
PTH: 8 pg/mL

The patient is referred to another physician for a more thorough workup including laboratory work and CT imaging.


For the 3 months that she had her urinary symptoms, she avoided places like long lines and long train rides.

Even after being successfully treated for her urinary condition, she continues to show restricted social interaction.

The patient is being treated for urge incontinence but is being referred for psychiatric evaluation to help with some of her old avoidance behavior.


He does not smoke cigarettes or consume alcohol, and past medical history is insignificant.

Blood pressure is 115/75 mmHG and heart rate is 125/min.

After initial treatment with IV digoxin the patient's heart rate drops to 85/min and remains irregular.


The incidence of hepatitis A infection was found to be 25%, and the total number of deaths recorded among the incident cases was 5 individuals.

A case series investigation with prospective and retrospective follow-up found that 500 individuals dined at the restaurant during the week of study.


The EMT personnel found the patient alert with anterograde amnesia for the several minutes preceding the accident.

On physical examination, the patient is drowsy but follows commands.

While the patient is being transferred to observation, his level of consciousness acutely declines.

Pupils are equal, round, and reactive to light.

The remainder of the initial examination is unremarkable.

Repeat vital signs are significant for a blood pressure of 190/110 mm Hg.

Ophthalmic examination now shows a fixed and dilated left pupil with no pupillary light reflex.

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

He was driving a motorcycle and collided with a bus.


He has type 1 diabetes mellitus, for which he takes insulin.

He complains of frequent episodes of waking up in the middle of his sleep.

When he wakes up, he feels excessive sweating, hand tremors, and weakness.

His morning blood glucose is high on repeated measurement.


To ensure that all instruments are free of the pathogenic organism, he uses a disinfectant that oxidizes and denatures proteins.


She has had type 1 diabetes mellitus for 5 years and is on insulin.

Her temperature is 37.1°C (98.7°F), blood pressure is 120/60 mm Hg, and pulse is 90/minute.

Her random blood glucose is 220 mg/dL and HbA1C is 8.5%.

She also has mitral stenosis, for which she has been advised to undergo a balloon valvotomy.

She wants to discuss possible complications concerning her pregnancy.


The pain is present throughout the day, and even at night when he lies down.

He also complains of difficulty walking upstairs and says he recently started to wear adult diapers because he seems to have difficulty controlling his bowel movements.

His vital signs are within normal limits.

The neurological examination revealed bilateral lower limb weakness, diminished temperature sensation, and decreased vibratory sense.

The rectal examination revealed a hard nodular mass and a weak rectal sphincter tone.


He reports that he goes to bed around 9 p.m. and wakes up for class at 8 a.m..

He first noticed the daytime sleepiness about a year ago but reports that it significantly worsened once he started college.

He naps between classes for a total of 4 hours during the day.

Despite this, he wakes up feeling exhausted.

He easily falls asleep during class and while studying.

This has started to affect both his academics and his social life.

On weekends, he can sleep up to 20 hours a day.

He reports 2 recent episodes of sudden generalized body weakness along with ptosis and difficulty speaking that occurred after he became angry.

Each episode lasted about 10 seconds, but he says he felt back to normal within 15 minutes without any persistent deficits.

His Epworth Sleepiness Scale score is 17.


She has had diabetes mellitus for 22 years.

Her medications include folic acid, vitamin B12, amlodipine, and erythropoietin.

She worries she might eventually lose her balance and fall.

At the clinic, her blood pressure is 135/80 mm Hg when lying down before dialysis and 110/55 mm Hg when seated after hemodialysis.

Cardiopulmonary examination shows no abnormal findings.

Laboratory studies after hemodialysis show a Hb of 10.5 mg/dL, a blood sugar of 189 mg/dL, and a hemoglobin A1C of 7.1%.


Her past medical history is notable for major depressive disorder, obesity, fibromyalgia, and severe tension headaches.

She previously took paroxetine for a 2-month trial but switched to citalopram 6 months ago as she did not feel like paroxetine was adequately helping her symptoms.

Her mood has been stable on her current dose of citalopram.

She takes ibuprofen for her headaches but previously borrowed a friend’s headache medication when her headaches became very severe.

