Her past medical, family, and social histories are all non-contributory.

The patient is quite anxious about the implications of this diagnosis.

Her physical examination is within normal limits.

Her vital signs do not show any abnormalities at this time.


Darunavir has been particularly efficacious in recent patients; however, some have experienced an increased incidence of hyperglycemia.

A new drug called DN501 is developed with the same mechanism of action as darunavir but fewer side effects.


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

He has worked as a fruit picker for the past 25 years.

His current medications include captopril and metformin.

Examination of the oral cavity shows a single ulcer near the vermillion border.


Endometrial cells obtained from study participants are plated on growth media and the distribution of cell cycle phase is measured with flow cytometry.

Drug X, which is known to activate cyclin-dependent kinase 4, is administered to all the cells, and the distribution of cell cycle phase is measured again 1 hour later.


His past medical history is significant for human immunodeficiency virus (HIV) diagnosed 10 years ago with which he admits to not always being compliant with his antiretroviral medication.

The patient reports a 20-pack-year smoking history but no alcohol or recreational drug use.

He also says he has been having intermittent fevers and severe night sweats which require a change of bed sheets the next day.

A review of systems is significant for a 6 kg (13.2 lb) unintentional weight loss over the past 2 months.

The vital signs include: temperature 37.8℃ (100.0℉) and blood pressure 120/75 mm Hg.

On physical examination, there are multiple non-tender swollen lymph nodes averaging 2 cm in diameter that is palpable in the anterior and posterior triangles of the neck bilaterally.

Axillary and inguinal lymphadenopathy is present on the right side.

Laboratory studies show the following:
Hemoglobin 9 g/dL
Mean corpuscular volume 88 μm3
Leukocyte count 18,000/mm3
Platelet count 130,000/mm3
    Serum creatinine 1.1 mg/dL
Serum lactate dehydrogenase 1,000 U/L
An excisional biopsy of a superficial axillary lymph node on the right is performed and a histopathologic analysis confirms the most likely diagnosis.


Parameters such as patient demographic, type of implant, number of wires used, fracture union rate, and potential complications were thoroughly recorded and analyzed in all the patients, with a mean duration of patient follow-up of 16 months.

Union was achieved in all patients with a mean duration of 90 days, and there were no complications found in patients included in the study.

The authors were satisfied with their findings and, due to the prospective nature of their research, submitted their study to a journal as a cohort study (which they noted in the study title as well).

However, the journal editor returned the article, suggesting that it should be submitted as a case series instead.


She has seemed more confused lately and is unable to verbalize her symptoms.

Her temperature is 102°F (38.9°C), blood pressure is 117/65 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 95% on room air.

Physical exam is notable for a right upper quadrant mass that elicits discomfort when palpated.

Ultrasound is notable for pericholecystic fluid and gallbladder wall thickening without any gallstones.


She has no significant past medical history but reports a family history of diabetes in her mother.

She states that she has been undergoing a difficult divorce over the past few months.

She states that she has never had an episode like this before.

The patient is found to have a blood glucose level of 35 mg/dL.

C-peptide level was found to be decreased.

The patient returned to her baseline after glucose replacement.


He has no family history of prostate disease.

He is frustrated that he has to wake up 2 or 3 times per night to urinate even though he tried reducing the amount of water he consumes before bed and made some other dietary changes without any improvement.

Physical examination is negative for any suprapubic mass or tenderness, and there is no costovertebral angle tenderness.

He does not complain of any pain during urination.


Current medications include aspirin, which she takes almost daily for headaches.

Her temperature is 37.4°C (99.3°F) and her blood pressure is 150/90 mm Hg.

Physical examination shows costovertebral tenderness to percussion bilaterally.

Laboratory studies show a hemoglobin concentration of 10.2 g/dL and serum creatinine concentration of 2.4 mg/dL.

Urine studies show:
Urine
Protein
3+
RBC > 16/hpf
WBC 2/hpf
There are no casts or dysmorphic RBCs visualized on microscopic analysis of the urine.


Her medications include folic acid and a multivitamin.

She has smoked one pack of cigarettes daily for 15 years.

She has had spotting during the last 3 days.

Her temperature is 37°C (98.6°F), pulse is 110/min, and blood pressure is 89/65 mm Hg.

Pelvic examination shows a dilated cervical os and a uterus consistent in size with an 11-week gestation.

Ultrasonography shows an embryo of 4 cm in crown-rump length and no fetal cardiac activity.


She develops type I hypersensitivity-mediated histamine release, resulting in pruritic wheals on the skin.


The past year the child has been admitted to the hospital 3 times with pneumonia.

Her parents are also concerned that she has not gained much weight due to her frequent hospital visits.

She was born at 39 weeks gestation via spontaneous vaginal delivery and is up to date on all vaccines and is meeting all developmental milestones.

For the past 1 week, the child has been experiencing thick purulent cough and says that her chest feels ‘heavy’.

Her stools have been loose and foul-smelling over the past week.

On physical exam, the temperature is 39.1°C (102.4°F).

She appears lethargic and uncomfortable.

Crackles are heard in the lower lung bases, with dullness to percussion.

A small nasal polyp is also present on inspection.


He is a non-smoker and does not drink alcohol.

The vital signs are as follows: heart rate 98/min, respiratory rate 16/min, temperature 37.6°C (99.68°F), and blood pressure 132/70 mm Hg.

He says that he finds it difficult to walk a few blocks and has to rest.

He also complains of a cough for the past 3 months, which is dry and hacking in nature.

The physical examination is significant for inspiratory crackles over the lung bases.

An echocardiogram shows a normal ejection fraction.

A chest radiograph is performed and shown below.

The medical history is relevant for an idiopathic arrhythmia for which he takes amiodarone daily.


The mother has HIV and received triple antiretroviral therapy during pregnancy.

Her HIV viral load was 678 copies/mL 1 week prior to delivery.

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

Physical examination of the newborn shows no abnormalities.


The patient was diagnosed with diabetes 5 years ago and is compliant with her medications.

The medical history is otherwise unremarkable.

She says that the shortness of breath is worse on exertion and improves with rest.

While she could previously walk to the nearby store for her groceries, she now has to drive because she gets ''winded'' on the way.

The physical examination reveals gross ascites and visibly engorged periumbilical veins.

Bilateral pitting edema is noted around the ankles.

The finger-prick blood glucose level is 100 mg/dL.


Menses have occurred at regular 28-day intervals since menarche at the age of 12 years and last for 5 to 6 days.

She is sexually active with two male partners and uses condoms inconsistently.

The pain occurs a few hours before her menstrual period and lasts for 2 days.

Physical examination shows no abnormalities.

She has been taking ibuprofen, which has provided some relief.


Five weeks ago, the patient was in Mexico, where he went on several spelunking expeditions with friends.

His parents report that he has been experiencing flu-like symptoms for one week prior to hospital admission.

Autopsy of brain tissue suggests a viral infection.

The patient ultimately becomes comatose and dies.


He undergoes a skin biopsy and is found to have an absence of melanocytes in the epidermis.


His past medical history is significant for hypercholesterolemia, well managed with rosuvastatin, and hypertension, well managed with hydrochlorothiazide.

His current medications also include aspirin.

Three years after the initial diagnosis, the patient presents with swollen cervical and axillary lymph nodes, unintentional weight loss of 4.5 kg (approx.

10 lb), and “rib pain” on his right side.

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

His laboratory tests are significant for the following:
WBC 29,500/mm3
Hematocrit 26.1%
Hemoglobin 9.1 g/dL
Platelet count 298,000/mm3
A peripheral blood smear and differential shows 92% small normocytic lymphocytes.

On physical examination, there is palpable, firm, non-tender cervical and axillary lymphadenopathy bilaterally.

He also has moderate splenomegaly, which, when palpated, elicits pain.

The patient’s diagnosis in confirmed by bone marrow biopsy and flow cytometry.

At his last annual visit, his physical and laboratory tests were unremarkable.

He is monitored through regular follow-up visits.


Laboratory studies show:
Serum
Na+ 136 mEq/L
K+ 3.2 mEq/L
Cl- 115 mEq/L
Mg2+ 1.4 mEq/L
Urine
pH 7.0
Arterial blood gas analysis on room air shows a pH of 7.28 and a HCO3- concentration of 14 mEq/L.


He reports that he graduated from college last month and returned 3 days ago from a 2 week vacation to Vietnam and Cambodia.

The patient has a past medical history of asthma managed with albuterol as needed.

He is sexually active with both men and women, and he uses condoms “most of the time.” On physical exam, the patient’s temperature is 102.5°F (39.2°C), blood pressure is 112/66 mmHg, pulse is 105/min, respirations are 12/min, and oxygen saturation is 98% on room air.

For the past 2 days, he has developed a worsening headache, malaise, and pain in his hands and wrists.

He has tenderness to palpation over his bilateral metacarpophalangeal joints and a maculopapular rash on his trunk and upper thighs.


She has no history of any serious illness.

Current medications include norepinephrine, ceftriaxone, and acetaminophen.

Her temperature is 37.5°C (99.5°F), heart rate is 96/min, and blood pressure is 85/55 mm Hg.

Examination of the back shows costovertebral tenderness bilaterally.

Examination of the thyroid gland shows no abnormalities.

Laboratory studies show:
  Hospital day 1 Hospital day 3
Leukocyte count 18,500/mm3 10,300/mm3
Hemoglobin 14.1 mg/dL 13.4 mg/dL
Serum
Creatinine 1.4 mg/dL 0.9 mg/dL
Fasting glucose 95 mg/dL 100 mg/dL
TSH   1.8 µU/mL
T3, free   0.1 ng/dL
T4, free   0.9 ng/dL
Repeat blood cultures are negative.

Her blood cultures are positive for Escherichia coli, for which she has been receiving appropriate antibiotics since admission.


Blood pressure in the upper limb is 140/90 mm Hg and lower limbs are 110/70 mm Hg.

There is a brachiofemoral delay in the pulse.

Auscultation shows a loud S1, loud S2, and S4.

There is a presence of an ejection systolic murmur in the interscapular area.

Chest X-ray reveals the notching of the ribs.


He underwent a total knee arthroplasty of his left knee joint 4 months ago.

Current medications include glucosamine, amlodipine, and meloxicam.

Examination shows a tender, swollen left knee joint; range of motion is limited by pain.

His temperature is 38.1°C (100.6°F), pulse is 97/min, and blood pressure is 118/71 mm Hg.

Analysis of the synovial fluid confirms septic arthritis, and the prosthesis is removed.


He has had diabetes mellitus for 15 years, for which he takes metformin and gliclazide.

On examination, he is ill-appearing, and he has a tender liver edge that is palpable approx.

Percussion and movement worsens the pain.

His vital signs include a temperature of 38.3°C (101.0°F), pulse of 85/min, and blood pressure of 110/70 mm Hg.

