yeet
A 55-year-old man with a history of hypertension (well controlled with medication) and cigarette smoking presents to his general practitioner with a 2-day history of constant and gnawing epigastric pain. The pain has been steadily worsening in intensity. He says the pain radiates to his lower back and both groins at times. There is a palpable pulsatile mass just left of midline above the umbilicus. He is immediately referred to a regional vascular service for definitive management, but during transfer becomes hypotensive and unresponsive.
Abdominal aortic aneurysm
A 65-year-old man presents to his local aneurysm surveillance team for a screening ultrasound scan. He has been feeling well and in his usual state of good health. His medical history is notable for mild hypertension and he has a 100-pack-year smoking history. On ultrasound an infrarenal AAA is identified.
Abdominal aortic aneurysm
A 62-year-old woman with systemic lupus erythematosus undergoes a head magnetic resonance imaging for acute mental status changes suggesting lupus cerebritis. The patient has been taking prednisone each day for several months. She has a diagnosis of GORD, for which she takes a proton-pump inhibitor. During the imaging study in the supine position, the patient vomits and aspirates gastric contents consisting of yellowish-greenish fluid. Severe respiratory distress and hypoxaemia develop, and she requires endotracheal intubation, mechanical ventilation, and admission to the intensive care unit. Physical examination reveals bilateral crackles and wheezes.
Acute aspiration
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 reliever inhaler, with worsening symptoms, despite increased use. She has been taking her asthma medications regularly, which consist of an inhaled corticosteroid and a leukotriene receptor antagonist for maintenance therapy and salbutamol as reliever therapy. Her cough is disrupting her sleep pattern and as a consequence she is experiencing daytime somnolence, which is affecting her job performance.
Acute asthma exacerbation in adults
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 upper respiratory tract infection are noted. Scattered wheezes are present diffusely on lung auscultation.
Acute bronchitis
A 70-year-old woman describes increasing exertional dyspnoea for the last 2 days and now has dyspnoea at rest. She has a history of hypertension for the last 5 years and a 35 pack-year smoking history, but no other established illnesses. Current medications are a diuretic daily for the last 3 years. She has been prescribed an ACE inhibitor but failed to collect the prescription. On examination her BP is 190/90 mmHg, and her heart rate is 104 bpm. There is an audible S4 and the jugular venous pressure is elevated 2 cm above normal. Lung examination reveals fine bibasal crepitations. Echocardiogram demonstrates normal biventricular size, a left ventricular ejection fraction of 60%, and no significant valvular disease.
Acute heart failure
A 73-year-old woman with a history of myocardial infarction presents to the accident and emergency department. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure is elevated 5 cm above normal, there is a gallop rhythm, and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination. Echocardiogram shows an ejection fraction of 35%
Acute heart failure
A 60-year-old man develops shortness of breath while he is in hospital recovering from a recent myocardial infarction. He is unable to lie flat without significant discomfort, has marked laboured breathing, and has a respiratory rate of 36 breaths per minute. Auscultation of the chest reveals diffuse rales. During examination, breathing becomes more rapid and shallow and the patient slowly loses consciousness.
Acute respiratory failure
A 67-year-old man with known COPD presents with fever and cough. He complains of worsening shortness of breath and the inability to get enough oxygen. His mental status waxes and wanes and he is cyanotic around the lips and cheeks. During examination, ventilatory efforts rapidly deteriorate.
Acute respiratory failure
A 17-year-old boy presents with an 18-month history of pain in his right ankle and both heels, with early morning stiffness and fatigue. Walking short distances is proving difficult due to heel pain, and he has given up sport. Examination reveals marked tenderness and swelling over bilateral Achilles tendons.
Ankylosing spondylitis
A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is an avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms. He has to get up regularly and move around. His back symptoms also wake him in the second half of the night, after which he can find it difficult to get comfortable. He normally takes an anti-inflammatory drug during the day, and finds his stiffness is worse when he misses a dose. He has had 2 bouts of iritis in the past.
Ankylosing spondylitis
A 59-year-old man presents to the accident and emergency department with a sudden onset of excruciating chest pain, which he describes as tearing. He has a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.
Aortic dissection
A 31-year-old black man presents to clinic for the first time for a routine physical examination. He denies any complaints. On physical examination 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.
Aortic regurgitation
A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, 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.
Aortic regurgitation
A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises 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 examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.