Of note, she has been trying to lose weight and recently started taking an amino acid supplement at the suggestion of her nephew who is a nutritionist.

She is also trying out a new low-carbohydrate diet.

She works as a nurse at a local primary care clinic.

Her temperature is 101.5°F (38.6°C), blood pressure is 144/80 mmHg, pulse is 108/min, and respirations are 22/min.

She developed worsening malaise and diaphoresis over the past 48 hours.

Her maximum temperature was 102°F (38.9°C) taken the night before presentation.

Patellar and brachioradialis reflexes are 3+ bilaterally.

Tone is increased in her bilateral upper and lower extremities.

Rapid dorsiflexion of her right ankle elicits 3 beats of clonus.

Pupils are equally round and reactive to light.

A basic metabolic panel is within normal limits.


He has had these symptoms before but did not seek treatment.

His past medical history is not known as he is not typically followed by a doctor and is homeless.

His temperature is 99.0°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 89/min, respirations are 22/min, and oxygen saturation is 90% on room air.

Physical examination is notable for crackles noted in the bases of the lungs bilaterally.


Her blood pressure is 160/100 mm Hg and pulse is 67/min.

Blood tests reveal high blood glucose and low potassium level.

Abdominal CT scan shows a well-circumscribed homogeneous mass in the left adrenal gland.


He has a past medical history of insomnia and is currently taking alprazolam.

He states that this is the worst headache he has ever had and that his symptoms have not been improving.

The patient complains of pain in his jaw that is worse when he chews.

His temperature is 98.2°F (36.8°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Physical exam is notable for tenderness over the patient's scalp, jaw, and temporal area.


In addition to intermittent nausea, he has mild weakness, tingling, and numbness in his left hand.

With his affected hand, he is able to grip, but occasionally drops small objects.

He was recently treated with cyclophosphamide, vincristine, doxorubicin, dexamethasone, and dasatinib.

His oncologist tells him that one of his chemotherapy agents likely caused his neuropathy given its strong association with neurotoxicity.


The mother is a healthy 32-year-old woman who did not have regular prenatal exams.

On physical examination, you notice low-set ears and retrognathia with abnormal extremity development.


She reports extreme fatigue since beginning her chemotherapy regimen.

Her pulse is 98/min, respirations are 16/min, and blood pressure is 132/84 mm Hg.

Her hemoglobin is 10.4 g/dL, leukocyte count is 800/mm3 with 5% monocytes, and platelet count is 50,000/mm3.

One week later, serum studies show a hemoglobin of 10.6 g/dL, a leukocyte count of 2,000/mm3 with 2% monocytes, and a platelet count of 56,000/mm3.

The patient is started on a new medication.


Cardiopulmonary examination shows normal heart sounds, intercostal retractions, and nasal flaring.

An x-ray of the chest shows low lung volumes, air bronchograms, and diffuse ground-glass opacities.

He is started on nasal continuous positive airway pressure.


She has hypertension and hyperlipidemia.

Seven years ago, she underwent resection of the terminal ileum because of severe Crohn's disease.

She is 155 cm (5 ft 2 in) tall and weighs 79 kg (175 lb); BMI is 32 kg/m2.

During these episodes, she has had nausea and vomiting.

She has no diarrhea, dysuria, or hematuria and is asymptomatic between episodes.

Her temperature is 36.9°C (98.5°F), pulse is 80/min, and blood pressure is 130/95 mm Hg.

Cardiopulmonary examination shows no abnormalities.

The abdomen is soft, and there is tenderness to palpation of the right upper quadrant without guarding or rebound.

The stool is brown, and test for occult blood is negative.

Laboratory studies show:
Hemoglobin 12.5 g/dL
Leukocyte count 9,500 mm3
Platelet count 170,000 mm3
Serum
Total bilirubin 4.1 mg/dL
Alkaline phosphatase 348 U/L
AST 187 U/L
ALT 260 U/L
Abdominal ultrasonography shows a normal liver, a common bile duct caliber of 10 mm (normal < 6 mm) and a gallbladder with multiple gallstones and no wall thickening or pericholecystic fluid.


She works as a graduate student at the local university, and she informs you that she recently returned to the west coast from a trip to New York for an Economics conference.