Stool is negative for Entamoeba histolytica antigen.


The patient complains that he has experienced a loss of sensation in his toes and fingertips, which has caused him to injure himself often.

Examination of his face reveals skin that is thick and contains many lesions.


During this period, he has had recurrent episodes of low-grade fever lasting for 7 to 10 days, and an 8-kg (18-lb) weight loss.

Physical examination shows nontender, right axillary, cervical, and inguinal lymphadenopathy.

His serum calcium concentration is 15.1 mg/dL and parathyroid hormone (PTH) concentration is 9 pg/mL.

A lymph node biopsy shows granuloma formation and large CD15-positive, CD30-positive cells with bilobed nuclei.


He feels well but has not seen a physician in several years, and his immunization records are unavailable.

Physical examination shows no abnormalities.


She reports that the child develops severe sunburns every time the infant is exposed to sunlight.

She has applied copious amounts of sunscreen to the infant but this has not helped the problem.

On examination, there are multiple areas of reddened skin primarily in sun exposed areas.

The child’s corneas appear irritated and erythematous.


His past medical history is notable for gout for which he takes allopurinol.

He runs 4 times per week and eats a balanced diet of mostly fruits and vegetables.

He does not smoke and drinks a glass of wine with dinner.

He first noticed a firm mass on the anterior aspect of his neck approximately 4 months ago.

The mass is painless and has not increased in size since then.

He has also noticed occasional fatigue and has gained 10 pounds in the past 4 months despite no change in his diet or exercise frequency.

His temperature is 97.8°F (36.6°C), blood pressure is 127/72 mmHg, pulse is 87/min, and respirations are 19/min.

On exam, he has a firm, symmetric, and stone-firm thyroid.

His family history is notable for medullary thyroid cancer in his maternal uncle.


For study purposes, the researchers labeled incident cases at the initial occurrence of SLE diagnosis in the hospital database, while prevalent cases were those that were coded as harboring SLE at any time, with patients maintaining their diagnosis until death.

These estimates were not only based on hospital discharges, but also on physician billing codes.


She has had progressive shortness of breath over the last year with an intermittent non-productive cough.

In addition, she complains of difficulty raising her arms to brush her hair.

Her temperature is 99.6°F (37.6°C), pulse is 80/min, blood pressure is 130/85 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.

Neurologic exam shows 4/5 strength in the deltoid muscles bilaterally.

Diffuse dry crackles are heard on lung auscultation.

A faint erythematous rash is noted on the malar cheeks, periorbital areas, lateral proximal thighs, and the elbows.


He has been taking over-the-counter cough medications, but they have not helped much.

There is no past history of any specific medical disorder.

His father died of lung cancer at the age of 54 years.

He adds that he expectorated bloody sputum the previous night.

He denies breathlessness but mentions that he frequently experiences fatigue after little physical exertion.

His temperature is 37.0°C (98.6°F), the pulse rate is 82/min, the blood pressure is 118/80 mm Hg, and the respiratory rate is 18/min.

Auscultation of his chest reveals the presence of localized rhonchi over the interscapular region.

A plain radiograph of the chest shows a coin-like opacity in the right lung.

Further diagnostic evaluation confirms the diagnosis of small cell carcinoma of the lung.


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

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

He can point to the spot 1-2 inches above the umbilicus where he feels the pain.

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

He reports that he used to eat three large meals per day but has found that eating more frequently improves his pain.

He has gained four pounds since his past appointment three months ago.

The patient denies any diarrhea or change in his stools.

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

He tried a couple pills of ibuprofen with food over the past couple days and thinks it helped.

The patient undergoes endoscopy with biopsy to diagnose his condition.


The patient is in kindergarten and doing well in school.

She is learning to read and is able to write her first name.

The patient’s past medical history is significant for moderate persistent asthma, which has required three separate week-long courses of prednisone over the last year and recently diagnosed myopia.

The patient’s mother is 5’7”, and the patient’s father is 5’10”.

The patient’s mother is concerned that the patient is a picky eater and often returns home from school with most of her packed lunch uneaten.

The patient’s weight and height are in the 55th and 5th percentile, respectively, which is consistent with her growth curve.

On physical exam, the patient has a low hairline and a broad chest.

Her lungs are clear with a mild expiratory wheeze.

The patient’s abdomen is soft, non-tender, and non-distended.

She has Tanner stage I breast development and pubic hair.


The decision is made to stop the statin and return to the clinic in 2 weeks to assess any changes in symptoms.

He complains of pain in his legs and general weakness.

On physical exam, he has full range of motion of his extremities but complains of pain.

His blood pressure is 126/84 mm Hg and heart rate is 74/min.

After stopping the statin, his muscular symptoms resolve.


A portion of the specimen is cut and stained with hematoxylin and eosin.

The remainder is analyzed and is found to contains type II collagen and chondroitin sulfate.


Abdominal examination shows a distended abdomen and intact abdominal surgical incisions.

Computed tomography shows a small bowel perforation.

Her temperature is 37.3°C (99.1°F), pulse is 76/min, and blood pressure is 111/50 mm Hg.

The remainder of the physical examination shows no abnormalities.

The patient is prepared for emergent exploratory laparotomy.

She is sedated with midazolam, induced with propofol, intubated, and maintained on nitrous oxide and isoflurane for the duration of the surgery.

The ventilator is set at an FiO2 of 50%, tidal volume of 1000 mL, respiratory rate of 12/min, and positive end-expiratory pressure of 2.5 cm H2O.

A single perforation in the terminal ileum is diagnosed intraoperatively and successfully repaired.

The patient is transferred to the intensive care unit.


He is thin and diaphoretic with pinpoint pupils, poor dentition, and track marks on his arms and legs.

On physical exam, temperature is 100.6 deg F (38.1 deg C), blood pressure is 109/56 mmHg, pulse is 94/min, and respirations are 18/min.

A high-pitched systolic murmur is heard, loudest in the left sternal border and with inspiration.

One of the blood cultures drawn 12 hours ago returns positive for Staphylococcus aureus.

He is admitted to the hospital and started on broad-spectrum antibiotics.


He has not seen a doctor since he became uninsured 2 years ago.

Abdominal examination shows mild, diffuse tenderness throughout the lower quadrants.

The liver is palpated 2–3 cm below the right costal margin, and the spleen is palpated 1–2 cm below the left costal margin.

His CD4+ T-lymphocyte count is 49/mm3 (N ≥ 500 mm3).

Blood cultures grow acid-fast organisms.

A PPD skin test shows 4 mm of induration.


Two weeks ago, she had a routine Pap smear that showed atypical squamous cells.

Colposcopy shows an area of white discoloration of the cervix with application of acetic acid solution.

Biopsy of this area shows carcinoma-in-situ.


In a pilot study of 50 patients, the imaging test detected the presence of CMV retinitis in 50% of the patients.

An ophthalmologist slit lamp examination, which was performed for each patient to serve as the gold standard for diagnosis, confirmed a diagnosis of CMV retinitis in 20 patients that were found to be positive through imaging, as well as 1 patient who tested negative with the device.


She has no past psychiatric history and she denies hearing voices or seeing objects.

Although she has lived in the same community for years, she says she usually keeps to herself and does not have many friends.

She holds a regular job at the local hardware store and lives alone.

She vaguely explains that the necklace is to mask her scent from the moles tracking her.


Digital rectal exam was positive for a slightly enlarged prostate but did not detect any additional abnormalities of the prostate or rectum.

The patient’s serum PSA was measured to be 6 ng/mL.

Image A shows a transabdominal ultrasound of the patient.


He finds his work as a computer programmer rewarding and looks forward to coming into the office every day.

His past medical history is noncontributory.

However, he often falls asleep during meetings even though he usually gets a good night sleep and has limited his exposure to alcohol and caffeine in the evening.

The patient returns one month later to report no changes to his condition.

His vital signs are within normal limits.

The sleep journal reveals that the patient is getting sufficient sleep and wakes up rested.

The questionnaire reveals that the patient does not snore nor does he stop breathing during his sleep.

A sleep study reveals mean sleep latency of 6 minutes.

The primary care provider recommends keeping a sleep journal and provides a questionnaire for the patient’s wife.


He has hypertension treated with enalapril.

The patient has smoked a pack of cigarettes daily for the past 20 years.

The patient reports that he first noticed the swelling several weeks ago, but it is not always present.

Physical examination shows a 10-cm, soft, cystic, nontender right 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.


His past medical history is significant for type 2 diabetes mellitus and hypertension for the past 25 years.

Clinical examination shows the presence of wound dehiscence in the lower 3rd of the sternal region.

The wound surface shows the presence of dead necrotic tissue with pus.

Computed tomography (CT) of the thorax shows a small fluid collection with fat stranding in the perisurgical soft tissues.

He recently had a triple coronary artery bypass graft 3 weeks ago.


He says that he has tried to keep himself healthy and active by jogging and gardening since his retirement at age 50.

He adds that he spends his mornings in the park and his afternoons in his garden.

The patient denies any smoking history and drinks alcohol occasionally.

On physical examination, the following lesion is seen on his scalp (see image).


At a routine well-child examination 4 months later, the physician notices that he has persistent head lag.

On examination, he has blue eyes, pale skin, blonde hair, and generalized hypotonia.

His serum prolactin level is markedly elevated.

He is started on a special diet and the hyperphenylalaninemia resolves.


She further expresses her concerns about the possibility of contracting tuberculosis as one of the patients under her care is being treated for tuberculosis.

At a follow-up appointment 3 months later the patient presents with fatigue.

She has also been experiencing occasional dizziness, weakness, and numbness in her feet.

A PPD skin test is done and reads 11 mm on day 3.

Chest X-ray demonstrates a cavitary lesion in the right upper lobe.

Physical exam is positive for conjunctival pallor.

Lab work is significant for a hemoglobin level of 10 g/dL and mean corpuscular volume of 68 fl.

The standard anti-tuberculosis medication regimen is started.


She is feeling well but is concerned because her brother was recently diagnosed with hereditary hemochromatosis.

Today, she denies fever, chills, joint pain, or skin hyperpigmentation.

Her temperature is 37.0°C (98.6°F), pulse is 85/min, respirations are 16/min, and blood pressure is 123/78 mm Hg.

Her serum iron, hemoglobin, ferritin, and AST and ALT concentrations are normal.

All first-degree relatives were encouraged to undergo genetic screening for any mutations associated with the disease.

Gene screening will involve a blood specimen.


Her menstrual cycles are 28–30 days apart with 3–5 days of vaginal bleeding.

The pain is in her right lower quadrant (RLQ), which is also where it began.

She has had no nausea or vomiting despite eating a snack 2 hours ago.

She had a similar episode last month which resolved on its own.

Her blood pressure is 125/75 mm Hg, the pulse is 78/min, the respirations are 15/min, and the temperature is 37.2°C (99.0°F).