Aortic stenosis
A 55-year-old woman presents for evaluation of a chronic cough, productive of thick, yellow sputum that sometimes becomes blood-tinged. She has experienced recurrent episodes of fever associated with pleuritic chest pain. She states that she is embarrassed by the persistent, intractable nature of her cough and has been prescribed multiple courses of antibiotics. Over the last 5 years, she has developed shortness of breath with exertion. Her past medical history is significant for pneumonia as a child and sinus polyps during adulthood for which she has had surgery.
Bronchiectasis
A 10-week-old boy presents to his family doctor in January because his mother feels his breathing is laboured. His pregnancy, labour and delivery were uncomplicated. His mother smoked during pregnancy and continues to do so. The family history is negative for asthma or allergy. He developed rhinitis and a tactile fever 3 days prior to presentation. Over the next few days he developed increasing cough, increased work of breathing, and decreased oral intake. On examination, his temperature is 38.0°C (100.4°F), his respiratory rate is 42 breaths per minute, and his oxyhaemoglobin saturation, measured by pulse oximetry, is 93% while breathing room air. He has a wet cough. His chest examination reveals mild intercostal and subcostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally.
Bronchiolitis
A 40-year-old man presents with a 2-year history of increasing heel pain. Physical examination reveals a posterior redness and swelling with a palpable bump, which is tender on direct palpation.
Bursitis
A 60-year-old woman presents with progressive complaints of lateral hip and thigh pain associated with a disabling limp, without a previous history of trauma or lumbar pathology. Physical examination shows localised pain over the greater trochanter to palpation and a full pain-free range of motion of the hip.
Bursitis
A 72-year-old woman presents with polyarticular joint pain. She has long-standing mild joint pain, but over the last 10 years notes increasing discomfort in her wrists, shoulders, knees, and ankles. She has had several recent episodes of severe pain in one or two joints, with swelling and warmth of the affected areas. These episodes often last 3-4 weeks. Her examination shows severe bony changes consistent with osteoarthritis in many joints, and slight swelling, warmth, and tenderness without erythema in the second and third metacarpophalangeal joints, left shoulder, and the right wrist.
Calcium pyrophosphate deposition
An 80-year-old man presents with a swollen red wrist, fever, and chills. He recalls falling out of his wheelchair several days ago but seemed well until 24 hours before admission, when he developed pain in his right wrist. His daughter noted fever and some confusion and brought him to the hospital. On examination, he appears ill and has a fever of 39ºC (102ºF). There is swelling, tenderness, and redness around the right wrist with oedema over the dorsum of the hand.
Calcium pyrophosphate deposition
A 70-year-old woman with a history of hypertension, hyperlipidaemia, 40 pack-years of cigarette smoking, and remote percutaneous transluminal coronary angioplasty is witnessed falling to the ground while brushing her pavement. She has not complained of any preceding symptoms. The emergency medical personnel who respond quickly to the scene find her unconscious and pale, with agonal respirations but without a pulse. After the pads from an automated external defibrillator are attached, the patient is noted to be in ventricular fibrillation.
Cardiac arrest
A 50-year-old woman presents with numbness and tingling in her hands. The symptoms are worse in her right (dominant) hand and with activities such as holding a book or a steering wheel, or brushing her hair. The discomfort in her hands frequently wakes her at night, and she has to shake or hang her hand out of her bed for relief.
Carpal tunnel syndrome
A 60-year-old man presents to the accident and emergency department. He reports being progressively short of breath. He has a history of hypertension, non-insulin-dependent diabetes mellitus, and has been a heavy smoker for more than 40 years. He underwent a successful primary angioplasty for a large acute anterior myocardial infarction 2 months ago. His blood pressure is 75/40 mmHg, his heart rate 110 beats per minute, and his respiratory rate 30. He has elevated neck veins and a prominent S3. His ECG shows sinus tachycardia, and a transthoracic echocardiogram performed in the A&E department reveals impaired left ventricular systolic function, with an ejection fraction of 20%.
Chronic congestive heart failure
A 67-year-old woman presents to her primary care physician complaining of increasing shortness of breath, especially when trying to sleep. She has a history of poorly controlled hypertension and hyperlipidaemia, and is being treated with a beta-blocker and statin therapy. She does not smoke and drinks alcohol in moderation. On examination, her blood pressure is 160/90 mmHg and heart rate is 126 beats per minute. There is an audible S4 and the jugular venous pressure is elevated 3 cm above normal. There is no oedema, but she has fine bilateral mid to lower zone crepitation on lung examination. The ECG shows left ventricular hypertrophy and a transthoracic echocardiogram shows left ventricular hypertrophy, left atrial dilatation, normal left and right ventricular systolic function, with a left ventricular ejection fraction of 60%.