Her medical history is positive only for frequent bouts of sinusitis.

She currently denies any smoking, drinks a glass of red wine/day, and she denies any past illicit drug use.

The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 87/min, and respiratory rate 23/min.

Her physical examination shows decreased air movement throughout the right lung but otherwise clear lungs on auscultation, grade 2/6 holosystolic murmur, and a gravid uterus without acute findings.

On physical examination, she is afebrile, tachycardic to 121/min, normotensive, and demonstrates an O2 saturation of 92%.


He denies fever or recent upper respiratory tract infections.

After the first cycle of chemotherapy, the patient notices that his urine becomes red.

The urine tests are positive for blood on further analysis.

His temperature is 37.1°C (98.7°F), the blood pressure is 115/72 mm Hg, and the pulse are 82/min.

On examination, a 4-cm (1.5 in), firm, non-tender mass is detected on the mid-left neck.

Excisional biopsy of the mass reveals Hodgkin’s cells.

The patient is referred to the oncology department and chemotherapy is started.


She has had nausea, occasional episodes of vomiting, myalgia, and a generalized rash for the past week.

Her temperature is 39.1°C (102.3°F), pulse is 118/min, and blood pressure is 94/60 mm Hg.

Cardiac examination shows no abnormalities.

There is a widespread erythematous rash on the trunk and extremities with skin peeling on the palms and soles.

Laboratory studies show:
Hemoglobin 13.6 g/dL
Leukocyte count 19,300/mm3
Platelet count 98,000/mm3
Serum
Urea nitrogen 47 mg/dL
Glucose 88 mg/dL
Creatinine 1.8 mg/dL
Total bilirubin 2.1 mg/dL
AST 190 U/L
ALT 175 U/L
Urinalysis shows no abnormalities.

There is no family history of serious illness.


His long-standing male partner passed away 2 years ago in a fatal car accident.

He reports that over the last 6 months he slept a lot more than usual and lost 14.9 kg (33 lbs) without trying to lose weight.

He also complains of chest pain and shortness of breath that is worse when he is working and in the yard.

His blood pressure is 145/75 mm Hg, the pulse is 90/min, the respiratory rate is 23/min, and the temperature is 38°C (100.5°F).

On physical examination, he has pale mucous membranes, conjunctival hemorrhages, and petechiae on his lower extremities.

There is a new-onset high-pitched blowing diastolic murmur best heard over the right upper sternal border.

There are small, painless, red macules on both palms.

His spleen is palpable 3 cm below the left costal margin.

Hemoglobin 8.4 g/dL
Mean corpuscular volume 72 µm3
Platelet count 400,000/mm3
Leukocytes 6,000/mm3
Serum ferritin 8 ng/mL
Serum iron 27 µg/dL
Total iron-binding capacity 450 µg/dL
Colonoscopy with biopsy is later performed showing a neoplastic growth in the descending colon.


She is in good spirits and has been fully compliant with her medications and clinic visits.

Other medications include prophylactic co-trimoxazole.

Thirty minutes after the first dose, the patient develops difficulty breathing, severe muscle pain, and vomiting.

Recent blood studies show the following:
Hemoglobin (Hb%)  11 g/dL
Mean corpuscular volume (MCV)  80 fl
Reticulocyte count 0.5%
Erythrocyte count 2 x 106/mm3
Leucocyte count 700/mm3
Neutrophils 40%
Platelet count 20,000/mm3
Assays also show a decreased viral DNA and mRNA burden, as well as a significantly diminished viral load.

Her pulse rate is 120/min and the blood pressure is 80/50 mm Hg.

To avoid modifying the effective anti-retroviral therapy, she is started on a ‘blood improving’ medication.


She has hypertension treated with hydrochlorothiazide.

She was diagnosed with breast cancer 12 years ago and was treated with left-sided mastectomy.

She has been mumbling to herself and wandering around the neighborhood.

These symptoms are worse in the evenings and she has hardly slept at night.

She has not been eating or drinking much for the past 6 days.

The patient is oriented to person but not to place or time.

Her temperature is 37.1°C (98.8°F), pulse is 78/min, respirations are 18/min, and blood pressure is 122/80 mm Hg.

Physical examination shows a supple neck.