Abdominal examination shows moderate pain on direct pressure over the RLQ which decreases with the release of pressure.


The patient states he was at a barbecue around noon.

Lunch was arranged as a buffet without refrigeration.

Within 2 to 3 hours, he had abdominal pain with 3 episodes of watery diarrhea.

On exam, vital signs are T 99.1, HR 103, BP 110/55, RR 14.

Abdominal exam is significant for pain to deep palpation without any rebounding or guarding.

There is no blood on fecal occult testing (FOBT).


He has a history of major depressive disorder and had an ischemic stroke 4 months ago.

Current medications are aspirin and sertraline.

While in the waiting room, he has a generalized, tonic-clonic seizure.

His pulse is 78/min, and blood pressure is 135/88 mm Hg.

Physical examination shows moist oral mucosa, normal skin turgor, and no peripheral edema.

Laboratory studies show a serum sodium of 119 mEq/L and an elevated serum antidiuretic hormone concentration.


She states that she has always had an irrational and excessive fear of dogs but has been able to avoid it for most of her life while living in the city.

When she sees her neighbors walking their dogs outside, she is terrified and begins to feel short of breath.

Recently, she has stopped picking up her children from the bus stop and no longer plays outside with her children in order to avoid seeing any dogs.


The patient was found unconscious with a large metal spike protruding from his abdomen by a coworker who was unable to estimate the amount of time the patient went without medical aid.

Upon arrival to the ER, the patient was unconscious and unresponsive.

The patient remained sedated after surgery and continued to have relatively stable vital signs until his third day in the intensive care unit, when he experiences an oxygen desaturation of 85% despite being on a respirator with 100% oxygen at 15 breaths/minute.

His vital signs are BP: 80/40, HR: 120 bpm, RR: 25 bpm, Temperature: 97.1 degrees, and SPO2: 99%.He is taken to the operating room to remove the foreign body and control the bleeding.

Although both objectives were accomplished, the patient had an acute drop in his blood pressure during the surgery at which time ST elevations were noted in multiple leads.

On auscultation air entry is present bilaterally with the presence of crackles.

Readings from a Swan-Ganz catheter display the following: central venous pressure (CVP): 4 mmHg, right ventricular pressure (RVP) 20/5 mmHg, pulmonary artery pressure (PAP): 20/5 mmHg.

Pulmonary capillary wedge pressure (PCWP): 5 mm Hg.

This resolved with adequate fluid resuscitation and numerous blood transfusions.

The patient dies soon after this episode.


He is a 60 pack-year smoker, worked as a shipbuilder 30 years ago, and recently traveled to Ohio to visit family.

Chest radiograph shows increased bronchovascular markings, reticular parenchymal opacities, and multiple pleural plaques.

Labs are unremarkable except for a slight anemia.


His past medical history is significant for prediabetes, which he controls with exercise and diet.

He reports having shortness of breath over the last 6 months, but he has felt worse since he contracted a cold that has been traveling around his office.

Today, he reports body aches, headache, and fever along with this chronic cough.

His blood pressure is 130/85 mmHg, pulse rate is 90/min, temperature is 36.9°C (98.5°F), and respiratory rate is 18/min.

Physical examination reveals diminished breath sounds bilateral, a barrel-shaped chest, and measured breathing through pursed lips.

A chest X-ray reveals a flattened diaphragm and no signs of consolidation.

Pulmonary function testing reveals FEV1/FVC ratio of 60%.


He and his wife have three unaffected daughters.


The patient reports that he noticed a decrease in his hearing approximately 10 years ago.

His wife says that he watches television at an elevated volume and appears to have trouble understanding what is being said to him, especially when there is background noise.

He states that he also experiences constant ear ringing and episodes of unsteadiness.

On physical examination, the outer ears are normal and otoscopic findings are unremarkable.

The patient is unable to repeat the sentence said to him on whisper testing.

When a vibrating tuning fork is placed in the middle of the patient's forehead, it is heard equally on both ears.

When the vibrating tuning fork is placed by the ear and then on the mastoid process, air conduction is greater than bone conduction.


He wears soft contact lenses and has not removed them for 2 days.

Ophthalmologic examination shows a deep corneal ulcer, severe conjunctival injection, and purulent discharge on the right.

Treatment with topical ciprofloxacin is initiated.


She said that about a year ago, she had trouble with her vision, and that it eventually recovered in a few days.

On physical exam, bilateral internuclear ophthalmoplegia, hyperreflexia in both patella, and bilateral clonus, are noted.

A magnetic resonance imaging (MRI) study was done (Figure 1).


The course of her pregnancy has been unremarkable and she has no significant co-morbidities.

The BMI is 25.6 kg/cm2 and she has gained 3 kg (6.72 lb) during the pregnancy.

She is concerned about the results of a dipstick test she performed at home, which showed 1+ glucose.

She does not know  if her liquid consumption has increased, but she urinates more frequently than before.

The blood pressure is 110/80 mm Hg, the heart rate is 82/min, the respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉).

The lungs are clear to auscultation, the heart sounds are normal with no murmurs, and there is no abdominal or costovertebral angle tenderness.


Pregnancy and delivery were uncomplicated.

He was diagnosed with eczematous dermatitis at 3 months old.

His height and weight are below the 5th percentile.

Immunologic evaluation shows a defect in activated regulatory T cells.

A genetic analysis shows a mutation in the FOXP3 gene.


He has smoked 1 pack of cigarettes daily for 37 years.

He has a 12-year history of drinking 6 to 8 beers daily.

He describes the stools as bulky, foul-smelling, and difficult to flush.

He also has a 4-month history of recurrent dull upper abdominal pain that usually lasts for a few days, worsens after meals, and is not relieved with antacids.

He has had a 10-kg (22-lb) weight loss in the past 4 months.

He is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2.

His vital signs are within normal limits.

Abdominal examination shows mild epigastric tenderness without rebound or guarding.

He has no personal or family history of serious illness.

The remainder of the examination shows no abnormalities.


In the past, he has had significant sun exposure including multiple blistering sunburns.

He notes a pink bump that has rapidly developed on his forehead over the last month.

The physical examination reveals a 2 cm dome-shaped plaque with a central keratin plug (as shown in the image).

Excisional biopsy of the lesion reveals an exophytic nodule with central invagination, full of keratin.


His past medical history is notable for hypercholesterolemia and hypertension.

He reports a 2-month history of exertional chest pain that commonly arises after walking 5 or more blocks.

He describes the pain as dull, burning, non-radiating substernal pain.

His temperature is 98.9°F (37.2°C), blood pressure is 150/85 mmHg, pulse is 88/min, and respirations are 18/min.

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

An exercise stress test is performed to further evaluate the patient’s pain.


His past medical history is notable for iron deficiency anemia, osteoarthritis, and paraneoplastic Lambert-Eaton syndrome.

However, he reports that he recently developed multiple “spots” all over his body.

He denies any overt bleeding from his gums or joint swelling.

His temperature is 98.5°F (36.9°C), blood pressure is 130/70 mmHg, pulse is 115/min, and respirations are 20/min.

On examination, a rash is noted diffusely across the patient’s trunk and bilateral upper and lower extremities.

Results from a complete blood count are shown below:
Hemoglobin: 11.9 mg/dl
Hematocrit: 35%
Leukocyte count: 5,000/mm^3
Platelet count: 20,000/mm^3

The oncologist would like to continue chemotherapy but is concerned that the above results will limit the optimal dose and frequency of the regimen.

He has responded well to etoposide and cisplatin with plans to undergo radiation therapy.


During his annual physical, he reports that he has been taking over the counter pain medications, but that no amount of analgesics can relieve his constant pain.

Laboratory results reveal that his renal function has deteriorated when compared to his last office visit 2 years ago.

Serum creatinine is 2.0 mg/dL, and urinalysis shows 1+ proteinuria.

There are no abnormalities seen on microscopy of the urine.

A renal biopsy shows eosinophilic infiltration and diffuse parenchymal inflammation.


The patient has a past medical history of COPD and a 44-pack-year smoking history.

The patient has been admitted before for a similar presentation.

The patient says he feels as if he is unable to take a deep breath.

The patient claims he is still short of breath.

His temperature is 98.7°F (37.1°C), blood pressure is 177/118 mmHg, pulse is 123/min, respirations are 33/min, and oxygen saturation is 80% on room air.

Physical exam reveals bilateral wheezes and poor air movement.

The patient is started on 100% oxygen, albuterol, ipratropium, magnesium, and prednisone.


He has hypertension treated with enalapril.

He has smoked 1 pack of cigarettes daily for 60 years.

He says that the pain is sharp, radiates to his left side, and has a burning quality.

He has had a cough occasionally productive of blood-streaked sputum for the past 2 months.

He has had 3.2-kg (7.0-lb) weight loss in that time.

He is now unable to walk without assistance and has had constipation and difficulty urinating for the past 2 weeks.

He is unable to lie recumbent due to severe pain.

His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 150/80 mm Hg.

He is oriented to person, place, and time.

Neurologic examination shows 3/5 strength of the lower extremities.

Deep tendon reflexes are hyperreflexive.

Sensory examination shows decreased sensation to pinprick below the T4 dermatome.

An x-ray of the chest shows multiple round opacities of varying sizes in both lungs.


The patient reports that he has had a fear of flying since being a teenager.

He went on a family vacation 15 years ago, and during the flight there was turbulence and a “rough landing”.

He did not go to his cousin’s wedding because it was out of the country.

He also was unable to visit his grandmother for her 80th birthday.

The last time his job asked him to meet a client out of state, he drove 18 hours instead of flying.

Two years ago he promised his fiancé they could fly to Florida.

Upon arrival at the airport, he began to feel dizzy, lightheaded, and refused to go through security.

He recognizes that his fear is irrational.

During the clinic visit, the patient appears anxious and distressed.

He is upset that it is affecting his relationship with his wife.

Additionally, his current job may soon require employees in his sales position to fly to meet potential clients.

He is embarrassed to have a conversation with his manager about his fear of flying.


A skin biopsy is performed, which shows an epidermal basement membrane with immunoglobulin G (IgG) antibodies and linear immunofluorescence.


She does not have friends and spends most of the time reading by herself.

She states that she likes reading and feels more comfortable on her own.

Her father says that she comes up with excuses to avoid family dinners and other social events.

On mental status examination, her thought process is organized and logical.


During this period, he has had generalized malaise and a cough productive of moderate amounts of green sputum.

For the past 10 days, he has had fever, a sore throat, and generalized aches; these symptoms initially improved, but worsened again over the past 5 days.

His temperature is 38.7°C (101.7°F), pulse is 109/min, respirations are 27/min, and blood pressure is 100/70 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 93%.

There are decreased breath sounds and crackles heard over the upper right lung field.

