EOR - PC1

Esophageal web

- Non-circumferential, thin, squamous, mucosal membrane in mid or upper portion of esophagus - Clinical: Typically asymptomatic --- May cause dysphagia to solids only - Associated with severe iron deficiency and dysphagia • Plummer-Vinson syndrome - Treatment: esophageal bougie

Peritonsillar abscess

- Severe sore throat, fever, odynophagia - PE: anterior chain adenopathy, drooling, trismus, "hot potato" voice, asymmetry of oropharynx with uvula deviation - Leukocytosis

Pulmonary stenosis

A full-term 3.3 kg newborn nondysmorphic girl is found to have a systolic ejection murmur shortly after birth. She is clinically asymptomatic and fully saturated while breathing room air.

Bacterial meningitis

A 1-month-old girl presents to her primary care physician with a high fever that has lasted 24 hours, feeding difficulties, and irritability. Examination reveals altered mental status and a bulging fontanel.

Atopic dermatitis

A 12-year-old female presents with dry, itchy skin that involves the flexures in front of her elbows, behind her knees, and in front of her ankles. Her cheeks also have patches of dry, scaly skin. She has symptoms of hay fever and has recently been diagnosed with egg and milk allergy. She has a brother with asthma and an uncle and several cousins who have been diagnosed with eczema.

Bipolar (child)

A 13-year-old girl has been treated for ADHD since she was 4 years old, and her parents describe her behavior as deteriorating over the past year. She has always been oppositional and impulsive, and has struggled academically, but more recently she has become increasingly irritable and sexually provocative, with several recent boyfriends. She has trashed the house on several occasions, and her parents have discovered she has been accessing pornography on the internet and suspect she has been using cannabis. Several months ago, her parents separated acrimoniously and her mother has a new partner. When interviewed, she is wearing a lot of make-up and revealing clothing, and behaves in a seductive manner, talking rapidly. She is disinhibited, inattentive, and restless, and explodes angrily toward her parents. She describes high levels of energy, and her mood fluctuates from irritable to low, with occasional suicidal thoughts. There is a family history of ADHD, depression, and bipolar disorder.

Salmonellosis

A 14-year-old boy presents with nausea, vomiting, and diarrhea. Eighteen hours earlier, he had been at a picnic where he ingested undercooked chicken along with a variety of other foods. He reports moderate-volume, nonbloody stools occurring 6 times a day. He has mild abdominal cramps and a low-grade fever. He is evaluated at an acute care clinic and found to be mildly tachycardic (heart rate 105 bpm) with a normal BP and a low-grade temperature of 100.1°F (37.8°C). His physical exam is unremarkable except for mild diffuse abdominal tenderness and mild increased bowel sounds. He is able to take oral fluids and is instructed on the appropriate oral fluid and electrolyte rehydration.

Bipolar (child)

A 15-year-old boy is brought to the ER by his parents owing to uncontrollable behavior over the previous month. The family had returned early from vacation because he had dismantled the hotel room in the belief that he was being monitored by the FBI and, because he had special telepathic powers, was on trial for a position as a secret agent. In the 3 months leading up to this episode he was stressed with his school work and was up late at night studying. Several relatives had a history of bipolar disorder, and he had been treated for depression after the death of a grandparent 2 years previously. When interviewed, he speaks rapidly, changing the subject frequently, convinced he is going to be summoned to the White House as a security adviser. He has been sleeping 3 hours a night, describes high levels of energy, and makes inappropriate comments.

Bipolar (adult)

A 20-year-old man presents to the ER accompanied by his parents, owing to a change in mental status and behavior, marked by uncharacteristic argumentativeness, eruptions of laughter, excessive talking, and unusual thoughts. He is being treated for depression and insomnia, and has recently been drinking more alcohol. For the past 2 weeks, he has missed college classes, while staying up most nights until 4 or 5 a.m., writing feverishly into several notebooks. When asked, he reports that he is writing 2 novels at the same time and also documenting his accomplishments in an autobiography. He denies any illicit substance use while admitting to increasing alcohol consumption "like all the great novelists do." Efforts by his family to understand his recent change in thinking and behavior have been met with loud and rambling discourses, and he angrily accuses them of wanting him to stay "subjugated by the tyranny of depression."

Generalized anxiety disorder

A 25-year-old female presents to her primary care physician with complaints of muscle tension, especially in her shoulders and neck, contributing to tension headaches. She describes decreased sleep, chronic fatigue and constant restlessness in addition to poor concentration at work, with repeated run-ins with her coworkers. She has been a worrier since childhood, with worsening bouts when under stress; currently she reports having a hard time controlling her worry, which extends into several topics. Physical exam reveals a healthy, tense female with normal vital signs and generalized muscular tension. She does not abuse substances, and medical history is unremarkable.

Iron deficiency anemia

A 25-year-old gravida 3 para 3 female presents with a history of fatigue, ice craving, and dyspnea upon exertion. She was unable to tolerate her prenatal vitamins during pregnancy, because of nausea. Examination reveals pallor and spooning of her nails. Vital signs are normal. There is no lymphadenopathy or hepatosplenomegaly.

Vaginitis

A 25-year-old white woman presents to the office with malodorous vaginal discharge and pruritus for the last 15 days. She reports the smell is worse after intercourse and the discharge is white. She is in a stable monogamous relationship and has never been pregnant. She denies any significant medical or gynecological history. She reports this is the first time she has had these symptoms and is worried about STDs. Physical examination shows a white discharge in the posterior vaginal fornix, but there is no vaginal erythema or bleeding.

Bulimia nervosa

A 25-year-old woman complains that she is obsessed with eating and weight. She has tried unsuccessfully to lose weight. She becomes so hungry that she overeats to the point of regurgitating.

Fungal meningitis

A 25-year-old woman presents with increasing headache for 3 to 4 weeks together with confusion, nausea and vomiting, and diplopia for 1 week. On examination she is drowsy, but is able to cooperate with the medical examination. On neurologic examination she has a left 6th cranial nerve palsy and has reduced visual acuity and papilledema. There are no further positive findings on examination.

Bulimia nervosa

A 30-year-old woman presents with marked weight fluctuations. She says that her weight has changed by 3 kg over a few days, unrelated to menstruation. Physical exam is normal except for bilateral parotid hypertrophy.

Hyperthyroidism (toxic thyroid adenoma)

A 30-year-old woman presents with several months of gradually increasing heat intolerance and nervousness. She has lost 2 to 3 kg. There is no history of head and neck irradiation. She grew up in a mountainous area of Greece and recently immigrated to the US. Her grandmother had a goiter. Physical exam reveals a mildly anxious woman with pulse 90 bpm and BP 140/60 mmHg. There is a 4-cm mobile right-sided thyroid nodule without lymphadenopathy or bruit. She has mild stare and lid lag without exophthalmos; warm moist skin; and a slight tremor. Reflexes are brisk. The remainder of the exam is normal.

Hyperthyroidism (painless lymphocytic thyroiditis)

A 31-year-old woman is 4 months postpartum, breastfeeding, and found to have a resting heart rate of 92 bpm. She has a slightly enlarged non-nodular, nontender thyroid and no proptosis. Serum TSH is undetectable, free T4 and T3 are modestly elevated, and thyroid peroxidase antibodies are positive. The ratio of total serum T3 to T4 is 12.

Bipolar (adult)

A 32-year-old nurse presents to her primary care provider complaining of frequent headaches, irritable bowel, insomnia, and depressed mood. She currently takes no medication and has no history of substance abuse or major medical problems beyond treatment for a single depressive episode when she was a college freshman. Her physical exam, routine labs, and CT brain are all within normal limits. Her family history is notable for several ancestors who have been affected by psychiatric illness, including depression, bipolar disorder, and schizophrenia. Her paternal grandfather and a maternal aunt committed suicide. She has had 3 prior episodes of several weeks' duration characterized by insubordinate behavior at work, irritability, high energy, and decreased need for sleep. She regrets impulsive sexual and financial decisions that she took during these episodes, and has recently filed for personal bankruptcy. For the past month her mood has been persistently low, and she has had reductions in sleep, appetite, energy, and concentration, with some passive thoughts of suicide.

Migraine headache (adult)

A 32-year-old woman presents with a 13-year history of 1 to 3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On 4 occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field and then faded away over 45 minutes. Examination is normal.