Neurologic examination shows psychomotor agitation.

Attention and concentration are impaired; she makes multiple errors while performing the serial sevens test.

Her fingerstick blood glucose concentration is 122 mg/dL.


She has no history of travel outside the United States.

Current medications include insulin and an oral contraceptive.

She has been having dull right-side abdominal pain during this period.

Her temperature is 40°C (104°F), pulse is 118/min, and blood pressure is 106/70 mm Hg.

On examination, the liver is palpated 2–3 cm below the right costal margin and is tender.

There are decreased breath sounds over the right lung base.

Laboratory studies show:
Hemoglobin 14.1 g/dL
Leukocyte count 17,100/mm3
Segmented neutrophils 74%
Eosinophils 1%
Lymphocytes 20%
Monocytes 5%
Serum
Glucose 79 mg/dL
Creatinine 1.1 mg/dL
Total bilirubin 0.9 mg/dL
Alkaline phosphatase 180 U/L
AST 69 U/L
ALT 100 U/L
A right upper quadrant ultrasound is shown.

The remainder of the examination shows no abnormalities.


He was diagnosed with type 2 diabetes 3 months ago and has been started on metformin and lifestyle modifications.

The patient does not have any current complaints except for occasional numbness in both hands and feet.

His HbA1C is 8.5% and serum glucose is 240 mg/dL.


He presents with severe retrograde memory loss, confusion, and confabulation.

Neurologic examination showed horizontal nystagmus.

He also has bilateral pretibial pitting edema and perioral erythema.

The duty physician suspects the patient may be vitamin deficient.


She is in active labor and has lost a lot of blood in the past 2 hours, but appears alert and cooperative.

At the hospital, her blood pressure is 88/65 mm Hg, the pulse is 110/min, and the respirations are 23/min.

Neither the hospital nor the emergency department is equipped for high-risk pregnancies.

The patient and her husband request a transfer to a more capable center.

They are informed of the hospital’s obligations under the Emergency Medical Treatment and Labor Act and the risks of transfer.


Laboratory work reveals eosinophilia and positive skin tests for allergens.


She has no past medical history and takes no medications.

She plays volleyball and gets good grades in school.

Physical examination reveals normal female external genitalia and pubic hair along the mons pubis and superomedial thighs.

Transabdominal ultrasound reveals an absent uterus.

Serum testosterone levels is within the normal range for females.


She has gastroesophageal reflux disease and Hashimoto's thyroiditis.

Menarche was at the age of 10 years and her last menstrual period was 2 years ago.

Current medications include omeprazole and levothyroxine.

On questioning, she has had fatigue and an increase in abdominal girth despite a 5-kg (11.0-lb) weight loss over the past 6 months.

Her last Pap smear 3 years ago showed atypical squamous cells of undetermined significance.

Abdominal examination shows shifting dullness.

There is tenderness to palpation of the right lower quadrant but no guarding or rebound.

Bimanual palpation shows a small uterus and a right adnexal mass.


1 month ago, he had a radical prostatectomy, pelvic radiation, and several rounds of chemotherapy for aggressive prostate cancer in Nicaragua and was discharged from the hospital with a suprapelvic catheter and a plan for more chemotherapy.

He was coming to the United States to spend time with some extended family.

She is not aware of his past medical status or medications.

According to the grand-daughter his mental status was altered upon arrival and his health began to decline.

At the hospital, his blood pressure is 98/60 mm Hg, the pulse id 110/min, the respiratory rate is 21/min, and the temperature is 35.6°C (96.1°F).

On physical exam, the patient appears cachectic, drowsy, and only responds to questions by nodding his head.

His heart rate is tachycardic with a regular rhythm and his lungs are clear to auscultation bilaterally.

The patient admitted to the hospital and stabilized and started on broad-spectrum antibiotics.

The catheter tube produces no urine over 24 hours and only thick green-white puss can be expressed.

The cystotomy incision for his suprapelvic catheter is red and swollen.

The treatment team concludes this patient has urinary tract obstruction.


His past medical history is otherwise notable for hypertension and hyperlipidemia.

His only home medication is pravastatin.

The patient smokes half a pack per day of cigarettes and drinks 2-3 beers throughout the day.