His hemoglobin concentration is 13.3 g/dL, leukocyte count is 15,000/mm3, and platelet count is 289,000/mm3.

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


His breathlessness worsens while walking, climbing the stairs, and lying flat on his back.

He also finds it difficult to sleep well at night, as he often wakes up to catch his breath.

His pulse is 98/min and blood pressure is 114/90 mm Hg.

On examination, he has mild respiratory distress, distended neck veins, and bilateral pitting edema is evident on the lower third of his legs.

His respiratory rate is 33/min, SpO2 is 93% in room air, and coarse crepitations are heard over the lung bases.

On auscultation, the P2 component of his second heart sound is heard loudest at the second left intercostal space, and an S3 gallop rhythm is heard at the apex.

Medication is prescribed for his symptoms which changes his cardiac physiology as depicted with the dashed line recorded post-medication.


Past medical history and family history are insignificant.

He also complains of abdominal pain and constipation for the same duration.

On further questioning, he reports that he has lost 8 pounds in the last 2 weeks.

His temperature is 37.3° C (99.2° F), respirations are 21/min, pulse is 63/min, and blood pressure is 99/70 mm Hg.

On physical examination, he is a tired-appearing, thin male.

He has a bronze discoloration to his skin, but he denies being outside in the sun or any history of laying in tanning beds.


The obstetrician is worried that the child may have been infected due to the mother's haphazard use of her anti-retroviral medications.


He was diagnosed with chronic obstructive pulmonary disease (COPD) the previous year and since then has been on a short-acting β-agonist to help alleviate his symptoms.

Since his diagnosis, he has quit smoking, a habit which he had developed about 30 years ago.

He used to smoke about 2 packs of cigarettes daily.

Today, he has come in with an increase in his symptoms.

He tells his physician that he has been having a fever for the past 3 days, ranging between 37.8°–39°C (100°F–102.2°F).

Along with this, he has a persistent cough with copious amounts of greenish-yellow sputum.

He has also been having difficulty breathing.

On examination, his temperature is 38.6°C (101.5°F), the respirations are 22/min, the blood pressure is 110/80 mm Hg, and the pulse is 115/min.

Slight crackles and respiratory wheezes are prominent in the lower lung fields.

His FEV1 is 57% of his normal predicted value.

He is started on oxygen and a dose of oral prednisone.


His headaches tend to occur in the morning and are associated with nausea and vomiting.

His temperature today is 37.5°C (98.5°F).

An MRI of the brain shows bilateral ventricular enlargement and enlargement of the subarachnoid space.

One month ago, the patient was admitted to the hospital because of fever, irritability, and neck rigidity, and he was successfully treated with antibiotics.


Physical examination shows bilateral saccadic eye movement in all directions and brief, involuntary muscle contractions of the trunk and limbs.

There is an ill-defined, nontender mass in the upper right abdomen.

He undergoes surgical resection of the tumor.


Average baseline LDL levels for each group were identical.

Statistical analysis reports a p-value of 0.052.

The group receiving statin A exhibited an 11 mg/dL greater reduction in LDL in comparison to the statin B group.


Other medical history reveals that she has had 3 past spontaneous abortions at < 10 weeks of gestational age but has never been diagnosed with any diseases.

She drinks socially but has never smoked or used drugs.

She has never taken any medications except for over the counter analgesics and antipyretics.

Physical exam shows that the cord-like lesion is tender, thick, and hardened on palpation.

She says that she has had multiple such lesions previously.

In addition, she has a lacy mottled violaceous rash on multiple extremities.


The patient denies dyspnea, fatigue, and syncope.

Her temperature is 37.0 degrees C, blood pressure is 115/75 mm Hg, pulse is 76/min, and respiratory rate is 16/min.

Transthoracic echocardiography reveals a large, pedunculated tumor in the left atrium.


She was born at 39 weeks via spontaneous vaginal delivery, has met all developmental milestones and is fully vaccinated.

Past medical history is significant for mild allergies to pet dander and ragweed, as well as a severe peanut allergy.

She normally carries both an emergency inhaler and EpiPen but forgot them today.

On physical examination, the patient has severe edema over her face and an audible stridor in both lungs.

The vital signs include: blood pressure 112/87 mm Hg, heart rate 111/min, respiratory rate 25/min, and temperature 37.2°C (99.0°F).


On microscopic examination, the biopsy sample shows uniform squamous cells in layers.

He obtains a biopsy from the mainstem bronchus of a patient.


She has severe facial acne and dense black hairs on her upper lip, beneath her hairline anterior to her ears, and the back of her neck.

Ultrasound reveals bilateral enlarged ovaries with multiple cysts.


He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size.

Dermatopathology determines that the lesion contains neoplastic cells of melanocytic origin.


She has hypertension and hyperlipidemia.

Her medications prior to admission were hydrochlorothiazide and atorvastatin.

During the fall she sustained a right-sided subdural hematoma.

Physical and neurologic examinations show no abnormalities.

Laboratory studies show:
Serum
Na+ 130 mEq/L
K+ 4.0 mEq/L
Cl- 103 mEq/L
HCO3- 24 mEq/L
Urea nitrogen 14 mg/dL
Creatinine 1.1 mg/dL
Osmolality 270 mOsmol/kg H2O
Urine
Sodium 45 mEq/L
Osmolality 326 mOsmol/kg H2O
A CT scan of the head shows an unchanged right-sided subdural hematoma.


The mother states that she noticed the bleeding today, which appeared as brown discharge with clots in the patient’s diaper.

She does mention that the patient has been limping and complaining of left leg pain since a fall 2 months ago.

On physical exam, there are multiple 2-3 cm hyperpigmented patches on the patient’s trunk.

There is bilateral enlargement of the breasts but no pubic hair.

The vaginal orifice is normal and clear with an intact hymen.

A plain radiograph of the left lower leg shows patchy areas of lytic bone and sclerosis within the femoral metaphysis.

The mother denies frequent nosebleeds or easy bruising.


Cardiac catheterization shows occlusion that has caused a 50% reduction in the diameter of the left circumflex artery.


Examination of the lower extremities shows no redness or swelling.

When the child stands on his right leg, his left leg drops and his pelvis tilts towards the left.

Sensation to light touch is normal in both legs.


Physical examination shows a well-appearing toddler with a palpable left-sided abdominal mass that does not cross the midline.

A CT of the abdomen shows a large, necrotic tumor on the left kidney.

Histological examination of the kidney mass shows primitive blastemal cells and immature tubules and glomeruli.


His father received a renal transplant in his 20s.

His mother says they have to speak at a higher volume for him to understand them.

He also complains of having difficulty reading his favorite books because he is not able to see the words clearly.

The vital signs are within normal limits.

The physical examination shows no abnormalities.

Laboratory studies show:
Serum
Urea nitrogen 15 mg/dL
Creatinine 1.0 mg/dL
Urine
Blood 1+
Protein 1+
RBC 15–17/hpf
WBC 1–2/hpf
The audiometry shows bilateral high-frequency sensorineural hearing loss.

The ophthalmologic examination shows anterior lenticonus.


She has never had a period and is anxious that she is not “keeping up” with her friends.

The patient is a competitive ice skater and has never been sexually active.

Her mother has a history of migraine headaches, and her older sister has a history of bipolar disorder.

Review of systems reveals that she has also been getting headaches every few months over the last year with some photosensitivity and nausea each time.

At this visit, the patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 118/65 mmHg, and respirations are 13/min.

Cardiopulmonary and abdominal exams are unremarkable.

Both breasts are Tanner IV with no expressable discharge.

Pelvic and axillary hair growth is also Tanner IV.

The patient is unable to tolerate a full pelvic exam, but the part of the vaginal canal that is examined is unremarkable.

Laboratory studies are ordered and are below:

Serum:
Na+: 139 mEq/L
K+: 4.1 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 12 mg/dL
Glucose: 73 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 9.7 mg/dL
Mg2+: 1.7 mEq/L
AST: 11 U/L
ALT: 11 U/L
Follicle Stimulating Hormone (FSH): 16.2 mIU/mL (4.7-21.5 mIU/ml)
Estrogen: 240 pg/mL (64-357 pg/mL)

Abdominal ultrasound is performed and shows a normal uterus and ovaries.


He has had similar episodes in the past when he also had to be rushed to the hospital.

Physical examination shows body temperature is 37.2°C (98.9°F), pulse rate is 100/min, respiratory rate is 28/min and blood pressure is 110/60 mm Hg.

Also, it shows decreased breath sounds on both sides, the peak expiratory flow rate is 200 L/min and SpO2 is 89% on room air.

An arterial blood gas analysis shows the following:
pH 7.48
PaO2 59 mm Hg
PaCO2 26 mm Hg
HCO3- 26 mEq/L
After administering oxygen by mask, the man’s PaO2 increases to 75 mm Hg.

The man is given an initial treatment with nebulization using an inhaled short-acting β-agonist.


A physical exam on admission reveals scleral icterus and a flapping tremor of the wrists during extension.

The next morning on rounds, he complains of eleven episodes of diarrhea and near-constant flatulence overnight.

The patient is admitted to the hospital and his treatment is started after appropriate investigation.


His medical history is notable for poorly controlled hypertension and hyperlipidemia.

He takes enalapril, hydrochlorothiazide, aspirin, and atorvastatin.

He has a 40 pack-year smoking history and drinks 3-4 beers per day.

His diet consists primarily of fast food.

He reports a 4-day history of steady right lower quadrant pain.

He has had one small bowel movement in 4 days.

Normally he has a bowel movement once a day.

His temperature is 101.8°F (38.8°C), blood pressure is 160/95 mmHg, pulse is 90/min, and respirations are 16/min.

Relevant findings included multiple small, pedunculated polyps which were removed, multiple colonic mucosal outpouchings, and no other masses.

A review of the patient’s medical record reveals colonoscopy results from 1 year ago.


Past medical history is significant for hypertension and a hemorrhagic stroke 6 years ago, which was treated surgically.

The patient’s eldest daughter says that he couldn’t move his arm during the episode.

After admission, the patient gets increasingly worse and loses consciousness.

A noncontrast CT of the head shows a subarachnoid hemorrhage (SAH).

Several days later, a repeat CT of the head shows an enlarging aneurysm in a different vessel in the brain.

The patient is taken to the operating room, where the SAH evacuated, and the vessel is repaired.

Postoperatively, the patient is unresponsive.

The patient’s daughter is asked to consent to a non-emergent, life-saving operation since the patient is in a comatose state.

She does not consent to the operation even though the physician stresses it would be life-saving.

Upon further discussion, the physician finds out that the patient was abusive and neglectful to his children, and the daughter wants “to live in peace.” The patient has no written advanced directive.


On physical examination, the patient is unconscious with a GCS of 9/15 and is cyanotic.