Chronic congestive heart failure
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 rhinorrhoea. 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 haemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.
Chronic obstructive pulmonary disease (COPD)
A 66-year-old man with a smoking history of one 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 oedema.
Chronic obstructive pulmonary disease (COPD)
A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool, and a change from his normal bowel habit as he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well and there is no family history of gastrointestinal disease. Examination of his abdomen and digital rectal examination are normal.
Colorectal cancer
A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical examination reveals a temperature of 38.3°C (101°F), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. Chest x-ray reveals a left lower lobe infiltrate.
Community-acquired pneumonia (non COVID-19)
A 26-year-old woman presents at her local COVID-19 testing clinic with symptoms of a sore throat and loss of taste. She denies having a fever, and has not knowingly been in contact with a confirmed case of COVID-19. After being tested, she is advised to go home, self-isolate until her test results are sent to her via text message, and call her doctor if her symptoms get worse. She receives a text message later that day confirming that her test is positive for SARS-CoV-2, and that she must self-isolate according to her local public health recommendations.
Coronavirus disease 2019 (COVID-19)
A 61-year-old man presents to hospital with fever, dry cough, and difficulty breathing. He also reports feeling very tired and unwell. He has a history of hypertension, which is controlled with enalapril. On examination, his pulse is 120 bpm, his temperature is 38.7°C (101.6°F), and his oxygen saturation is 88%. He appears acutely ill. He is admitted to hospital in an isolation room and is started on oxygen, intravenous fluids, and venous thromboembolism prophylaxis. Blood and sputum cultures are ordered. Chest x-ray shows bilateral lung infiltrates, and computed tomography of the chest reveals multiple bilateral lobular and subsegmental areas of ground-glass opacity. A nasopharyngeal swab is sent for real-time reverse transcriptase polymerase chain reaction testing, and the result comes back positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a few hours later.
Coronavirus disease 2019 (COVID-19)
A 2-year-old boy is brought to the emergency department by his parents in the middle of the night. He has had mild symptoms of an upper respiratory infection for 48 hours, awoke with a sudden onset of seal-like barky cough, and has had inspiratory stridor when crying. The stridor disappeared at rest, but the seal-like barky cough has persisted.
Croup
A 3-year-old boy is brought to the emergency department by his parents in the late evening. He has developed a sudden onset of a seal-like barky cough, accompanied by clear nasal discharge. His parents became alarmed when he developed stridor, which persists throughout the trip to the hospital. On examination, he has a seal-like barky cough and inspiratory stridor when at rest, which worsens with agitation. Persistent sternal indrawing is also evident at rest.
Croup
A 1-year-old child presents with failure to thrive. By history, the child was born at the 50th percentile for weight, but has crossed multiple percentile lines despite having a ravenous appetite. The child has more bowel movements per day than other children of the same age, and the stools often look shiny and have an unusually foul smell. In addition, the child has been treated with multiple courses of antibiotics for a persistent, wet cough. On measurement, the child is small for age, with weight and length below the third percentile.
Cystic fibrosis
A 65-year-old woman presents with unilateral leg pain and swelling of 5 days' duration. She has a history of hypertension, congestive heart failure, and recent hospitalisation for a total knee replacement. She had been recuperating at home but on beginning to walk, her right leg became painful, tender, and swollen. On examination there is pitting oedema on the right and the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left. There is tenderness on palpation in the popliteal fossa behind the right knee.
Deep vein thrombosis
A baby girl is seen for a routine examination at 2 weeks of age. She was born at term with no pregnancy or delivery complications. A screening examination 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.
Developmental dysplasia of the hip
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 physiotherapy. 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 analogue 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.
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.