Cystitis (interstitial) / Bladder pain syndrome

A 33-year-old woman presents with a history of experiencing sudden, strong urges to urinate without incontinence since the age of 14 years and with concomitant pelvic pain from the age of 22 years. She has been evaluated by several urologists/gynecologists and has undergone multiple cystoscopies and laparoscopies. She has previously had diagnoses of endometriosis, menorrhagia, recurrent bacterial cystitis, and chronic pelvic pain. All urine cultures were negative and transvaginal ultrasounds were noncontributory. Her 3-day voiding diary demonstrates 18 to 25 voids per 24 hours, with 4 to 8 voids after bedtime. Fluid intake was reasonable at 2 litres.

Tuberculosis

A 34-year-old man presents to his primary care physician with a 7-week history of cough that he describes as nonproductive. He has had a poor appetite during this time and notes that his clothes are loose on him. He has felt febrile at times, but has not measured his temperature. He denies dyspnea or hemoptysis. He is originally from the Philippines and has lived in the US for 10 years. He denies any history of TB or TB exposure. Physical examination reveals a thin, tired-appearing man but is otherwise unremarkable.

Pyelonephritis (acute)

A 34-year-old woman who is otherwise healthy has had a fever, nausea, and right-sided back pain for 2 days. The physical exam shows a temperature of 102.2ºF (39.0ºC), blood pressure of 120/60, pulse of 110, respiratory rate of 18, and right-sided costovertebral angle tenderness to percussion. Dipstick urinalysis is positive for leukocytes, nitrites, and blood.

Fungal meningitis

A 35-year-old man originally from sub-Saharan Africa presents with a 3-week history of headache and fever. On questioning, he has had intermittent diarrhea and weight loss of 10 kg over the last year. The patient's Glasgow Coma Scale score is 15, he is hemodynamically stable, and the only positive findings on examination are a fever of 100.4°F (38.5°C) and oral candidiasis.

Tension headache

A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a workday. The pain is generalized and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.

Hyperthyroidism (Grave's disease)

A 38-year-old woman, who in the past had tried to lose weight without success, is happy to see that in the last 2 months she has lost 25 pounds. She also has difficulty sleeping at night. Her husband complains that she is keeping the house very cool. She recently consulted her ophthalmologist because of redness and watering of the eyes. Eye drops were not helpful. She consults her doctor for fatigue and anxiety, palpitation, and easy fatigability. On physical examination, her pulse rate is 100 bpm and her thyroid is slightly enlarged. Conjunctivae are red and she has a stare.

Migraine headache (adult)

A 40-year-old man complains of a 1-year history of twice-monthly global headache, worse on the left side in the postauricular region. It comes on gradually and, at its most severe, the vision in his left eye becomes distorted. He often has to stop watching television as the picture becomes "blurry." His nose becomes blocked, although sometimes he has a "runny nose." He takes a nonsteroidal anti-inflammatory drug (NSAID) that helps a little, but he feels that his head is about to explode at times. When the headache occurs, he needs to go into a dark quiet room and sleep until it resolves. He reports the problem is "really getting him down," and he is having difficulties with his employer due to loss of work time.

Hypothyroidism (central/hypothalamic-pituitary)

A 40-year-old woman visits her physician with a 4-month history of chronic headaches and visual problems. She has no past medical history. Review of symptoms reveals easy fatigability, cold intolerance, galactorrhea, and amenorrhea for the past 6 months. Physical exam findings include a bitemporal hemianopia, periorbital edema, normal-sized thyroid, bradycardia, galactorrhea, and vaginal atrophy.

Subacute granulomatous thyroiditis

A 40-year-old woman with no prior thyroid history presents with 7 days of fevers to 104°F (40°C), shaking chills, myalgias, and pharyngitis. In the last day she has developed a severe neck pain that radiates to her ear and jaw. She noted rapid heartbeat, palpitations, tremor, and feeling hot. The neck pain is severe and has changed from the left side of her neck to the right side in the last 24 hours. She cannot eat or drink anything because it exacerbates the pain. She indicates that the pain is not in her pharynx but over her lower neck and radiates to her ear and jaw. She is mildly distressed and will not let you touch her neck because it hurts so much. On examination, her thyroid is enlarged, firm, and very tender to palpation.

Diabetes insipidus

A 42-year-old man undergoes transsphenoidal surgery for a large, nonfunctioning pituitary macroadenoma. Preoperatively, dynamic pituitary hormone tests were normal, as was his fluid intake and output. Two days following surgery he developed acute polyuria, extreme thirst, and polydipsia. His urine output over the next 24 hours was 6 liters, with frequent nocturia.

Hypothyroidism (primary)

A 45-year-old white woman presents with symptoms of fatigue, depression, and mild weight gain. Physical exam demonstrates heart rate of 58 beats per minute, coarse dry skin, and bilateral eyelid edema. Serum TSH is 40 milli-international units/L (mIU/L) (normal range, subject to laboratory standards, 0.35 to 6.20 mIU/L), and free T4 is 0.5 nanograms/dL (usual normal range, subject to laboratory standards, is 0.8 to 1.8 nanograms/dL). Therapy is begun with levothyroxine 100 micrograms daily and the patient's symptoms improve. Repeat testing 6 weeks later reveals a normal TSH (5 mIU/L). The patient is maintained on this dose and repeat TSH testing is planned yearly or if symptoms recur.

Rosacea

A 45-year-old woman presents with several years' history of easy blushing, facial redness, and small, prominent blood vessels on the face. She is also concerned that her nose appears to be enlarging. On physical examination, there are numerous telangiectases on a background of blanching erythema. Closer inspection demonstrates erythematous papules and pustules mostly on the central periorificial face.

Vaginitis

A 46-year-old black woman presents to the office with complaints of white vaginal discharge, dyspareunia, pruritus, and vulvar burning, especially when she urinates. She reports the vaginal discharge looks like cottage cheese and has no odor. She has a 10-year history of diabetes mellitus type 2, which is treated with metformin; she denies any other medical history. She has not had similar symptoms in the past. On physical examination, the vaginal walls are covered by white plaques with the appearance of cottage cheese. Upon detaching them from the base, an erythematous area is left. Hyphae and budding yeast are noted on the wet mount. There is also an erythematous area in the upper third of the vulva, near the urethra. There is no other abnormal finding on the physical exam.

Acromegaly

A 47-year-old man presents with arthritic pain of knees and hips, soft-tissue swelling, and excessive sweating. He also noticed progressive enlargement of the hands and feet. He has been taking antihypertensive medication for the past 3 years. On physical examination, he has coarse facial features with prognathism and prominent supraorbital ridges. The tongue is enlarged and the fingers are thickened. His wife complains that he frequently snores. Laboratory workup reveals an elevated plasma insulin-like growth factor 1 (IGF-1) concentration of 560 micrograms/L (normal for age, 120-235 micrograms/L) and a basal plasma growth hormone level of 15 micrograms/L. MRI examination of the sella turcica region shows a 14 mm pituitary mass with right cavernous sinus invasion.

Pyelonephritis (chronic)

A 55-year-old man presents with a long history of uncontrolled hypertension, increased urinary albumin excretion, and benign prostatic hypertrophy. He reports a past history of bladder infections and surgery on the bladder as an infant. For the past 1 to 2 weeks he has been feeling ill, and he noted some blood in his urine last night. On physical exam the physician notes the patient is obese, in mild distress, with blood pressure 150/90 mmHg, regular pulse 84 beats per minute, and temperature 98.6°F (37°C). The patient has no costovertebral angle tenderness.

Tension headache

A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is quite certain that the only time he is headache-free is when he sleeps. He states the headache is generalized and his neck and shoulders are always "tight". He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.

Erectile dysfunction

A 56-year-old man presents with the inability to obtain a full erection 6 months following radical retropubic prostatectomy for localized prostate cancer. He is otherwise healthy. He has regained continence and continues on active surveillance for his cancer with no evidence of recurrence.

Benign prostatic hyperplasia

A 60-year-old man presents to his primary care physician with a 3-month history of increasing urinary frequency without burning and nocturia 3 times each evening. He has limited his fluid consumption and caffeine intake in the evening without much benefit. There is no personal or family history of prostate cancer. Examination demonstrates no suprapubic mass or tenderness. A rectal examination demonstrates normal rectal tone and a moderately enlarged prostate without nodules or tenderness.

Erectile dysfunction

A 60-year-old man presents with frequent inability to maintain an erection for intercourse. He has a history of HTN and diet-controlled type 2 DM. His medications include hydrochlorothiazide, lisinopril, and aspirin. He quit smoking 2 years ago, rarely exercises, and is married in a stable relationship.