The patient’s vitals are as follows: blood pressure 80/40 mm Hg, heart rate 111/min, respiratory rate 39/min, and temperature 37.1°C (98.8℉).

There are open fractures of the left femur and left tibia, a likely shoulder dislocation, multiple contusions on the limbs and thorax, and a puncture wound on the left side of his chest.

There are no breath sounds on the left side and there is hyperresonance to percussion on the left.

Preparations are made for an emergency needle thoracostomy to be performed to treat this patient’s likely tension pneumothorax.


The researchers collect data through interviewer-administered questionnaires (for behavioral and sociodemographic data) as well as through clinical and serological evaluation/screening methods for HIV and other sexually transmitted infections.

An additional aim is to evaluate the association between HIV acquisition and certain sociodemographic factors.


His hemoglobin concentration is 8.3 g/dL and mean corpuscular volume is 72μm3.

Colonoscopy shows a 2.3-cm polypoid mass in the ascending colon.

A photomicrograph of a biopsy specimen of the lesion is shown.


Her pain is not improved by over the counter analgesics.

Laboratory analysis is notable for a calcium level of 11.5 mg/dL, creatinine level of 2.0 mg/dL, and blood urea nitrogen level of 30 mg/dL.

Large eosinophilic casts are seen on renal biopsy.


Past medical history includes diabetes, congestive heart failure, and incontinence.

She is currently taking metformin, lisinopril, hydrochlorothiazide, metoprolol, and oxybutynin.

She could not get up without assistance and complained of severe pain in her right hip and buttock.

The nurse who evaluated her tried to stand her up, but when the patient tried to stand on her right leg, she dropped her left hip and lost her balance.

The nurse then recognized that her patient had a foreshortened right leg fixed in the adducted position and a large swelling in her right buttock.

Physical exam confirmed the nurse’s findings.

Radiographs proved the presence of a right posterior hip dislocation without fractures.

At the receiving hospital, the patient was confused and, though she knew her name, she couldn’t remember the date and insists to leave the hospital immediately to see her family.


She is healthy with no prior history of significant illness.

She exercises 3-4 times a week and eats a plant-based diet with no carbonated drinks.

When asked if anything is bothering her, she reports that she has been having recurring episodes of sneezing, congestion, and itchy eyes for the past year.

She denies any fever, sick contacts, cough, headaches, chest pain, urinary symptoms, or constipation/diarrhea during these episodes.

She is told to take a medication to alleviate her symptoms as needed.


Although she has not had any recent changes in her daily routines, she also complains of increasing fatigue, muscle weakness, and weight loss.

She has a blood pressure of 126/77 mm Hg, respiratory rate of 14/min, and heart rate of 88/min.

Physical examination reveals regular heart and lung sounds.

Anti-U1 RNP antibodies and increased creatinine kinase were found in her serum.


During high school, the patient went through similar episodes of low mood and poor sleep.

At that time, she would repeatedly engage in binge eating and purging behavior, for which she was referred to therapy.

During this time, she has also has had low energy and has lost interest in playing the guitar.

Her physician offers to prescribe a medication for her current symptoms.

There is no evidence of suicidal ideation.


He has hypertension and type 2 diabetes mellitus.

Current medications include glyburide, hydrochlorothiazide, and enalapril.

He reports that his vision has progressively improved over the past 6 months and he no longer needs the glasses he used while driving.

Examination shows 20/20 vision bilaterally.

Fundoscopy shows a few microaneurysms of retinal vessels.


Past records show that this patient has been in the ER 7 times in the past year with similar symptoms.

She also complains of diarrhea and nausea.

She is sexually active with one male partner and admits to having pain during intercourse.

There is vague and diffuse tenderness to palpation in all four abdominal quadrants.

No erythema or edema is noted on the right arm.


The patient has a history of severe meningoencephalitis at the age of 17 requiring four days in the intensive care unit.

During that episode, he reported seeing monkeys in his hospital room.

He is accompanied by his mother who reports that the patient recently experienced a 5-day episode of minimal sleep and unusual levels of energy.

The patient admits to spending $2,000 of his parent’s money, without asking, on a down payment for a motorcycle.

The patient’s medical history is notable for multiple month-long episodes in the past 2 years of feeling sad, sleeping more than usual, being uninterested in his hobbies, and feeling constantly tired and guilty.

He states that he feels sad and guilty about what happens.

On exam, he is a well-appearing, cooperative male in no acute distress.

He is alert and oriented with a normal affect.

The episode resolved after 5 days, at which point the patient felt guilty and upset.


She was diagnosed with ulcerative colitis 1 year ago but has had difficulty complying with her drug regimen.

Examination shows a distended, rigid abdomen and hypoactive bowel sounds.

Her temperature is 38.2°C (100.8°F), pulse is 120/min, and blood pressure is 92/56 mm Hg.


He felt a sudden difficulty in breathing and called for the ward nurse.

He says that he is unable to take deep breaths and has a sharp pain on the right side of his chest with each inspiration.

He experiences pain in his right calf on dorsiflexion.

He has been confined to bed for the past 5 days and is under observation.

His temperature is 37.5°C (99.8°F), the pulse is 111/min, the respirations are 31/min, and the blood pressure is 85/55 mm Hg.

There are no other prominent findings on physical examination.

His chest X-ray does not show anything significant.


The patient is a retired banking executive and was active as a triathlete until the age of 60.

He does not smoke and drinks 2-3 alcoholic beverages per day.

His family history is notable for normal pressure hydrocephalus in his mother and Alzheimer dementia in his father.

Approximately 6 months ago, she started noticing that he was walking more slowly than usual.

He has fallen more than 6 times in the past month, and she is worried that he will sustain a serious injury if he does not stop falling.

His temperature is 97.8°F (36.6°C), blood pressure is 131/81 mmHg, pulse is 68/min, and respirations are 19/min.

On exam, his movements appear slowed and forced.

Tone is increased in his upper and lower extremities bilaterally.


His mother says that he has not yet begun to walk.

He is at the 20th percentile for length, 10th percentile for weight, and 50th percentile for head circumference.

Physical examination shows erosion of the enamel on the lingual surface of the incisors and carious molars.

His wrists are widened, his legs appear bowed, and there is beading of the ribs.


The patient is in acute distress and cannot provide history due to disorientation.

On examination, his sclera and skin are icteric.

On abdominal examination, the patient moans with deep palpation to his right upper quadrant.

Temperature is 38.7°C (101.6°F), blood pressure is 80/50 mm Hg, pulse is 103/min, respiratory rate is 22/min, and BMI is 20 kg/m2.

Laboratory test
Complete blood count
Hemoglobin 14.5 g/dL
MCV 88 fl
Leukocytes 16,500/mm3
Platelets 170,000/mm3
Basic metabolic panel
Serum Na+ 147 mEq/L
Serum K+ 3.8 mEq/L
Serum Cl- 106 mEq/L
Serum HCO3- 25 mEq/L
BUN 30 mg/dL
Serum creatinine 1.2 mg/dL
Liver function test
Total bilirubin 2.8 mg/dL
AST 50 U/L
ALT 65 U/L
ALP 180 U/L
The patient is treated urgently with intravenous fluid, dopamine, and broad spectrum antibiotics.

On ultrasound of the abdomen, the common bile duct is dilated.

The patient’s blood pressure improves to 101/70 mm Hg.


Over the past 2 years, she has had five urinary tract infections.

Physical examination shows bilateral, nontender upper abdominal masses.

Serum studies show a urea nitrogen concentration of 29 mg/dL and a creatinine concentration of 1.4 mg/dL.

Renal ultrasonography shows bilaterally enlarged kidneys with multiple parenchymal anechoic masses.


She has a past medical history significant for sarcoidosis which was recently diagnosed 6 months ago and is currently being treated.

She reports that the pain started 2 weeks ago and is localized to the left hip and groin.

The pain has been getting progressively more intense.

Her temperature is 98.1°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Physical exam is notable for pain with manipulation without restriction of range of motion of the hip.


The patient states that he just arrived in the United States to live with his wife, with whom he is monogamous.

The patient denies painful urination or urethral discharge, but admits that 10 days ago he “felt like he had a fever” and the right side of his face was swollen and painful.


Pregnancy has been complicated by gestational diabetes.

Pregnancy and delivery of her first child were uncomplicated.

Current medications include insulin, folic acid, and a multivitamin.

Ten minutes later, the patient has dizziness.

The cervix is 100% effaced and 10 cm dilated; the vertex is at -1 station.

The fetal heart rate is reactive with no decelerations.

Her pulse is 68/min, respirations are 16/min, and blood pressure is 90/60 mm Hg.

Epidural anesthesia is performed and the patient's symptoms improve.

Intravenous fluid resuscitation is begun.


Her medical history includes asthma and sickle cell disease.

She takes hydroxyurea, uses oxycodone as needed for pain, and an albuterol inhaler as needed for shortness of breath.

She is accompanied by her son, who states that the patient had just returned home an hour ago from walking the dog when suddenly the patient stated she felt “strange.” When her son asked her what was wrong, her speech was slurred and her "face looked funny.” The son quickly called an ambulance.

The paramedic upon arrival noted that the patient had left-sided facial droop.

She has trouble articulating her words, and her speech is garbled.

The patient’s temperature is 97°F (36.1°C), blood pressure is 145/72 mmHg, pulse is 93/min, and respirations are 14/min with an oxygen saturation of 96% on room air.

On physical examination, a left-sided facial droop is appreciated.

She is put on 2 L of oxygen by nasal cannula.


Soon after hospitalization, he develops respiratory distress with crackles present bilaterally on physical examination.

Autopsy reveals heavy, red lungs and histology is shown in Image A.

The patient does not respond to mechanical ventilation and 100% oxygen and quickly dies due to respiratory insufficiency.


He has a history of several episodes of mild bone pain in the past treated with over the counter analgesics.

On physical examination, the child is icteric with nonspecific pain in his hands.

His hands are swollen, tender, and warm.

There is no chest pain, abdominal pain, fever, or hematuria.

A complete metabolic panel and complete blood count with manual differential are performed:
Total bilirubin
8.4 mg/dL
WBC
9,800/mm3
Hemoglobin
6.5 g/dL
MCV 82.3 fL
Platelet count  465,000/mm3
Reticulocyte 7%
Peripheral blood smear shows multiple clumps of elongated and curved cells and erythrocytes with nuclear remnant.

The patient's hemoglobin electrophoresis result is pictured below.


He was diagnosed with heart failure 1 year ago.

He reports that he has been taking low-dose aspirin and digoxin regularly for 1 year, and verapamil was recently added to prevent his frequent migraine headaches.

An electrocardiogram is performed urgently and shows paroxysmal atrial tachycardia with block.

Suspecting digitalis toxicity, the emergency medicine physician sends blood to the lab for a serum digoxin level, which is 3.7 ng/mL (therapeutic range: 0.8–2 ng/mL).