His family history is significant for Parkinson disease in his father.

He reports that for the last several years he has noticed this "shaking" when he brushes his teeth and prepares a cup of coffee in the morning.

The shaking then gradually improves over the course of the day.

On physical exam, his blood pressure is 159/84, pulse is 74/min, and respirations are 12/min.

He has a high frequency bilateral hand tremor elicited on finger-to-nose testing.


They range in age from 7 to 11, and most of them had no abnormal activities prior to developing the paralysis.

These patients concern her because she has not seen this type of paralytic illness in over 20 years of practice.

Based on this experience, she decides to write up the initial presentation and clinical course of these patients and publish them in a journal.


He is unconscious upon arrival and is found to have severe internal bleeding due to trauma.

Over the subsequent week, serial labs are drawn showing target cells, thrombocytosis, and leukocytosis.

He is taken for emergency surgery and severely damaged tissues are removed.

After surgery, the boy is taken into the PICU for recovery.

He is started on a prophylactic regimen that is continued upon discharge.


The patient has a previous documented allergy to albendazole.

Of note, the patient denies any recent travel, sexual contacts, fever, dysuria, or diarrhea.

His temperature is 98.1°F (36.7°C), blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 12/min.

On exam, the patient demonstrates severe excoriations in his perianal region with slight erythema over the areas that are torn.

He does not have any other dermatologic findings.


You have seen the patient in the past for amenorrhea and infertility issues, but she denies taking any medication at this time.

At the office, the blood pressure is 168/114 mm Hg.

On examination, the patient is short and normal weight but has a webbed neck.


He is a well-known case of sickle cell disease treated with hydroxyurea and tramadol as needed for pain.

The patient asks if his disease can adversely affect his kidneys because his friend was recently diagnosed with end-stage renal failure.


You note a penetrating wound at the level of L3.


Group 1, the study treatment group, is given drug A, while group 2, the control group, is given the current standard antifungal therapy.

A total of 500 participants are recruited for the study and are randomized into 2 groups in equal numbers.

After the completion of therapy, 190 participants from the study treatment group and 165 participants from the control group are cured.


Past medical history includes generalized anxiety disorder, for which she currently takes no medication.

The patient had been previously medicated with paroxetine for 5 years.

This pain has been accompanied by sleeping issues.

Her friend recommended that she try yoga to relieve the pain, but she says this has not helped her at all.

Se says the symptoms have begun to impact her daily functions and keep her from doing things she used to enjoy.

On physical examination, several areas of point tenderness are found on the occipital region, elbows, and medial surface of both knees.


He currently works and trains 60 hours per week as a resident and has a 10-hour shift external to his residency program on Saturdays.

He is free of any educational and work obligations on Sundays.


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

On presentation, he is found to have scalp and trunk lacerations that are still actively bleeding.

On physical exam, he is found to be anxious but does not have any visible injuries other than the lacerations.

On presentation, his temperature is 98.6°F (37°C), blood pressure is 110/74 mmHg, pulse is 82/min, and respirations are 17/min.


His mother notes that he seems to have gained a lot of weight despite the fact that he eats a healthy, well-balanced diet.

His teachers have also become concerned because he leaves class to use the restroom frequently throughout the day.

A physical exam is significant for a short, overweight child with nonpitting edema and decreased reflexes.

His systolic blood pressure drops by 20 mm Hg when he stands.

Fundoscopic exam is significant for papilledema and visual field exam is significant for bitemporal hemianopsia.

He has no medical problems and family history is insignificant.


In normoxia, von Hippel-Lindau (VHL) protein hydroxylates prolyl residues on oxygen-dependent degradation domains of HIF-1a, targeting it for proteasomal degradation.

Hydroxylation by VHL is inhibited under hypoxic conditions, allowing HIF-1a to escape degradation, dimerize with HIF-1ß, and translocate to the nucleus.

This results in the upregulation of hypoxic response elements, leading to angiogenesis.

Renal cell carcinoma (RCC) can mimic the hypoxic state to promote angiogenesis by inhibiting HIF-1a hydroxylation, even in the absence of hypoxia.

A researcher wants to perform an experiment to detect HIF-1a in RCC under normoxic conditions with blotting techniques.