Pyelonephritis (chronic)

A 60-year-old woman presents with a long history of poorly controlled type 2 diabetes mellitus, musculoskeletal pains attributed to fibromyalgia, and depression. She has been seen several times with a variety of vague complaints; today, she states that she has lost her appetite and has been feeling feverish. Her lower back is bothering her more than ever, especially on the right, and her usual pain medication is not helping. Temperature is 100.5°F (38°C), weight is 8 lb lower than on her last visit, and physical examination is remarkable for right costovertebral angle tenderness.

Hyperthyroidism (painless lymphocytic thyroiditis)

A 62-year-old man presents with atrial fibrillation. He has not noticed any tremulousness, heat intolerance, or weight loss. His thyroid gland is non-nodular, nontender, and slightly enlarged. Serum TSH is undetectable, free T4 and T3 are modestly elevated, and thyroid peroxidase antibodies are positive with a low titer. A 24-hour radioiodine uptake is 0.2%.

Tuberculosis (extrapulmonary)

A 66-year-old black man presents to the ER with a history of fever and weight loss. He reports that he has had little appetite for the last 3 months and has lost 11 kg during that time. He has noted tactile fevers over the last 6 weeks but has not had access to a thermometer. He has been having headaches for the last week but denies cough, hemoptysis, or chest pain. He has been intermittently homeless over the last 2 years and has a history of heavy alcohol use but recently stopped. On examination, he is a thin man with a temperature of 101.9°F (38.8°C) and respiratory rate of 20 breaths per minute. Physical examination is notable for temporal wasting and hepatomegaly without tenderness.

Iron deficiency anemia

A 68-year-old man presents with fatigue and dark stools. On examination his vital signs are normal but he is pale and has a rectal mass. Later biopsy of the rectal mass reveals adenocarcinoma.

Folate deficiency

A 70-year-old man presents for routine physical exam. He complains of fatigue, shortness of breath, and painful swallowing. He admits to daily alcohol consumption and decreased consumption of fresh vegetables and fruits. Physical exam reveals pallor, glossitis, flow murmur, and normal neurologic exam.

Hemorrhagic stroke

A 70-year-old man with a history of chronic HTN and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness, as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.

Ischemic stroke

A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be normal 1 hour ago when the family member spoke to him by phone. There is a history of treated HTN and diabetes.

Benign prostatic hyperplasia

A 72-year-old man presents with a 6-month history of weak stream, straining, and hesitancy. There is no history of prostate cancer. The physical exam demonstrates a severely enlarged prostate without nodules. There is moderate suprapubic fullness prior to voiding. A urinalysis is normal and the PSA level is 3.0 nanograms/mL.

Diabetes insipidus

A 75-year-old woman presents to her family physician with a 6-month history of progressive fatigue and malaise with polyuria, polydipsia, and nocturia. She has a longstanding history of bipolar affective disorder, and has been receiving lithium for the past 15 years.

Meningococcal disease

A 9-month-old girl is brought to the emergency department with a history of fever and a rash. She was in good health until this morning, when she developed a fever, irritability, and poor feeding. In the afternoon her parents noticed purple bruises on her legs and trunk. On examination she is alert but appears acutely ill with fever, tachycardia, cool extremities, delayed capillary refill time of 5 seconds, and multiple ecchymoses on her legs and trunk.

Psoriasis

A middle-aged man with a known history of psoriasis presents with white scaly papules and plaques on his elbows, extensor arms, knees, and shins. In the past 6 months, these lesions have become much worse and have started to appear on his waist and hip. Scaly and flaky eruptions are also present on his scalp, ears, and eyebrows. The lesions are itchy and irritating. He is a heavy smoker and has been unsuccessful in a previous attempt at smoking cessation.

Acne vulgaris

A teenage boy presents with closed comedones and slightly tender erythematous papules and pustules on his forehead, cheeks, chin, chest, and upper back. Small lesions developed several years ago as he entered puberty, and they have progressively worsened over the last year. Previous lesions have left residual red-brown hyperpigmentation.

Endometriosis

Adolescents who complain of moderate to severe dysmenorrhea since menarche and whose complaints progress and become more acyclic may have XXX. This group is often overlooked.

Bacterial meningitis

An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness.

Mitral regurgitation

Chronic XXX is associated with a laterally displaced apical impulse (with left ventricular dilation), diminished S1, with or without S3, with or without right ventricular heave, and palpable P2 (if pulmonary hypertension has developed).

Anorexia nervosa

Criteria: A. Restriction of energy intake leading to a significantly low weight in the context of age, sex, developmental trajectory, and physical health B. Intense fear of gaining weight or persistent behavior that interferes with weight gain C. Disturbance in body image.

Cystitis (acute)

Hospitalized patients with urinary catheters, urinary retention, or history of recent urinary tract instrumentation are at high risk for XXX. In these settings, the typical symptoms of dysuria and frequency may be absent and the infection is usually detected on a urinalysis and urine culture done for the evaluation of fever.

Cirrhosis

In the early stages of XXX, patients may be completely asymptomatic or complain of unexplained fatigue, weakness, and/or weight loss, and liver enzymes will show only mild abnormality.

Vaginitis

Irritant or allergic XXX presents with similar symptoms of vulvodynia, dyspareunia, or pruritus, with or without a history of atopy. Patients may report douching, and/or a recent change in soaps, contraceptive devices, tampons, and medications.

Stroke

Most common symptoms are partial or total loss of strength in upper and/or lower extremities, expressive and/or receptive language dysfunction, sensory loss in upper and/or lower extremities, visual field loss, slurred speech, or difficulty with fine motor coordination and gait. In most cases the symptoms appear rapidly, over seconds or minutes, and may be preceded by 1 or more TIA's.

COPD

Other presentations include weight loss, hemoptysis, cyanosis, and morning headaches secondary to hypercapnia. Physical examination may demonstrate hypoxia, use of accessory muscles, paradoxical rib movements, distant heart sounds, lower-extremity edema and hepatomegaly secondary to cor pulmonale, and asterixis secondary to hypercapnia.

Viral meningitis

Parents bring their 2-year-old child who has been ill for 1 day with irritability, vomiting, and fever. The child has a widespread maculopapular rash.

GERD

Patients may have only nocturnal symptoms. Traditional alarm symptoms are anemia, dysphagia, hematemesis, melena, persistent vomiting, and involuntary weight loss (>5% body weight), which raise the possibility of esophagitis, peptic stricture, or cancer. Extraesophageal symptoms are hoarseness (acid laryngitis), persistent nonproductive cough, pressure deep in the throat, and throat clearing. Extraesophageal manifestations include asthma, bronchitis, chest pain, oral disease, and recurrent pneumonia.

Vaginitis

Patients with atrophic XXX present postmenopause with symptoms of dryness, dyspareunia, vaginal spotting, and, less commonly, dysuria. Atrophic XXX may occur in nonmenopausal women with a history of chemotherapy, radiation therapy, or oophorectomy.

Conjunctivitis (allergic)

Typically bilateral with itching and a ropy or watery discharge.

Ankle fracture

usually the result of a low-energy fall but may also be seen in those who have had high-energy trauma. They are the result of a fracture of either the lateral or medial malleolus or both and can also include a fracture of the posterior malleolus. If there is an associated subluxation or dislocation of the ankle joint (tibio-talar joint) there may be an associated deformity of the ankle with the foot more commonly externally rotated and laterally positioned.

Diffuse Esophageal Spasm (motility disorder)

-Intermittent dysphagia -Anterior chest pain unrelated to exertion or eating -Provocation by stress, large food boluses, hot or cold liquids -Barium swallow showing corkscrew contractions or "rosary bead" appearance -Manometry shows intermittent, simultaneous contractions of high amplitude not related to swallowing along with periods of normal peristalsis Dz is usually self-limiting

Mitral stenosis

A 52-year-old woman presents with gradually increasing dyspnea on exertion over the past 2 years. Recently she has required 2 pillows at night to alleviate recumbent dyspnea. On examination, she has an apical diastolic murmur.

Appendicitis

A 12-year-old girl presents with sudden-onset severe generalized abdominal pain associated with nausea, vomiting, and diarrhea. On exam she appears ill and has a temperature of 104°F (40°C). Her abdomen is tense with generalized tenderness and guarding. No bowel sounds are present.