During his last visit to his primary care physician, he was doing well and the lab results were normal.


He has acute myeloid leukemia and is currently receiving chemotherapy.

On arrival, his temperature is 37°C (98.6°F), pulse is 63/min, respirations are 10/min, and blood pressure is 100/70 mm Hg.

He does not respond to any commands, but does groan.

Painful stimuli cause him to open his eyes and withdraw all extremities.

There are multiple bruises over the face, trunk, and right upper and lower extremities.

There is a 4-cm (1.6-in) laceration over his right cheek.

There are decreased breath sounds over the right lung base.

There is tenderness to palpation over the left chest wall.

Cardiac examination shows no abnormalities.

The abdomen is soft and shows diffuse tenderness to palpation with no guarding or rebound.

There is swelling of the right elbow and wrist.

The right lower extremity is shorter than the left lower extremity.

There are 2 lacerations around 2 cm (0.8 in) each on the right leg.


Due to the cumulative effects of diabetes, various health screenings and vaccinations are routinely recommended.


Past medical history is negative for any neurological and cardiovascular problems.

Consciousness is regained after cardiopulmonary resuscitation.

Physical examination reveals a prominent A wave on the jugular venous pulse and a double apical impulse.


The patient does not smoke cigarettes but reportedly drinks 2 glasses of wine daily.

He has multiple sexual partners and history regarding the contraceptive use is unavailable.

According to the attendants, he has complained of recurrent headaches for the past 2 weeks.

There is no history of fever, head trauma, or a seizure disorder.

The patient’s vitals include: blood pressure 137/88 mm Hg, temperature 37.2°C (99.0°F).

On physical examination, he is obtunded.

He grimaces on pain and localizes in response to pain in both upper extremities.

Pupils are bilateral 3-mm in diameter and equally round and reactive.

Laboratory tests are within normal limits.

An MRI of the brain with contrast is shown in the exhibit (see image).

A brain biopsy is performed that reveals perivascular clusters of lymphocytes.


She is gravida 1, para 0 with an estimated gestational age of 19 weeks.

She says that the murmur was found in her childhood, and the doctor at that time placed her under observation only.

However, she has been lost to follow-up and has not had proper follow up in years.

Currently, she complains of dizziness and occasional dyspnea on exertion which has gradually increased during her pregnancy.

Prior to her pregnancy, she did not have any symptoms.

The vital signs are as follows: blood pressure 125/60 mm Hg, heart rate 81/min, respiratory rate 13/min, and temperature 36.7°C (98.0°F).

Her examination is significant for acrocyanosis and a fixed splitting of S2 and grade 3/6 midsystolic murmur best heard over the left upper sternal border.


He denies taking any medications or illicit drugs and states he is generally healthy.

The patient states that he has not felt well for the past 24 hours and his symptoms are no longer tolerable.

Physical exam is notable for rhinorrhea, lacrimation, and piloerection.

During the exam, he begins actively vomiting.

His temperature is 99.3°F (37.4°C), blood pressure is 122/88 mmHg, pulse is 107/min, respirations are 19/min, and oxygen saturation is 99% on room air.

Physical exam demonstrates an ill appearing young man.

The patient’s pupils are dilated and reactive to light.

During placement of an ultrasound guided IV, multiple scars are noted in the antecubital fossa, and it is noted that it is very difficult to place an IV in this patient.


She and her husband recently bought a new house in the area.

She reports blacking out and waking up outside the house with a bandage on her arm.

The patient says she has tried to enter the house several times over the last several months but can not bring herself to cross the threshold for fear of more spiders.

While cleaning the house, they discovered a nest of spiders.

Her husband says that she began screaming and ran out of the house, breaking a window, and cutting her arm.

She wants to overcome her extreme and irrational fear.


He has long-standing hypertension, coronary artery disease, and hypercholesterolemia.

Current medications include aspirin, carvedilol, enalapril, and atorvastatin.

He reports that these symptoms seem to worsen with each fall.

Initially, he could not remember directions to his home but now cannot remember recent conversations or appointments he has made.

He often repeats questions that he asked shortly before.

Examination shows a bruise over the left temple and an unsteady gait.

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

Short-term memory is impaired; he can recall 0 out of 5 objects after 10 minutes.

Muscle strength is decreased in the left lower extremity.

The Babinski sign is present on the left.

He has no delusions or hallucinations.
A CT scan of the head is shown.


On examination, the cervix is 100% effaced and 10 cm dilated.

After 5 minutes of pushing, there is a prolonged deceleration of the fetal heart rate to 90/min.

A decision to perform an episiotomy is made to expedite vaginal delivery.

The anesthesiologist locates the ischial spines by palpating the posterolateral vaginal sidewall and administers an anesthetic.

Three minutes later, pinching the posterior vulva does not provoke pain.


She has not been compliant with antiretroviral or prophylactic medication.

On evaluation, the patient is in moderate respiratory distress.

After 30 minutes, the patient develops severe respiratory distress.

The temperature is 38.8°C (102.0°F), the blood pressure is 124/82 mm Hg, the pulse is 96/min, and the respiratory rate is 20/min.

Pulse oximetry is 92% on 4 L oxygen by nasal cannula.

Repeat vital signs show: temperature 38.3°C (101.0°F), blood pressure 80/50 mm Hg, pulse 104/min, respiration rate 32/min and pulse oximetry 85% on nasal cannula.

Breath sounds are absent on the right side and the neck veins are distended.

IV antibiotics and glucocorticoids are administered.


Physical examination shows tenderness to palpation over the left adnexa and rebound tenderness in the left lower quadrant.

Her last menstrual period was 2 weeks ago.

There is no tenderness in the right lower quadrant.

An ultrasound is ordered to confirm the diagnosis of ruptured ovarian cyst.


She has a history of major depressive disorder but has been off medications for the past 3 years.

Her father had Parkinson's disease and died 6 months ago.

She has noticed trembling of her hands for the past 5 months.

These movements are only present when she reaches to pick up an object or answer the phone.

Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 118/74 mm Hg.

A low-frequency tremor is present that worsens as she reaches out for an object.

There is no tremor present when her arms are held outstretched.

There is increased tone in the lower extremities and Babinski's sign is positive bilaterally.


Four months ago, he had an episode of narrow-angle glaucoma.

He reports having clear liquid discharge from his nose and sneezing.

He says that his symptoms began suddenly the previous night, 30 minutes after he had dinner at a seafood restaurant.

He has had similar symptoms occasionally in the past as well.

His vital signs are within normal limits.

Nasal exam shows clear, serous secretions, with edematous and erythematous mucosa and turbinates.

Paranasal sinuses are not tender to palpation.


He lives in a conservative community and does not know any openly gay men.

Two days ago, he joined a local group considered by many organizations to be a hate group.

Together with the other members, he attacked a gay couple on their way home from dinner.


The patient was previously healthy except for mild untreated hypertension.

The patient states that she has noticed a pink tinge to her urine as well.

Of note, she has not had any fevers, but endorses several months of fatigue and constipation.

On exam, her temperature is 98.6°F (37.0°C), blood pressure is 130/84 mmHg, pulse is 76/min, and respirations are 12/min.

On further workup, the patient is found to have calcium oxalate nephrolithiasis with hypercalciuria.

Blood studies demonstrate increased parathyroid hormone (PTH) and hypercalcemia.


She has felt tired and unwilling to engage in any activities lately.

She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort.

She no longer finds any happiness in activities that she previously enjoyed.

She also states that she really struggles to sleep and at times can't sleep for several days.

The patient is started on appropriate first-line therapy and sent home.

She returns 1 week later stating that her symptoms have not improved.

She is requesting help as her performance at work and school is suffering.


Since almost a year and a half ago, she intentionally restricted her diet at the expense of carbohydrates, exercised intensively, and lost 18.0 kg (39.7 lb).

On physical examination, the vital signs include blood pressure 100/60 mm Hg, heart rate 55/min, respiratory rate 12/min, and temperature 35.9°C (96.6°F).

Her weight is 55.0 kg (121.3 lb), and her height is 166 cm (5 ft 5 in).

Physical examination reveals the good development of muscles and decreased adiposity.

A bone scan shows decreased calcium mineral deposits.

She had her menarche at the age of 12 and menstruated normally until last year.


Her sore throat is worse on the right side.

She has difficulty swallowing and opening her mouth due to pain.

She has also noticed a change in the quality of her voice over the last day.

Her temperature is 38.2°C (100.8°F), pulse is 86/min, respirations are 18/min, and blood pressure is 110/75 mm Hg .

Examination shows cervical lymphadenopathy.

Oropharyngeal examination shows erythematous tonsils and swelling of the right tonsillar pillar.


She has had a lot of stress at work and has been on sick leave for 2 weeks, but states that she would like to return to work.

She was diagnosed with peptic ulcer disease 6 months ago.

She has had several episodes of lower abdominal pain.

On mental status examination she is tired and has a depressed mood.

There are numerous crusts along the course of her left arm veins.

There is generalized weakness of the proximal muscles.

Her temperature is 36.5° C (97.7° F), pulse is 120/min, and blood pressure is 90/65 mm Hg.

Physical examination shows pale conjunctivae and dry mucous membranes.

A grade 2/6 systolic ejection murmur is heard along the right-upper sternal border.

Abdominal examination shows no abnormalities.

Laboratory studies show:
Hemoglobin 7.5 g/dL
Mean corpuscular volume 89 μm3
Reticulocyte count 13.3%
Serum
Sodium 139 mEq/L
Potassium 3.9 mEq/L
Calcium 8.5 mg/dL
Test of the stool for occult blood is negative.

Abdominal ultrasonography show no abnormalities.


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

Examination shows jaundice of the skin and conjunctivae.

Abdominal examination shows moderate tenderness over the liver.

Her temperature is 38.3°C (100.9°F), pulse is 80/min, and blood pressure is 138/76 mm Hg.

The liver is palpated 2 to 3 cm below the right costal margin.

Laboratory studies show:
Hemoglobin count 12.0 g/dL
Leukocyte count 10,400 mm3
Segmented neutrophils 55%
Bands 1%
Eosinophils 13%
Lymphocytes 28%
Monocytes 3%
Platelet count 160,000 mm3
Serum
Alkaline phosphatase 102 U/L
Aspartate aminotransferase 760 U/L
Bilirubin
Total 3.8 mg/dL
Direct 3.1 mg/dL
Anti-HAV IgG positive
Anti-HAV IgM negative
Anti-HBs positive
HBsAg negative
Anti-HCV antibodies negative
Abdominal ultrasonography shows an enlarged liver.

A biopsy of the liver shows massive centrilobular necrosis.

During the surgery, she received a transfusion of 1 unit of packed red blood cells.

Three days after the surgery, she was stable enough to be transported back to the United States.


She has type 2 diabetes mellitus and hypertension.