Discogenic low back pain
A 65-year-old man re-presents to his physician, following treatment for pneumonia, with fever, increasing breathlessness, and right-sided chest pain. He feels lethargic and has lost 4 kg in weight. He initially presented 3 weeks earlier with a productive cough and breathlessness. At that time, he was diagnosed with community-acquired pneumonia and treated with a course of oral antibiotics. He has a past medical history of poorly controlled type 2 diabetes mellitus. On examination, he is septic, with a temperature of 101.3°F (38.5°C), BP 90/60 mmHg, pulse rate 110 beats/minute, and respiratory rate 28 breaths/minute. He has dullness to percussion and decreased breath sounds at the right lung base. Chest radiograph demonstrates a loculated right pleural effusion. Laboratory examination reveals WBC count 20 × 10⁹/L. He undergoes ultrasound-guided thoracentesis (pleural aspiration) that shows a septated pleural effusion, and frank pus is aspirated.
Empyema
A 28-year-old woman presents with a complaint of medial elbow pain for 4 days. She works as an office manager doing filing and clerical work. She does not recall an inciting event preceding her pain, nor can she recall similar symptoms previously. She does not use an ergonomically correct keyboard at work or home. Her pain is burning and aching in quality, along the volar, medial aspect of her proximal forearm, just distal to the medial epicondyle.
Epicondylitis
A 45-year-old lawyer presents 1 week after participating in a tennis tournament, with lateral elbow and dorsal forearm pain in his dominant arm. He recalls playing in four matches over the weekend preceding his symptoms. He notes that typing and computer work were uncomfortable the following week. He has night-time aching, but no neurological complaints. He does not recall any specific injury and had no prior history of injury or similar pain.
Epicondylitis
A 64-year-old black man presents for a check-up. He denies past medical problems, but has been told that his blood pressure was a little high. He has no complaints, takes no medications, tries to adhere to a healthy diet, and rarely exercises. He reports that over the previous 5 years he has gained 6.8 kg (15 lb). Review of systems is otherwise non-contributory. Physical examination is notable for obesity and blood pressure 172/86 mmHg. The remainder of the examination is unremarkable.
Essential hypertension
A previously healthy 35-year-old man presents after an all-night binge that included alcohol and cocaine. He is feeling weak and shaky with reduced exercise tolerance. His BP is 110/70 mmHg and heart rate 160 bpm and regular. An ECG shows a narrow complex atrial tachycardia. He is given adenosine 6 mg intravenously. There is abrupt slowing of the ventricular response rate with no effect on the atrial rate.
Focal atrial tachycardia
An 88-year-old woman with a history of dilated cardiomyopathy presents with nausea, light-headedness, and a racing heart. She is taking digoxin and recently her diuretic dosage has been increased. On examination she is alert but weak. Her BP is 108/88 mmHg, and pulse 88 bpm and regular. The lungs are clear. An ECG shows a sustained atrial tachycardia at 180 bpm with 2:1 AV block. Serum potassium is 2.8 mmol/L (2.8 mEq/L).
Focal atrial tachycardia
A 35-year-old female presents complaining of a mass located over the dorsal aspect of her wrist. She states the mass has been present for approximately 6 months and does not cause her any pain. It has slowly enlarged and is now interfering with her ability to slide on a bracelet. She claims that it has increased in size after strenuous activity and seems to shrink back to the current size with resting of the arm. She denies any paralysis or paraesthesias to her hand or fingers. She has good blood flow through her radial and ulnar arteries with brisk capillary refill. The mass is fluctuant and not firmly attached to underlying structures and is not painful with palpation. The structure trans-illuminates when examined with a penlight.
Ganglion cyst
A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4-6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. She has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m, weight 77.1 kg, and blood pressure 140/88 mmHg. The remainder of the examination is unremarkable.
Gastro-oesophageal reflux disease
A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had ('even covering my foot with the bed sheet hurts'). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot.
Gout
An 85-year-old man presents with several days of swelling and severe pain in both hands limiting his ability to use his walking frame. He has a history of gout but has not experienced these symptoms before. On examination, he has a temperature of 37.8°C (100.1°F). There is diffuse warmth, mild erythema, and pitting oedema over the dorsum of both hands. There is tenderness and limited hand grip bilaterally. There are multiple nodules around several of the proximal interphalangeal and distal interphalangeal joints, and effusion and tenderness in his left olecranon bursa with palpable nodules.
Gout
A 56-year-old woman presents to the emergency department with shortness of breath at rest, orthopnoea, and paroxysmal nocturnal dyspnoea that developed in the last 5 days. Her past medical history includes obesity, hypertension, diabetes mellitus, and chronic kidney disease stage II. She had a cardiac catheterisation done 2 years ago due to exertional chest pain that revealed non-obstructive coronary artery disease. On examination she is tachycardic with a heart rate of 110 bpm and her blood pressure is 192/98 mmHg. She has jugular venous distension up to her jaws, trace lower extremity oedema, and bi-basal crackles. She has a normal S1 and S2, but has a summation gallop with no murmurs.