Scleroderma Esophagus (motility disorder)

-Severe acid reflux -Strictures -Erosions -Heartburn -Dysphagia -Manometry showing diminished peristalsis with low pressures, relaxed LES -Barium swallow showing dilated, flaccid esophagus

Esophageal Stricture

-majority result from long-standing gastroesophageal reflux -cardinal feature = dysphagia -endoscopy and dilation often performed together during the initial session -goals of therapy are relief of dysphagia and prevention of recurrence -treatment = dilation (with balloon dilator or bougie dilator) -PPI to avoid further stricturing

Aortic regurgitation

A 31-year-old black man presents to clinic for the first time for a routine physical exam. He denies any complaints. On physical exam the only abnormality is a systolic murmur best heard over the second right intercostal space and an early diastolic murmur best heard over the third left sternal border. LVEF is 55% to 60% with mild LVH. Left ventricular end-systolic diameter is 45 mm and aortic root diameter is 3.5 cm.

Acute Sinusitis

A 19-year-old woman presents with a 12-day history of purulent nasal drainage and nasal congestion, and reports a history of fever, myalgia, and facial pressure. She is otherwise healthy and works as a teacher. After 5 days of illness, the patient's symptoms started to improve; however, they have worsened in the last few days, despite the use of over-the-counter medications. Physical exam shows edematous mucosa of the inferior turbinate. There is also thick mucus in the nasal cavity. Nasal endoscopy demonstrates purulent drainage and a small polyp in the ostiomeatal complex. The adenoids are small and erythematous.

Influenza

A 12-month-old infant presents in the winter months to the pediatrician with 2-day history of fever to 102°F (38.9°C), tachypnea, conjunctival erythema, and nasal congestion with clear discharge. There has been an associated loss of appetite, with one episode of emesis. Influenza has been reported recently in the locality. The parents are concerned that the child was not vaccinated, due to a known history of egg allergy.

Asthma acute exacerbation (child)

A 12-year-old girl presents to the emergency department with a 12-hour history of a troublesome cough followed by wheezing and increasing breathlessness unresponsive to inhaled albuterol. She has had troublesome asthma since the age of 18 months. Over the past few months, her asthma has been managed with fluticasone/salmeterol via a pressurized metered-dose inhaler and large-volume spacer, and an albuterol inhaler, which is used as needed. She has been poorly compliant with her preventive medication, adhering only when symptomatic. On exam, she is extremely distressed. She appears slightly cyanosed on air, and pulse oximetry shows an oxygen saturation of 84%. She has marked use of accessory muscles and is unable to speak in sentences but can say single words. She has marked pulsus paradoxus on palpation. On auscultation of the chest there is widespread expiratory wheeze but equal air entry.

Scoliosis

A 12-year-old white girl is referred by her pediatrician for evaluation of truncal asymmetry identified by screening during a routine physical exam. She and her parents have never noticed an abnormality in her appearance and she is asymptomatic. She describes herself as very active in school and in her recreational activities, and has recently noticed a growth spurt. On physical examination, she is thin and her right shoulder appears to be slightly elevated compared with the left. On forward bending she is very flexible, easily reaching the floor with her legs straight. A right-sided mid-thoracic prominence is noted, as well as a smaller left-sided paraspinal prominence at the thoracolumbar junction. These prominences significantly decrease in size with side bending in the forward flexed position. She has full and symmetric strength, normal sensation, and symmetric deep tendon reflexes throughout her upper and lower extremities. She has a normal gag reflex and symmetric abdominal reflexes. Her gait is normal, including toe and heel walking.

Conjunctivitis

A 14-year-old boy with no significant past medical history presents 3 days after developing a red, irritated right eye that spread to the left eye today. He has watery discharge from both eyes and they are stuck shut in the morning. He reports recent upper respiratory symptoms and that several children at his day camp recently had pink eye. He denies significant pain or light sensitivity and does not wear contact lenses. On examination, his pupils are equal and reactive and he has a right-sided, tender preauricular lymph node. Penlight examination does not reveal any corneal opacity.

Appendicitis

A 22-year-old male presents to the emergency room with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (100.5°F; 38°C), pain on palpation at right lower quadrant (McBurney sign), and leukocytosis (12,000/microliter) with 85% neutrophils.

Asthma (adult)

A 25-year-old woman presents with shortness of breath. She reported that in high school, she occasionally had shortness of breath and would wheeze after running. She experiences the same symptoms when she visits her friend who has a cat. Her symptoms have progressively worsened over the past year and are now a constant occurrence. She also finds herself wheezing when waking from sleep approximately twice a week.

Influenza

A 30-year-old woman presents in January with 2-day history of fever, cough, headache, and generalized weakness. She was in her usual state of health before an abrupt onset of these symptoms. A few viral illnesses have affected her during the current winter, but not to this severity. She reports sick contacts at work and did not receive the seasonal influenza vaccine this season.

Asthma acute exacerbation (adult)

A 27-year-old woman with a history of moderate persistent asthma presents to the emergency department with progressive worsening of shortness of breath, wheezing, and cough over 3 days. She reports prior exposure to a person who had a runny nose and a hacking cough. She did not receive significant relief from her rescue inhaler with worsening symptoms, despite increased use. She has been compliant with her maintenance asthma regimen, which consists of an inhaled corticosteroid and a leukotriene receptor antagonist for maintenance therapy and albuterol as rescue therapy. Her cough is disrupting her sleep pattern and as a consequence she is experiencing daytime somnolence, which is affecting her job performance.

Oral candidiasis

A 28-year-old man presents with pain on swallowing. He has no oral symptoms, but clinically has abundant, creamy white, loosely adherent plaques throughout his mouth. Lesions are especially prominent in his buccal, palatal, and pharyngeal mucosa. HIV infection was diagnosed 2 years ago, but he has not yet started antiretroviral treatment. His last CD4 count and viral load measurement was 8 months ago.

Foreign body aspiration

A 3-year-old boy was playing with colorful interlocking plastic bricks when he suddenly started coughing and gagging. The child subsequently developed a high-pitched sound and his breathing became labored. The child's caregiver called the paramedics, but while waiting for the ambulance the child's breathing slowed and he became unconscious.

Asthma (child)

A 3-year-old girl presents with a history of episodes of wheeze and troublesome cough over the past 2 years. These episodes are more common through the winter months. On 2 occasions she has been given oral corticosteroids because of severe wheeze, which was relatively unresponsive to beta-2 agonist given via MDI. In the past 6 months she has had monthly episodes of wheezing with shortness of breath, and 2 of these have resulted in need for frequent beta-2 agonist. At present she is using beta-2 agonist as required, but has used inhaled corticosteroids during the attacks in the past. Between these episodes she is well, although her mother has noted some wheeze after vigorous playing. Her father has asthma and the child herself has eczema.

Eustachian tube dysfunction

A 3-year-old girl presents with recurrent acute otitis media, refractory to antibiotics. She has been noted to have a mild conductive hearing loss and flat tympanograms on audiometric assessment. A serous effusion is present bilaterally on otoscopic exam.

Infective endocarditis

A 31-year-old woman presents with a 1-week history of fever, chills, fatigue, and unilateral ankle pain. Her past medical history includes mitral valve prolapse (MVP) and hypothyroidism. She admits to infrequent intravenous heroin use and has a 10-pack-year history of smoking. Physical exam reveals temperature of 102°F (39ºC), regular heart rate 110 bpm, BP 110/70 mmHg, and respiration rate of 16 breaths per minute. Her cardiovascular exam reveals a grade 2/4 holosystolic murmur that is loudest at the right upper sternal border. Her right ankle appears red and warm, and is very painful on dorsiflexion.

Chronic Sinusitis

A 35-year-old woman presents with a 4-month history of intermittent sinus pressure/pain with rhinorrhea, postnasal drainage, and congestion. Secretions are thick and green in color. She has been treated with antibiotics in the past, which improved but did not resolve her symptoms. She has a history of allergic rhinitis and positive allergy testing. Physical examination demonstrates tenderness to palpation over maxillary and frontal sinuses. Nasal examination shows a severely left deviated nasal septum with thickened, erythematous nasal mucosa with green purulence.

Mitral stenosis

A 36-year-old prima gravida presents with dyspnea on exertion and 2 pillow orthopnea during her second trimester. Previous physical examinations had disclosed no cardiac abnormalities. On current physical examination she has a loud S1 and a 2/6 diastolic rumble.

Barotrauma

A 38-year-old woman had enrolled on a beginners' diving course. She is a smoker and has just recovered from acute sinusitis. On her first pool dive she found it difficult to equalize her ears on descent, but managed to "push through" and reach a depth of 16 feet (5 m). She surfaced complaining of fullness in her left ear and muffled hearing. On her second dive, she was unable to descend past 10 feet (3 m) because of a blocked sensation in her left ear. While using considerable pressure to clear it, she felt a sudden pain in the same ear, accompanied by a feeling of cold water rushing in and intense vertigo.