Home medications include metformin, amlodipine, and enalapril.

She has also had several episodes of nosebleeds that resolved with compression after a few minutes.

Her vital signs are within normal limits.

Physical examination shows pale conjunctivae.

There are ecchymoses and petechiae over the upper extremities, chest, and back.

She recently completed treatment for a urinary tract infection.

Her last menstrual cycle was 5 years ago.

The remainder of the physical examination is unremarkable.


He did not take any medications, did not smoke, and had no family history of gastric cancer.

At the last visit a few months ago, he explained that he had been experiencing discomfort in his upper abdomen for awhile.

Today, despite the PPI, the patient says he is still experiencing discomfort.

At that time, the doctor empirically started him on a proton pump inhibitor (PPI).

He had never vomited up any blood and had not had any substantial weight loss.

Hearing this, the doctor decides to order a urease breath test.


She reports that she and her husband had been trying to have a child for the past three months.

She has no history of sexually transmitted disease, intravenous drug use, or blood transfusions, and she has never traveled outside of the United States.

She was up-to-date on all immunizations before her pregnancy.

Ultrasound is consistent with an 8-week gestational sac.

The patient requests as few tests as possible, although she does not want to compromise the health of her fetus.


The patient’s wife is with him and states that her husband is always complaining and critical of others.

He was recently fired from his job to which he claims that his boss was jealous of his hard work.

He also does not trust his neighbors and thinks they are out to get all the nice things he has.

His wife also says that he has begun to doubt her fidelity and believes that even the marriage counselor is on her side.


The patient has a past medical history of polysubstance abuse, depression, multiple suicide attempts, neuropathic pain, and schizophrenia.

He was found unconscious and covered in bruises outside of a local bar.


The dad reports he then heard a click and the patient immediately began to cry.

She does allow passive flexion and extension with full range of motion but supination is limited and causes pain.

On examination, the patient is holding her right forearm in a pronated position and her elbow slightly flexed.

Pain is localized to the lateral aspect of the elbow.

The mother reports that they were walking in the park and the patient’s dad was swinging the patient in the air by her arms.


He denies any headaches or change in vision.

A muscle biopsy reveals CD8+ lymphocyte infiltration in the endomysium.


He was born at 38 weeks gestation via a spontaneous vaginal delivery without any complications.

The mother reports that her child has difficulty rolling from his back to his front and sitting unsupported.

The patient is able to smile and furrow his brow normally, but she has noticed that he has a weak cry and suck.

The mother said that the patient appeared "normal" until the past few weeks.

On physical exam, his extraocular muscle movements are intact, and a symmetric smile is seen.

He has symmetric flaccid weakness of both his upper and lower extremities.


During this period, he has had 12 bowel movements.

He was born at 38 weeks' gestation and weighed 1800 g (3 lb 15 oz); he currently weighs 1700 g (3 lb 12 oz).

She has a history of intravenous heroin use.

Examination shows mild diaphoresis and a firm 2-cm midline neck swelling.

His temperature is 36.9°C (98.4°F), pulse is 180/min, and respirations are 50/min.

His mother has Graves' disease and received propylthiouracil during the last trimester of pregnancy.


He has also had pain in the right ankle for 3 days and pain and swelling in the left knee for 1 day.

Two weeks ago, he had several days of fever and bloody diarrhea, for which he was treated with antibiotics.

Examination shows a small left knee effusion and bilateral conjunctival injection.


Examination shows a 2.5-cm (1-in) firm, irregular swelling on the left side of the neck that moves with swallowing.

There is painless cervical lymphadenopathy.

Ultrasound of the neck shows a solitary left lobe thyroid mass with increased vascularity and hyperechogenic punctate regions.

A fine needle aspiration biopsy is scheduled for the following week.


He has been discontinuing heroin over the last month as part of his treatment plan.

He is HIV positive, hepatitis B (HBV) positive, and was recently treated for an infection with Streptococcus pneumoniae.

He reports pain over his abdomen, knees, and shoulder.


On physical examination, his temperature is 36.9ºC (98.4ºF), pulse rate is 110/min, blood pressure is 102/74 mm Hg, and respiratory rate is 16/min.

A resident working under the physician plots a Darrow-Yannet diagram for the patient.

The diagram is shown in the picture where the green dotted line represents the new fluid status.


Her only past medical history is migraines for which she takes appropriate medication.

She describes the pain as squeezing and tightness in her chest.

This pain has been happening every few days for 3 months.

She says there is no association of the pain with food or exercise.

She is able to climb up to her fourth floor apartment daily without issue.

Here temperature is 98.6°F (37°C), blood pressure is 120/68 mmHg, pulse is 60/min, respirations are 16/min, and oxygen saturation is 98% on room air.

The patient is not in pain on presentation and EKG in the office is normal.

24-hour ECG monitoring shows transient ST elevations during the episodes of pain that resolve completely.


She cannot confirm her vaccination history.

She complains of a rash involving her chest, face, and arms, a watery nasal discharge, and mild bilateral knee pain.

She has had these symptoms for about 5 days.

The symptoms do not seem to bother her too much, but she is concerned for the baby.

Her vital signs are as follows: blood pressure, 110/70 mmHg; heart rate, 89/min; respiratory rate, 12/min; and temperature, 37.6℃ (99.7℉).

Examination shows a moderately dense maculopapular lacy rash spread over the patient’s trunk, extremities, and face.

No lymph node, liver, or spleen enlargement is noted.

She had contact with her younger sister, who also had a rash and was diagnosed with rubella infection about 10 days ago at a family gathering.


She is sexually active with multiple partners and admits to using barrier protection inconsistently.

The patient denies any fever, chills, abdominal pain, menorrhagia, or flank pain.

She is afebrile and the vital signs are within normal limits.

Speculum examination reveals vaginal erythema with a profuse, greenish-yellow, purulent, malodorous discharge.

Vaginal swab and urine samples are obtained for microscopy and culture, and results are pending.

Her last menstrual period was 2 weeks ago.


Post-operatively, she reports a hoarse voice and difficulty speaking.

You suspect that this is likely a complication of her recent surgery.


His mother reports that he had trouble breathing soon after he started playing soccer with some friends and was unable to use his inhaler as it was empty.

The child’s temperature is 99.0°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 130/min, respirations are 28/min, and oxygen saturation is 91% on room air.

Physical examination demonstrates wheezing bilaterally in all lung fields.

The child is started on supplemental oxygen and a nebulized bronchodilator.

His family history is notable for emphysema in his paternal uncle and cirrhosis in his maternal grandfather.


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

He complains of increasing fatigue and dyspnea.

His temperature is 36.7°C (98.1°F), pulse is 90/min, respiratory rate is 18/min, and blood pressure is 125/70 mm Hg.

The examination of the heart and lungs shows no abnormalities.

The splenic margin is palpable 8 cm (3.1 in) below the costal margin.

Laboratory studies show:
Hemoglobin 8 g/dL
Mean corpuscular volume 90 μm3
Leukocyte count 3,000/mm3
Platelet count 85,000/mm3
Peripheral blood smear shows small lymphocytes with cell membrane projections.

Cell immunophenotyping is positive for CD25.


His symptoms started a few days ago and have been gradually worsening.

Initially, the patient had a fever and a cough which has progressed to abdominal pain, diarrhea, and confusion.

Laboratory studies are ordered as seen below.

His temperature is 102°F (38.9°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 94% on room air.

Physical exam is notable for localized crackles and decreased breath sounds in the left lower lung field.

The patient is confused and is answering questions inappropriately.


He has bronchial asthma treated with inhaled salbutamol.

He is struggling to open this eye because of the pain.

The vital signs include: temperature 37.0°C (98.6°F), pulse 85/min, and blood pressure 135/75 mm Hg.

The examination shows a visual acuity in the left eye of 20/25 and the ability to count fingers at 3 feet in the right eye.


He describes himself as being “generally healthy” before the cough began.

Past medical history includes hypertension.

The patient takes clopamide and a multivitamin daily.

His parents are both well and living in a senior living facility.

He does not smoke and only drinks alcohol occasionally.

During a review of symptoms, the patient described a hiking trip in and around the desert near Phoenix, Arizona, 4 months ago.

At the office, his temperature is 38.6°C (101.4°F), heart rate is 102/min, respirations are 20/min, and blood pressure is 120/82 mm Hg.

A focused chest exam reveals mild fremetus and dullness with percussion on the right side.

A chest X-ray shows a right-sided consolidation of the lower right lung, and a chest CT shows an irregular opacity measuring 3.8 cm x 3.0 cm in the sub-plural region of the right middle lobe, a small right-sided pleural effusion, and mild right-sided hilar adenopathy.

A lung biopsy is performed to rule out cancer and reveals necrotic granulomatous inflammation with multinucleated giant cells and spherules with endospores in the surrounding tissues.


He was in school when his teacher noted a drooping of his left face.

His temperature is 99.9°F (37.7°C), blood pressure is 122/89 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Physical exam is notable for facial asymmetry and 4/5 strength in the patient's upper and lower extremity.

A CT scan of the head does not demonstrate an intracranial bleed.


She is exclusively breastfed every 3–4 hours for 15–20 minutes.

She was delivered vaginally at 38 weeks' gestation at home and has not yet been evaluated by a physician.

The infant is at the 5th percentile for height and weight.

The infant has not received any immunizations.

Over the past month, she has had several episodes of watery stools.

The mother reports that her child is not gaining weight.

Her temperature is 38.5°C (101.3°F), pulse is 155/min, respirations are 45/min, and blood pressure is 88/50 mm Hg.

Oral examination shows white plaques covering the tongue and the palate.

Rales are heard bilaterally on cardiopulmonary examination.

Cervical and inguinal lymphadenopathy is present.


She returned from a business trip to Sudan 3 weeks ago.

She denies eating any seafood while traveling.

Medications include iron supplements and a multivitamin.

Her immunizations are up-to-date and she has never received blood products.

Her temperature is 38.9°C (102°F), pulse is 92/min, and blood pressure is 122/76 mm Hg.

Examination shows jaundice and mild asterixis.

Pelvic examination shows a uterus consistent in size with a 22-week gestation.

Laboratory studies show:
Hemoglobin 11.2 g/dL
Prothrombin time 18 sec (INR=2.0)
Serum
Total bilirubin 4.4 mg/dL
Alkaline phosphatase 398 U/L
AST 4,702 U/L
ALT 3,551 U/L
Lactate dehydrogenase 3,412 U/L
Anti-nuclear antibody negative
Anti-smooth muscle antibody negative
Anti-CMV antibody negative
Anti-EBV nuclear antigen antibody negative
An ELISA for HIV is negative.


His father underwent surgery for colon cancer 3 years ago.

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

The vomitus consists of undigested food and he has also had dark brown emesis twice today.

He has been having early satiety during this period.

He has had progressive severe episodic epigastric pain and dyspepsia for the past week.