Heart failure with preserved ejection fraction
A 55-year-old man with a history of peripheral vascular disease, who presents with a complaint of a left foot ulcer and pain when walking short distances, is found to have a popliteal stenosis and admitted for re-vascularisation. Four days after admission, on postoperative day 3, he develops shortness of breath, hypoxia, and a productive cough. Auscultation of his chest reveals decreased breath sounds at the lower aspect of the right side of his chest. His morning leukocyte count is slightly higher than the day before at 11,000 cells/mL3. An anterior-posterior bedside chest x-ray reveals right lower lobe opacity.
Hospital-acquired pneumonia (non COVID-19)
An 88-year-old female resident of a nursing home, who typically does not present to the acute care hospital, has frequent urinary tract infections (UTIs) that are managed by the nursing home physician. In the nursing home, she develops a UTI due to multidrug-resistant pathogens. On admission to hospital, she has poor mental status and her bed is left with the head elevated to only a 5° angle. On hospital day 4, a chest x-ray reveals a right lower lobe opacity.
Hospital-acquired pneumonia (non COVID-19)
A 21-year-old active college student with no past medical history has sudden loss of consciousness, 1 hour into a game of basketball. CPR is administered by bystanders. On the arrival of an emergency medical professional, he regained consciousness. The family history is significant for a murmur in his father and paternal grandmother. Physical examination reveals a systolic ejection murmur that increases in intensity when going from a supine to standing position and disappears with squatting.
Hypertrophic cardiomyopathy
A 60-year-old woman has progressive dyspnoea on exertion over the last 2 months. She is otherwise well, with no risk factors for ischaemic heart disease. Family history is significant for a cousin who died suddenly in his youth, and is otherwise unremarkable. Physical examination reveals a prominent jugular a-wave and a double apical impulse. There are no murmurs audible. An S4 is present. The remainder of the examination is normal.
Hypertrophic cardiomyopathy
A 65-year-old man presents with gradually progressive dyspnoea on exertion and a non-productive cough. He has no history of underlying lung disease and no features that would suggest an alternative aetiology for his cough and dyspnoea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He takes no medications and has no environmental exposures to organic allergens such as mould. On examination, he has fine crackles audible over his lung bases bilaterally; however, he has no lower-extremity oedema, elevations in jugular venous pressure, or any other findings to suggest volume overload. He has clubbing of his fingers.
Idiopathic pulmonary fibrosis
A 72-year-old man with a history of cigarette smoking presents with mild shortness of breath. He is treated initially with inhaled bronchodilators for a presumed diagnosis of chronic obstructive lung disease but has no symptomatic improvement. Pulmonary function tests are performed and show restriction rather than obstruction, along with impaired diffusing capacity for carbon monoxide. A follow-up chest radiograph shows prominent bi-basilar interstitial markings.
Idiopathic pulmonary fibrosis
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 and hypothyroidism. She admits to infrequent intravenous heroin use and has a 10-pack-year history of smoking. Physical examination reveals temperature of 39°C (102°F), regular heart rate 110 beats per minute, blood pressure 110/70 mmHg, and respiration rate of 16 breaths per minute. Her cardiovascular examination 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.
Infective endocarditis
A 5-year-old Caucasian boy is brought in to the orthopaedic clinic by his mother with complaints of a limp favouring the right side with no associated pain. This painless limp had started insidiously 3 weeks earlier and was first noticed by the school physical education teacher. The mother notes that it has recently been getting worse. He is one of 3 siblings and lives with his single mother. The other siblings include an elder sister (from his mother's earlier marriage) and a younger brother. His mother's current partner is a heavy smoker. His mother recalls that 1 year earlier he came from school and complained of right knee pain. This was initially overlooked for a few days, but when it persisted he was taken to the general practitioner who reassured his mother but did not arrange follow-up. The symptoms had recurred the following month when he was taken to the emergency department and blood tests and x-rays were reportedly normal.