Fibromyalgia

A 38-year-old woman sees her physician with 4 years of widespread body pain. The pain began after a motor vehicle accident and was initially limited to her neck. Gradually, the pain has spread and she now complains of hurting all over, all the time. She does not have any joint swelling or systemic symptoms. She does not sleep well and has fatigue. She has irritable bowel syndrome but is otherwise healthy. Physical exam reveals a well-appearing woman with normal musculoskeletal exam, except for the presence of tenderness in 12 out of 18 fibromyalgia tender points. Routine laboratory testing is normal.

Constipation (adults)

A 39-year-old woman presents with a 2-year history of gradually worsening constipation. She complains of bloating, gas, and lower abdominal discomfort with irregular bowel habits. She describes her stool as mostly sausage-shaped, hard, and lumpy. She takes metoprolol for hypertension and lansoprazole for heartburn. She has previously used senna and bisacodyl without improvement of her symptoms. She also increased her daily fiber and fluid intake without relief. Physical examination is unremarkable except for mild abdominal distention and palpable stool in the right and left lower quadrants. Perianal inspection is normal, and the anocutaneous reflex is present in all 4 quadrants. Digital rectal exam reveals a large amount of stool in the rectum. When asked to push and bear down, she shows adequate pelvic descent with normal anal relaxation.

Peptic Ulcer Disease

A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by ranitidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole. Physical examination reveals a fit, apparently healthy man in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen.

Endometriosis

A 41-year-old white female presents to her gynecologist for a routine healthcare visit. She has no complaints except for some mild lower abdominal bloating. Her past medical and surgical history is unremarkable. Her sister has recently been diagnosed with endometriosis. She and her husband have been trying to conceive for the past 2 years and have been unsuccessful. She is requesting a referral to an infertility specialist. On exam, she is thin and in no distress. Pelvic exam reveals 10 cm bilateral adnexal masses indistinguishable from the uterus. Transvaginal ultrasound performed in the office is significant for ovarian masses with homogeneous, low-level internal echoes.

GERD

A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4 to 6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. The patient has no dysphagia, vomiting, abdominal pain, exertional symptoms, melena, or weight loss. Past medical history and family history are noncontributory. The patient drinks alcohol occasionally and does not smoke. On physical exam, height is 5 feet 4 inches, weight 170 pounds, and BP 140/88 mmHg. The remainder of the exam is unremarkable.

Mitral valve prolapse

A 45-year-old man presents for a routine physical exam as part of an insurance medical assessment. He is asymptomatic and has no family history of cardiac disease or sudden cardiac death. On examination, he is of slim build. BP is 115/65 mmHg, and heart rate 60 bpm and regular. On cardiac exam, apex beat is of normal character and nondisplaced. On auscultation, he has a midsystolic click followed by a late-systolic high-pitched murmur. On standing and with Valsalva maneuver, the click and murmur occur earlier in systole and the murmur is of increased intensity. On squatting, the click and murmur occur later in systole and the murmur is softer in intensity. There are no clinical signs of heart failure.

Cervical cancer

A 46-year-old woman presents for a routine gynecologic examination. She has a history of unprotected intercourse with multiple sexual partners and is a smoker. Pap smear is abnormal.

Cardiac tamponade

A 47-year-old woman presents to her oncologist with decreased exercise tolerance. She was diagnosed with breast cancer 3 years ago and has undergone radical mastectomy, radiation, and aggressive chemotherapy. Despite these measures she was diagnosed recently with metastatic disease. She seems anxious and tachypneic, has an elevated JVP, and her heart sounds are muffled. Her blood pressure is 90/50 mmHg, heart rate is 110 beats per minute, and pulsus paradoxus is 15 mmHg.

Constipation (adults)

A 50-year-old woman presents with a lifelong history of constipation that has worsened over the past 2 years. She reports decreased stool frequency and straining during defecation. She has a feeling of incomplete evacuation and admits to applying pressure over her posterior vaginal wall during defecation. She describes her stool as separate hard lumps. She has had 2 vaginal deliveries, with no known history of tears. She has had a hysterectomy and bladder suspension surgery. She has used psyllium and milk of magnesia with limited relief. Examination is unremarkable. Her abdomen is soft and nondistended with no palpable masses. Perianal inspection is normal, and the anocutaneous reflex is present in all 4 quadrants. Digital rectal exam reveals no stool in the rectum. On digital rectal examination, resting anal tone is weak but her squeeze tone is normal. She does not relax the puborectalis muscle or the external anal sphincter when simulating defecation; she also has 2-cm perineal descent with straining.

Achalasia (motility disorder)

A 52-year-old man presents with a 6-month history of heartburn and atypical chest pain, both unrelated to food. He also described "gurgling" sounds in his chest. A month before presentation he developed intermittent dysphagia to both solids and liquids, regurgitation, and weight loss of 3 kg.

Rheumatoid Arthritis

A 52-year-old woman presents with a 2-month history of bilateral hand and wrist pain, and swelling in her fingers. She has also recently noted similar pain in the balls of her feet. She finds it hard to get going in the morning and feels stiff for hours after waking up. She also complains of increasing fatigue and is unable to turn on and off faucets or use a keyboard at work without a significant amount of pain in her hands. She denies any infections before or since her symptoms started.

Aortic regurgitation

A 55-year-old white man presents with weakness, palpitations, and dyspnea on exertion. On physical exam, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border. He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. The patient is taking hydrochlorothiazide for high blood pressure. Echocardiography reveals a left ventricular ejection fraction (LVEF) of 55%, left ventricular end-diastolic diameter of 70 mm, and end-systolic diameter of 50 mm.

Osteoarthritis

A 55-year-old woman has been complaining of pain and swelling in several fingers of both hands for the past 2 months. She describes morning stiffness lasting 30 minutes. Her mother tells her that she had a similar condition at the same age. She denies any other joint pain or swelling. On exam, she has tenderness, slight erythema, and swelling in one PIP joint and two DIP joints in each hand. She has squaring at the base of her right thumb (the first carpometacarpal joint). There is no swelling or tenderness in her MCP joints.

Ovarian cyst

A 58-year-old obese postmenopausal woman (gravida 4, para 3) presents to her annual gynecologic visit without initial complaint. During the interview, she denies postmenopausal bleeding but acknowledges increased abdominal bloating and early satiety. Over the past year, she has experienced pelvic and low back pain that is mildly bothersome but worsening. Her family history is notable for a sister with breast cancer and mother with an unknown female cancer. Abdominal exam is nondiagnostic due to her body habitus, and pelvic exam is limited. There is concern for a vague fullness that is appreciated on rectovaginal exam.

Conjunctivitis

A 6-year-old girl with no significant past medical history presents 4 days after developing a red, irritated left eye. Her mother states that she has been wiping thick whitish-yellow discharge from her eye, and the eye is matted shut in the morning. She denies any exposure to a sick contact, upper respiratory symptoms, or contact lens use. She also denies any significant pain or light sensitivity. On examination, the patient's pupils are equal and reactive. She does not have a tender preauricular lymph node. Penlight examination does not reveal any corneal opacity, but thick, whitish discharge is seen.

Osteoarthritis

A 60-year-old woman presents complaining of bilateral knee pain on most days of the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs. She complains of stiffness in the morning that lasts for a few minutes and a buckling sensation at times in the right knee. On exam, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favoring the right side.

Cirrhosis

A 60-year-old woman with a past medical history of obesity, diabetes, and dyslipidemia is noted to have abnormal liver enzymes with elevated aminotransferases (ALT: 68 U/L, AST: 82 U/L), and normal alkaline phosphatase and bilirubin. She denies significant alcohol consumption, and tests for viral hepatitis and autoimmune markers are negative. An abdominal ultrasound reveals evidence of fatty infiltration of the liver and slight enlargement of the spleen.

Cervical cancer

A 62-year-old woman with poor access to health care presents with low energy, weight loss, and pelvic pain with an exophytic mass on pelvic exam and renal failure.

Cardiac tamponade

A 65-year-old man without medical Hx presents with decreased exercise tolerance and progressive dyspnea at rest, beginning 3 days before presentation. He does not recall any recent illness, denies recent travel or illicit habits, and takes no medications. Over the past 24 hours he has also noted bilateral ankle edema. He is in mild distress, with a jugular venous pressure (JVP) of 13 cm and distant heart sounds. His lungs are clear and 1+ pedal edema is noted. His blood pressure is 120/80 mmHg and there is a pulsus paradoxus, which is <10 mmHg.