The pain is partially relieved with food or over-the-counter antacids, but worsens at night and several hours after eating.

He has also had a weight gain of 2 kg (4.4 lbs) during this period.

His temperature is 37.1°C (98.8°F), pulse is 106/min and blood pressure is 108/68 mm Hg.

The abdomen is mildly tender to palpation in the left upper quadrant; there is a tympanitic mass in the epigastrium.

A succussion splash is heard with a stethoscope when the patient is rocked back and forth at the hips.

Test of the stool for occult blood is positive.


He has hypercholesterolemia and hypertension.

He has smoked a pack of cigarettes daily for 34 years.

His current medications include atorvastatin, enalapril, and hydrochlorothiazide.

For the past 5 days, he has had intermittent stabbing pain in the middle of his chest that worsens with lying down or taking deep breaths.

He has also had a runny nose and a dry cough for the past 2 weeks.

His temperature is 38.3°C (100.9°F), pulse is 105/min, and respirations are 25/min.

Blood pressure is 107/72 mm Hg during expiration and 86/65 mm Hg during inspiration.

Examination shows jugular venous distention and pitting edema below the knees.


The patient has a past medical history of type II diabetes and is currently taking lisinopril, metformin, insulin, and fish oil.

The patient states that his symptoms came on while he was sleeping.

On physical exam, you note bipedal edema and jugular venous distention (JVD).

An EKG and chest radiographs are obtained (Figures A and B).

The patient is started on BIPAP and medical therapy and his symptoms improve rapidly.


She says that she has always felt a little short of breath compared to her friends; however, she did not think that it was abnormal until she started trying a new exercise regimen.

On physical exam, she is found to have mild conjunctival pallor and a peripheral blood smear is obtained showing echinocytes but no intracellular accumulations.

Upon further questioning, she recalls that several relatives have had similar issues with fatigue and pallor in the past.


During high school, the patient went through similar episodes of low mood and poor sleep.

At that time, she would repeatedly engage in binge eating and purging behavior, for which she was referred to therapy.

During this time, she has also had low energy and lost interest in playing the guitar.

The physician offers to prescribe a medication for her current symptoms.

There is no evidence of suicidal ideation.


He was born at 37 weeks' gestation, and the neonatal period was uncomplicated.

His mother reports that he has had multiple episodes of loose stools over the past 3 months.

He has been treated for otitis media 4 times and bronchiolitis 3 times since birth.

He is at the 10th percentile for height and 3rd percentile for weight.

His temperature is 38.3°C (100.9°F), pulse is 126/min, and respirations are 35/min.

Examination shows an erythematous scaly rash over his trunk and extremities.

The white patches on the tongue and buccal mucosa bleed when scraped.

Inspiratory crackles are heard in the right lung base.

An X-ray of the chest shows an infiltrate in the right lower lobe and an absent thymic shadow.


She has a history of hypertension and major depressive disorder.

Current medications include hydrochlorothiazide, aspirin, prophylactic unfractionated heparin, and fluoxetine.

Examination shows multiple hematomas on the upper extremities around the peripheral intravenous access sites.

The right calf is tender, erythematous and swollen.

Her temperature is 37.3°C (99.1°F), pulse is 90/min, and blood pressure is 118/92 mm Hg.

Cardiac examination shows an aortic click.


Physical examination shows hepatomegaly.

Laboratory studies show an α-fetoprotein concentration of 380 ng/ml (N < 10 ng/mL).

A CT scan of the abdomen with contrast shows a solitary mass in the left lobe of the liver that enhances in the arterial phase.


She is sexually active with multiple partners and has no history of intravenous drug use.

She also notes easy bruising and bleeding from her gums when brushing her teeth.

Physical exam is remarkable for petechiae and scattered ecchymoses on the patient's bilateral upper and lower extremities.

Laboratory results are as follows: Hgb 13.0 g/dL, WBCs 6,000/mL, platelets 95,000/mL, PT 13.2s, aPTT 30s.

Peripheral blood smear shows normocytic, normochromic red blood cells and few platelets with no morphologic abnormalities.


He was diagnosed with a gene defect on chromosome 7, which has caused dysfunction in a transmembrane protein.

This defect has resulted in several hospitalizations for various respiratory infections.

His temperature has ranged from 38.6°C–39.5°C (101.5°F–103.1°F) over the past week.

At the present time, he is struggling with a cough with thick purulent sputum.

A sputum sample is sent for culture and the patient is started on vancomycin.The pediatrician tells the patient’s family that there is a collection of mucus in the respiratory tree which increases the patient's chances of future infections.

He will have to undergo chest physiotherapy and they should report any signs of infection immediately to a medical professional.


The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours.

Her older son had a similar problem with vomiting that resolved around 12 months of age.

The patient’s mother is concerned that her milk production is not keeping up with the patient’s nutritional requirements.

She reports that about two weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds.

She reports that he seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards.

The patient’s mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of the regurgitation.

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

On physical exam, the patient is cooing in his mother’s lap and smiles reciprocally with her.

He lifts his head and shoulders off the examination table when placed in the supine position.

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

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

Four weeks ago, the patient’s height and weight were in the 40th and 34th percentiles, respectively.


In addition to the pain from the wound, he complains of weakness in his left leg.

Upon physical examination you find that he has no other visible injuries; however, he has 2/5 strength in the left lower extremity.

Complete neurologic exam also finds a deficit in vibration sense and light touch on the left lower extremity as well as a loss of pain and temperature sensation in the right lower extremity.


He says he has been unsuccessful at losing weight and would like help.

Past medical history is significant for obstructive sleep apnea (OSA) and hypertension.

Current medications are isosorbide dinitrate/hydralazine and aspirin 81 mg orally daily.

The patient denies any history of smoking or recreational drug use and drinks 1 or 2 beers on weekends.

Family history is significant for prostate cancer in his father and hypertension and diabetes mellitus type 2 in his mother.

His vital signs include: temperature 36.8°C (98.2°F), pulse 97/min, respiratory rate 16/min, blood pressure 120/75 mm Hg.

His last colonoscopy was 8 years previously, which was normal.


While observing sinus tachycardia on the patient's telemetry, you note that the radial pulse cannot be palpated during inspiration.

An EKG shows sinus tachycardia and chest radiograph reveals an enlarged cardiac silhouette.


He has smoked a pack of cigarettes daily for the past 40 years.

He drinks a beer daily and occasionally more on weekends.

He is 183 cm (6 ft 0 in) tall and weighs 66 kg (145 lbs); BMI is 19.7 kg/m2.

He does not experience shortness of breath at rest.

He has not had fever, chills, or night sweats.

His temperature is 37°C (98.6°F), pulse is 94/min, respirations are 21/min, and blood pressure is 136/88 mm Hg.

Lung auscultation reveals a prolonged expiratory phase and end-expiratory wheezing.

Spirometry shows an FEV1:FVC ratio of 62%, an FEV1 of 60% of predicted, and a total lung capacity of 125% of predicted.

The diffusion capacity of the lung (DLCO) is decreased.


As soon as the infant is clear of the vagina, a congenital malformation of the abdomen is observed.

Visual inspection shows loops of intestine protruding out of his abdomen on the right side.

His APGAR scores are 7 at 1 minute and 9 at 5 minutes.

His heart rate is 125/min, and his respirations are 45/min.

The infant is removed from the delivery room for further evaluation.


Past medical history is significant for rheumatoid arthritis diagnosed 23 years ago for which she takes naproxen as needed.

Her vital signs include: temperature 36.9°C (98.4°F), blood pressure 135/88 mm Hg, pulse 92/min.

Physical examination is significant for conjunctival pallor and bilateral ulnar deviation of the metacarpophalangeal joints.


His past medical history is significant for allergic rhinitis.

His mother brings him into your office because she feels she has had to increase the patient’s use of his inhaler to four times per week for the past month.

She also reports that he has woken up three times during the night from his symptoms this month.

The boy reports that he is upset because he can’t always keep up with his friends in the playground.

The patient’s temperature is 98°F (36.6°C), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 98% O2 on room air.

Auscultation of his lungs reveals bilateral late expiratory wheezes.


She has not had any changes in diet or lifestyle but reports weight loss despite an increase in appetite.

In addition, she has been experiencing chest palpitations, increased frequency of diarrhea, and heat intolerance.

Physical exam of her thyroid is unremarkable but her TSH was found to be 0.21 mIU/L.

A complex structure in her right ovary was detected on ultrasound.


Past medical history is noncontributory and he takes no medication.

On examination, he is very pale and his spleen is enlarged.

His temperature is 36.5°C (97.7°F), the blood pressure is 100/60 mm Hg and the pulse is 100/min.

His hemoglobin is 5 g/dL and platelet count is slightly reduced.

His peripheral blood smear is shown in the picture.

His father and aunt both suffer from mild anemia.

Over the next 2 weeks, the patient recovers, and his hemoglobin is 11 g/dL.


He is a bodybuilding competitor and has a competition coming up in 1 week.

He also complains of a gradual decrease in vision over the past 3 months.

The man reports that his symptoms appeared suddenly, 30 minutes after he took 2 foreign-manufactured fat-burning pills instead of the 1 he usually takes.

His blood pressure is 140/90 mm Hg, heart rate is 137/min, respiratory rate is 26/min, and temperature is 39.9°C (103.8°F).

Physical examination reveals a reddish maculopapular rash over the patient’s trunk, diminished lung and heart sounds, tenderness to palpation in his abdomen, and rotational bilateral nystagmus with an alternating gaze-dependent fast component.

Ophthalmologic examination shows bilateral cataracts.


She works as a professional ballet dancer and says, “I'm always trying to be in shape for my upcoming performances.” She is 163 cm (5 ft 4 in) tall and weighs 45 kg (99 lb); BMI is 17 kg/m2.

Physical examination shows tenderness and limited range of motion in her right knee.

Oral examination shows bleeding and swelling of the gums.

There are diffuse petechiae around hair follicles on her abdomen and both thighs.

Laboratory studies show a prothrombin time of 12 seconds, an activated partial thromboplastin time of 35 seconds, and a bleeding time of 11 minutes.

Arthrocentesis of the right knee shows bloody synovial fluid.


She has had regular menses since menarche at the age of 12.

She has no history of serious illness but is allergic to certain jewelry and metal alloys.

She does not wish to become pregnant until she finishes college in six months.

Her last menstrual period was 3 weeks ago.


The patient has no other significant past medical history and takes no other medications.

She says she has been compliant with her medication but has experienced no improvement.

The patient presents 2 weeks later with an acute onset rash on her torso consisting of targetoid lesions with a vesicular center.

She says the rash developed 2 days ago which has progressively worsened.

She also says that 1 week ago she developed fever, lethargy, myalgia, and chills that resolved in 3 days.

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

The patient is switched to a different medication.