Aortic stenosis

A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognizes having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical exam there is a loud systolic murmur at the right upper sternal border radiating to the carotids.

Endometrial cancer

A 65-year-old obese woman with hypertension and diabetes presents with postmenopausal vaginal bleeding, 12 years after menopause. She has never been pregnant. She has a first-degree relative and a second-degree relative who have had endometrial cancer. Bleeding is scanty but has persisted for more than 1 month. She has not recently used HRT and she had a normal Pap smear 6 months previously. She is morbidly obese with a BMI of 41, and vaginal examination reveals evidence of recent bleeding.

COPD

A 66-year-old man with a smoking history of 1 pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears cachectic and in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting edema.

Acute bronchitis

XXX can also present as wheezing that resembles asthma with minimal cough, or as a nocturnal cough only. While most patients with XXX will have a productive cough, patients in later phases of the illness may have a nonproductive cough.

COPD acute exacerbation

A 67-year-old woman with a history of COPD presents with 3 days of worsening dyspnea and increased frequency of coughing. Her cough is now productive of green, purulent sputum. The patient has a 100-pack-year history of smoking. She has had intermittent, low-grade fever of 100°F (37.7°C) for the past 3 days and her appetite is poor. She has required increased use of rescue bronchodilator therapy in addition to her maintenance medications to control symptoms.

Pulmonary regurgitation

A 7-year-old boy with a normal karyotype and dysmorphic features such as webbing of neck, short stature, and pectus carinatum is incidentally found to have a prominent main pulmonary artery and cardiomegaly on CXR for respiratory complaints.

Pleural effusion

A 70-year-old woman presents with slowly increasing dyspnea. She cannot lie flat without feeling more short of breath. She has a history of hypertension and osteoarthritis, and she has been taking NSAIDs with increasing frequency over the previous few months. On physical examination, she appears dyspneic at rest, her BP is 140/90 mmHg, and pulse is 90 bpm. Her jugular venous pressure is elevated to the angle of the jaw. The left lung field is dull to percussion with quiet breath sounds basally. Crackles are heard in the right lung field and above the line of dullness on the left. Lower extremities have pitting edema to the knee.

Tricuspid regurgitation

A 73-year-old woman presented for the first time 5 years ago with worsening shortness of breath and lower extremity edema. On clinical examination she has a laterally displaced apical impulse, with a loud 3/6 holosystolic murmur at the apex. Jugular veins are distended to the angle of the jaw. Lung examination shows some bibasilar crackles. There is 2-3+ pitting edema in both lower extremities. Echocardiography shows a reduced left ventricular ejection fraction (40%), hypokinesis of the inferior and lateral walls, ischaemic mitral regurgitation (severe), and mild tricuspid regurgitation (TR).

Asthma (child)

An 8-year-old boy presents with intermittent wheeze and cough, and with a history of asthma. Over recent months he has had problems with nighttime wheeze and shortness of breath. He is waking at least 3 or 4 nights per week since recovering from an upper respiratory infection. He requires his beta-2 agonist metered dose inhaler (MDI) to enable him to get back to sleep. He has also noted more problems with wheeze and shortness of breath on minimal playing at school. His general practitioner has tried cromolyn sodium and a leukotriene receptor antagonist in the past, but currently he is managed with beta-2 agonist as required. He now needs a new beta-2 agonist MDI every 2 to 3 weeks.

Foreign body aspiration

An 82-year-old man suddenly choked while eating loquat fruits at home. The patient subsequently presented to the ER with a severe cough. His physical exam was normal except for localized wheezing in the right lower lung field, best heard anteriorly. There were no focal neurologic deficits and no significant past medical history. However, the patient's wife stated that he often coughed while eating.

Tricuspid stenosis

An otherwise healthy 35-year-old male presents with complaints of fatigue, lower extremity swelling, fluttering neck sensation, and a sense of abdominal fullness. Symptoms began to occur over the last few months and have been slowly progressive. The patient, who is an avid cyclist, reports increasing dyspnea on exertion and the inability to exercise to his usual capacity. The patient's medical history is notable for an intermittent murmur, which was typically described as "innocent" when heard at routine well-child and health maintenance examinations. He underwent tonsillectomy and adenoidectomy at age 7 years for recurrent pharyngitis. There is no family history of early CAD, cardiomyopathy, or sudden death. He does not smoke and rarely drinks alcohol.

Asthma (child)

Children may present with episodes of recurrent cough. These episodes may be triggered by viral infections, change in weather, or exercise. The cough is typically dry in nature and only occasionally associated with an audible wheeze. Closer questioning may reveal the predominant trigger and a feeling of chest tightness and difficulty breathing accompanying the cough. A beta-2 agonist MDI typically provides relief.

Fibromyalgia

Chronic, widespread pain, which is ultimately diagnosed as XXX, often begins following a significant injury, trauma, illness, admission to the hospital, or emotionally stressful period, but an inciting event is not always seen. XXX often coexists with other rheumatologic conditions, such as rheumatoid arthritis, SLE, and osteoarthritis; importantly, the presence of these conditions does not exclude a concomitant diagnosis of XXX (i.e., XXX is not a diagnosis of exclusion). Patients with XXX often have coexistent depression and anxiety at a higher frequency than patients without the disease, but mental illness is not a prerequisite for its diagnosis.

Peptic Ulcer disease

Duodenal ulcers may penetrate posteriorly into the pancreas, causing severe abdominal pain radiating through to the back. Gastric and duodenal ulcers may cause occult blood loss and iron deficiency anemia. Rarely, the patient may develop pyloric stenosis from an ulcer of the pyloric channel and present with nausea, vomiting, early satiety, and a succussion splash on physical examination (caused by gastric outlet obstruction). The combination of peptic ulcer symptoms with diarrhea may indicate Zollinger-Ellison syndrome.

Aortic regurgitation

In acute XXX, patients can present with sudden onset of pulmonary edema and hypotension or in cardiogenic shock. Patients may also present with signs and symptoms of myocardial ischemia or aortic root dissection. Due to the acute nature of the XXX, there may be no increase in left ventricular size, and the diastolic murmur may be short and/or soft due to diastolic pressure equilibrium between aorta and ventricle occurring before the end of diastole. An apical diastolic rumble may be present. Pulse pressure may not be increased due to reduced systolic pressure.

Ankle fracture

Most commonly, XXX may present with only focal pain and swelling over either of the malleoli, but in some cases patients may be able to bear weight on the extremity. At the higher energy extreme there may be damage to the overlying skin, resulting in an open fracture, the wound being most commonly on the medial aspect of the ankle. More infrequently, there may be concomitant damage to the vascular supply of the foot from dislocation and subsequent kinking of vessels due to the nonanatomic placement of the foot or to direct damage of the vessels themselves.

Foreign body aspiration

Patients with XXX may present with acute asphyxiation and respiratory arrest, or may have only nonspecific symptoms such as dyspnea or cough. Unilateral wheezing suggests partial airway obstruction of the main or distal bronchi. Some patients may present with no memorable history of an XXX event and yet present with a chronic cough, wheeze, or other misdiagnosed respiratory diagnosis, such as asthma.

Developmental hip dysplasia

Some cases of XXX may present beyond the first year of life, typically with pain or abnormal gait as the presenting symptoms. Parents may notice "toe-walking", especially on one side, which may indicate a potential shortening on the affected side, or that the child walks with a limp.

Pulmonary Embolism

Symptoms that are predictive of XXX include chest pain, dyspnea, and a sense of apprehension. Syncope also sometimes occurs, and is strongly associated with increased clot burden. Important signs include tachypnea with a respiratory rate >16 breaths per minute, fever >100.0°F (37.8°C), and heart rate >100 bpm.

Ankle fracture (& Maisonneuve)

This presents with pain and swelling proximally in the fibula and associated pain in the leg and ankle. This results from the presence of a high fracture of the fibula with a concomitant separation of the tibiofibular syndesmosis and fracture of the medial malleolus or rupture of the medial ankle ligament complex, essentially representing a dissociation of the tibia and fibula below the level of the fibula fracture.

Tricuspid stenosis

XXX can occur as a result of bacterial endocarditis, especially among patients with endocardial pacemaker leads, artificial tricuspid valves, or in intravenous drug abusers. Under these conditions, the typical presenting symptoms may also include fever and other stigmata of infective endocarditis. Congenital XXX typically presents during infancy or very early childhood, as opposed to adulthood. It is often associated with other structural heart defects and often presents with cyanosis when an atrial level shunt is also present. Carcinoid heart disease can cause XXX and should be considered in any patient with typical carcinoid features, including facial flushing, intractable secretory diarrhea, and bronchoconstriction. XXX caused by rheumatic heart disease can present with atrial fibrillation in up to 40% to 70% of patients.

Asthma (adult)

XXX commonly presents in children, but may present in otherwise healthy middle-aged individuals. Symptoms may start as a non-productive cough, chest tightness, shortness of breath, or wheezing, either spontaneously or on exposure to trigger factors. When the cough is productive, it is associated with clear and sometimes stringy sputum. Frequently, the patient is a nonsmoker and will often have an atopic history, such as childhood eczema. In people with nasal polyps, examination of the lung is usually normal.

Aortic stenosis

XXX is a progressive disease that presents after a long subclinical period with symptoms of chest pain, syncope, and heart failure. While the most common complaint is dyspnea with exertion, patients also frequently note syncope or chest pain that may be identical to that caused by CAD. Many cases of XXX are diagnosed during the subclinical phase while a murmur noted on physical exam is being investigated. Even with severe XXX, patients may be truly asymptomatic. A careful history is important to determine if the patient has altered his or her habits in response to slowly worsening stenosis.

Developmental hip dysplasia

XXX is typically identified through a screening exam of the hips of infants. However, XXX may sometimes come to medical attention after the parents notice one or more of the following: one leg appearing shorter than the other, an extra deep crease on the inside of the thigh, one hip joint moving differently from the other and/or the knee appears to face outwards, one leg does not appear to move outwards as fully as the other (e.g., with diaper changes), or the child crawls with one leg dragging.

Influenza

XXX may present rarely with an afebrile upper respiratory illness more typical of a common cold, or it may present predominantly with fever and myalgia, with few respiratory symptoms. Patients in high-risk populations (e.g., those with chronic cardiac or pulmonary conditions, diabetes mellitus, renal disease, hemoglobinopathy, immunosuppression, residence in chronic care facilities, age >50 years, or third trimester of pregnancy) may present with an established primary viral or secondary bacterial pneumonia. Characteristic features of primary viral pneumonia are persisting or worsening course of fever, with dyspnea or other respiratory distress. Secondary bacterial pneumonia should be suspected if there is an initial improvement in symptoms followed by a relapse of fever with productive cough and shortness of breath. A chest x-ray confirms pulmonary infiltrates

Acute IE

can present with septic embolic phenomenon such as stroke, septic joint, or splenic infarct accompanied by fever and cardiac murmur.

Herniated Nucleus Pulposus (discogenic low back pain)

A 48-year-old insurance salesman presents with a 25-year history of back pain. He developed severe back pain while stacking shelves at the local supermarket at age 23. The pain resolved after 10 days of bed rest followed by 3 months of physical therapy. He has had multiple episodes of back pain occurring at increasing regularity over the years and, in the past 10 years, has changed his occupation to salesperson. Currently, he has back pain measuring 8 out of 10 on a visual analog scale and bilateral leg pain. The back pain is exacerbated by flexion, and the leg pain is reproduced by a straight leg raise of 70 degrees. He has numbness of both feet in the L5 dermatome; motor and reflexes are normal.

Constipation (children)

A 5-month-old baby boy presents with difficulty and delay in passing hard stools. His mother reports that he strains for several hours and may even miss a day, before passing stool with screaming and occasional spots of fresh blood on the stool or diaper. He has recently been weaned from breastfeeding to cows' milk formula, which he had been reluctant to drink initially. The child is thriving and now feeding normally. There was no neonatal delay in defecation and no history of excessive vomiting or abdominal distention.

Oral candidiasis

A 64-year-old man presents with a complaint of burning under his maxillary denture. He has hypertension and osteoarthritis. His medications include a thiazide diuretic, a nonselective beta-blocker, and an OTC analgesic. Intra-orally, he has severely erythematous palatal mucosa, with a distinct granular appearance. His mucosa is dry and his salivary flow is minimal.

Ovarian cyst

A 27-year-old woman (gravida 2, para 2) presents to her family practitioner with a chief complaint of pelvic pain. The pain began about 3 weeks previously and is characterized as dull with a pressure-like fullness in the right pelvis. The pain is exacerbated by some movements and by sexual intercourse. She noted no change in intensity or character with her last menses 2 weeks previously. Her past gynecologic and medical histories are unremarkable. Previous surgeries include one cesarean delivery and an appendectomy. Review of symptoms reveals some increased frequency of urination but no other notable menstrual, hematologic, GI, or genitourinary symptoms. Physical exam reveals a well-nourished female in no acute distress who demonstrates mild tenderness on deep palpation of the right lower quadrant of her abdomen. On pelvic exam, palpation of the right adnexa elicits moderate tenderness.

Endometriosis

A 32-year-old nulliparous white female presents with a history of progressively worsening menstrual pain that is now causing her distress for most of the month. She misses 2 to 3 days of work each month. She finds no relief from ibuprofen and can no longer tolerate the headaches associated with her birth control pills. She is currently sexually active with her long-term partner. Her relationship is being affected by associated stress and pain during intercourse. On vaginal examination, her pelvic musculature is moderately tender. Her uterus is of normal size and minimally tender. Rectovaginal exam reveals uterosacral nodularity and exquisite tenderness. Stool is soft, brown and heme-negative.

Acute Sinusitis

A 33-year-old man with a medical history of pediatric-onset asthma, atopic dermatitis, and allergic rhinitis presents with a 7-day history of facial pressure, dental pain, nasal blockage, and hyposmia. The patient developed these symptoms after recently mowing his lawn. The symptoms have not improved despite use of an intranasal corticosteroid, an antihistamine, and intranasal saline washes. Physical exam shows a septum deviated to the left side, and a large concha bullosa on the right side. There are no polyps, but there are swollen turbinates and thin, clear mucus present.

Acute bronchitis

A 34-year-old woman with no known underlying lung disease has had a 12-day history of cough that has become productive of sputum. Initially she was not short of breath, but now she becomes short of breath with exertion. She initially had nasal congestion and a mild sore throat, but now her symptoms are all related to a productive cough without paroxysms. She denies any sick contacts. On physical examination she is not in respiratory distress and is afebrile with normal vital signs. No signs of URI are noted. Scattered wheezes are present diffusely on lung auscultation.

Eustachian tube dysfunction

A 45-year-old man with a history of allergic rhinitis and chronic sinusitis complains of aural fullness and inability to "clear" his ears. His otoscopic exam is normal, but audiometric exam reveals mild negative ear pressure.

Asthma acute exacerbation (child)

A 5-year-old girl presents to the emergency department with a 2-day history of coryza and cough with intermittent low-grade fever. She developed an audible wheeze and respiratory distress that was initially responsive to albuterol via a pressurized metered-dose inhaler and small-volume spacer. However, symptoms have recurred within 2 hours of albuterol administration. The patient has had a number of episodes of wheeze and dyspnea over a 2-year period; these were more common during the winter months. She required prednisone on 2 occasions to treat severe wheeze. On exam, she is in visible respiratory distress with a respiratory rate of 40 breaths/minute and has accompanying accessory muscle use. Her oxygen saturations are 92% in room air, and on auscultation of her chest there is widespread polyphonic wheeze and equal air entry. She has an audible moist cough.

Mitral regurgitation

A 52-year-old woman presents with dyspnea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. On physical exam her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac exam reveals a slightly displaced apical impulse with a palpable P2. Cardiac auscultation reveals III/VI holosystolic murmur at the apex that radiates to the axilla with diminished S1 and P2 greater than A2.

COPD

A 56-year-old woman with a history of smoking presents to her primary care physician with shortness of breath and cough for several days. Her symptoms began 3 days ago with rhinorrhea. She reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. She has had similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. She denies hemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.

Pulmonary Embolism

A 65-year-old man presents to the emergency department with acute onset of SOB of 30 minutes' duration. Initially, he felt faint but did not lose consciousness. He is complaining of left-sided chest pain that worsens on deep inspiration. He has no history of cardiopulmonary disease. A week ago he underwent a total left hip replacement and, following discharge, was on bed rest for 3 days due to poorly controlled pain. He subsequently noticed swelling in his left calf, which is tender on examination. His current vital signs reveal a fever of 100.4°F (38.0°C), heart rate 112 bpm, BP 95/65 mmHg, and an O2 saturation on room air of 91%.

Herniated Nucleus Pulposus (discogenic low back pain)

A 68-year-old man presents with increasing back pain. The pain started when he was in his 30s, and has progressed over time. He now also reports heaviness in both his legs when he walks 2 blocks. He retired from his job as a teacher 3 years ago, and now spends a large proportion of his time gardening. He can sit for a only few minutes, and then has great difficulty in getting up. He has no other medical conditions. On examination, his spinal range of motion is very disturbed. He stands with a forward stoop. He can stand on his toes and heels and has a normal neurological examination. A straight leg raise causes no pain or restriction.

Tricuspid regurgitation

A 78-year-old man was diagnosed with left-sided systolic heart failure 14 years ago. He was subsequently found to have atrial fibrillation, and underwent atrioventricular node ablation and pacemaker placement 10 years ago that resulted in an improvement in his left ventricular ejection fraction from 35% to 50%. He did extremely well over the years and was very active; 3 years ago he completed a 210-mile bike ride across the Netherlands. Four months ago, however, he started developing chest tightness and back tightness when pulling his cart during golfing sessions. In addition, he developed significant dyspnea with activity and his symptoms have worsened. Now, he says his quality of life is extremely poor. He has problems walking up one flight of stairs where he experiences significant shortness of breath; even walking half a block causes shortness of breath and chest tightness. He has also noticed increased abdominal girth, early satiety, and easy fatigue.

Developmental hip dysplasia

A baby girl is seen for a routine exam at 2 weeks of age. She was born at term with no pregnancy or delivery complications. A screening exam of the hips, using the provocative tests of Barlow and Ortolani, reveals laxity of the left hip joint. A characteristic "clunk" is felt as the femoral head shifts out of the acetabulum with pressure applied directly posteriorly in the adducted hip, as well as when it shifts back into the acetabulum with the hip abducted and anterior pressure applied.

Pleural effusion

A thin 56-year-old man has pain in his right chest with deep inspiration and is short of breath at rest and with exertion. He has felt feverish for 1 week and complains of a productive cough with foul-smelling and -tasting sputum. He regularly drinks alcohol and was inebriated and vomited 1 week before his symptoms began. Past medical history and family history are unremarkable. On physical examination, he is febrile at 100.7°F (38°C), BP is 130/78 mmHg, and pulse is 110 bpm. He looks ill and has poor dental hygiene. Breath sounds are quiet over the right lower lobe with dullness to percussion and decreased tactile fremitus in the lower half of the lung field.

Constipation (children)

A 14-year-old girl, concerned about body image, altered her diet and decreased her oral intake hoping to lose weight. Additionally, she avoided restrooms at school due to their lack of cleanliness. She presented to her pediatrician with the complaint of abdominal pain, distention, bloating, and difficult, painful defecation.

Gigantism

A 15-year-old girl presents with primary amenorrhea and accelerated growth. On physical examination, her height is above the 90th percentile, her pubertal development is evaluated at Tanner stage 2, and she has soft-tissue swelling. Laboratory workup reveals a moderately elevated serum prolactin concentration of 44 micrograms/L (normal, <20 micrograms/L) and an elevated IGF-1 level of 1525 micrograms/L (normal for age, 198-551 micrograms/L). Pituitary MRI shows a 15 mm pituitary mass without parasellar extension.

Anorexia nervosa

A 15-year-old girl, accompanied by her mother, presents to her primary care physician complaining of fatigue and sleeplessness for 6 months' duration. The doctor notes the patient is quite petite and is wearing an oversized, baggy dress. Few physical signs are found. During the exam the patient mentions how fat she has become. She is weighed and is found to be 88% of the minimum weight requirements for her age and height. Her mother is concerned as her daughter has been eating little and exercising daily, and seems disinterested in her friends.

Contact dermatitis

A 16-year-old girl presents with a progressively worsening pruritic eruption in the periumbilical region. She reports wearing blue jeans with metal buttons and a belt with a metal buckle on an almost daily basis. She previously developed pruritic eruptions around the neck and earlobes when wearing costume jewelry. Physical exam reveals erythematous to hyperpigmented periumbilical papules and plaques with sharp demarcation, and hyperpigmented patches on the neckline and ear lobes.

Viral meningitis

A 19-year-old man presents with a 2-day history of headache and associated nausea. He says that bright light hurts his eyes. He has no significant past medical history, is not currently taking any medication, and reports no drug allergies. He works as a librarian and has not traveled overseas for the past year. He lives with his girlfriend whom he has been seeing for 2 years. They have a pet hamster.

Meningococcal disease

A 20-year-old college student presents to the emergency department with fever and confusion. The previous night he felt ill and complained of a headache. This morning he was difficult to arouse, seemed confused, and felt warm to touch. On physical exam he is acutely ill with fever, tachycardia, and mild hypotension. He opens his eyes and withdraws in response to painful stimuli. Nuchal rigidity and a few truncal petechiae are present.

Cystitis (acute)

A 26-year-old female newlywed presents complaining of painful urination, feeling of urgent need to urinate, and more frequent urination for 2 days. She denies any fever, chills, nausea, vomiting, back pain, vaginal discharge, or vaginal pruritus.

Psoriasis

A young man without a known history of psoriasis or skin disorder had a sudden onset of wide-spreading, white-scaly, oval- to round-shaped erythematous papules, which had been present for 2 weeks. Lesions primarily involve his trunk but are also scattered around his arms and legs. He recalls a recent episode of sore throat and upper respiratory tract infection. A short course of antibiotics seemed to help, but not clear the lesions.

Tuberculosis (extrapulmonary)

A 42-year-old Asian woman presents to her primary care physician with a 7-week history of an enlarging mass on the left side of her neck. She denies pain or drainage. The mass failed to respond to antibiotics. She denies cough, fever, night sweats, or anorexia. She is originally from Vietnam but has lived in the US for 15 years. She denies any history of TB or TB exposure. Physical examination reveals a well-appearing woman. There is a 2 x 4 cm left neck mass consistent with a lymph node in the anterior cervical chain. There is no tenderness; the node is firm and mobile. There are smaller subcentimeter lymph nodes in the left supraclavicular fossa. The physical examination is otherwise unremarkable.

Cluster headache

A 44-year-old male smoker presents with a 9-year history of recurrent headaches. Headaches occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). The headaches have increased to an average of 2 episodes per day. The acute episodes can occur at any time, and last between 2 and 4 hours. He always has a nocturnal event. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or gasoline. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs. He becomes severely agitated during attacks, often pacing the room or rocking back and forth. Physical exams, lumbar puncture, brain MRI (including pituitary views), and pituitary function blood tests are normal.

Contact dermatitis

A 45-year-old male factory worker presents with pruritic eruption of his hands, which has been present for several months. He works in a manufacturing plant where cutting oils are used. While at work, he wears protective clothing that covers his trunk, arms, and legs, but he often neglects to wear gloves. He noticed an improvement when he was on vacation for 2 weeks. Physical examination shows hyperpigmented scaly plaques and fissuring, confined to the dorsal hands and digits, with sharp demarcation at the wrist.

Ankle fracture

A 52-year-old woman presents with an acutely swollen, painful ankle, deformity, and inability to weight-bear after severely twisting her ankle coming down her steps.

Cirrhosis

A 56-year-old male with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical exam reveals telangiectasias, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (AST: 90 U/L, ALT: 87 U/L), and the patient is positive for anti-hepatitis C antibody.

Migraine headache (child)

A 9-year-old boy presents with a 6-month history of recurrent headaches. He does not experience aura. Each headache builds up gradually over 20 minutes and is usually unilateral in nature, pulsating in quality, of moderate intensity, and aggravated by exercise. Nausea, vomiting, photophobia, and phonophobia are common accompanying symptoms. During attacks he favors going to sleep in a dark room, and will often go to bed earlier than usual and wake fully recovered the next day. Attacks can be of variable duration (2 to 48 hours) but generally last around 16 hours. Neurologic examination during an attack is entirely normal. He is normotensive. He is completely well in between attacks and is making good academic progress. There is a strong family history of migraine with aura.

Cervical cancer

It is very common for XXX to present with no symptoms, and to be identified at screening with Pap smear. An alternate common presentation is with bleeding, discharge, pain, or obstructive uropathy.

Conjunctivitis (Neisseria gonorrhoeae)

Hyperacute presentation over 24 to 48 hours with copious whitish-yellow discharge from eyes in a sexually active person.

Lower esophageal ring (Schatzki ring)

• Circumferential, lower esophageal ring • Clinical: intermittent solid dysphagia • Diagnosis: barium swallow • Treatment: bougie dilators

Subacute IE

may be associated primarily with constitutional symptoms such as fever, malaise, weakness, and peripheral stigmata such as embolic phenomenon, Osler nodes, Janeway lesions, or splinter hemorrhages.