Legg-Calvé-Perthes' disease
A 7-year-old girl presents with a painless limp, although she has been treated for acute pain in the past. She has a free range of hip motion. Plain anteroposterior and frog lateral radiographs reveal Legg-Calvé-Perthes' disease of the right hip. She undergoes screening of the right hip under a general anaesthetic with an arthrogram to determine the best position of right femoral head containment in the hip joint. A surgical containment is performed by way of a varus lateral opening wedge osteotomy of the proximal femur, fixed with an AO (Arbeitsgemeinschaft fur Osteosynthesefragen) 3.5 mm pre-contoured plate and held with 3.5-mm AO screws, is performed. She is kept non-weight-bearing post-procedure. A radiograph 4 weeks later reveals a good containment of the hip joint, satisfactory alignment at the osteotomy and some early callus formation medially. A further radiograph 3-months postoperatively shows a good union at the osteotomy and a well-contained hip joint. Weight-bearing and resumption of normal activities is then allowed progressively.
Legg-Calvé-Perthes' disease
A 52-year-old woman presents with dyspnoea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, or lower extremity oedema. On physical examination her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac examination 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.
Mitral regurgitation
A 36-year-old prima gravida presents with dyspnoea on exertion and 2 pillow orthopnoea during her second trimester. Previous physical examinations had disclosed no cardiac abnormalities. On current physical examination, she has a loud first heart sound and a 2/6 diastolic rumble.
Mitral stenosis
A 52-year-old woman presents with gradually increasing dyspnoea on exertion over the past 2 years. Recently she has required 2 pillows at night to alleviate recumbent dyspnoea. On examination, she has an apical diastolic murmur.
Mitral stenosis
A 38-year-old man with no significant history of back pain developed acute lower back pain when lifting boxes 2 weeks ago. The pain is aching in nature, located in the left lumbar area, and associated with spasms. He describes previous similar episodes several years ago, which resolved without seeing a doctor. He denies any leg pain or weakness. He also denies fevers, chills, weight loss, and recent infections. Over-the-counter ibuprofen has helped somewhat, but he has taken it only twice a day for the past 3 days because he does not want to become dependent on painkillers. On examination, there is decreased lumbar flexion and extension secondary to pain, but a neurological examination is unremarkable.
Musculoskeletal lower back pain
A 56-year-old woman with a 6-week history of weight loss, anxiety, and insomnia presents with palpitation and dyspnoea. Her pulse rate is irregular at 140 to 150 bpm. Her BP is 95/55 mmHg. She looks thin, frail, and rather anxious and jittery. Her palms are sweaty and have fine tremors. She has a palpable smooth goitre. Examination of the eyes shows bilateral exophthalmoses.
New-onset atrial fibrillation
A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidaemia presents to the accident and emergency department with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest. His symptoms came on suddenly 4 hours ago. Physical examination shows an irregularly irregular radial pulse rate at 90 to 110 bpm, a BP of 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination.
New-onset atrial fibrillation
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain or haemoptysis. Medical history is significant for COPD and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or crackles.
Non-small cell lung cancer
A 41-year-old obese man presents with loud chronic snoring and gasping episodes during sleep. His wife has witnessed episodic apnoea. He reports unrefreshing sleep, multiple awakenings from sleep, and morning headaches. He has excessive daytime sleepiness, which is interfering with his daily activities, and he narrowly avoided being involved in a motor vehicle accident. His memory is also affected. He has been treated for hypertension, gastro-oesophageal reflux, and type 2 diabetes.
Obstructive sleep apnoea in adults
A 55-year-old woman has had pain and swelling in several fingers of both hands for the past 2 months. She describes morning stiffness lasting for 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 examination, she has tenderness, slight erythema, and swelling in one proximal interphalangeal joint and two distal interphalangeal 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 metacarpophalangeal joints.
Osteoarthritis
A 60-year-old woman presents complaining of bilateral knee pain almost daily for 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 examination, 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 favouring the right side.
Osteoarthritis
A 40-year-old man who suffered an open tibial fracture in a motor vehicle accident 6 months ago presents with swelling and pain in his lower leg.
Osteomyelitis
A 5-year-old boy fell off his bicycle 2 weeks ago, has stopped walking, and complains of non-specific leg pain. His mother reports that he apparently has had flu, with fever and chills.
Osteomyelitis
A 70-year-old man, 6 months after renal transplantation and on corticosteroid treatment, presents with severe back pain. X-ray evaluation of the thoracic and lumbar spine discloses evidence of multiple vertebral compression fractures.
Osteoporosis
A 70-year-old woman presents to the emergency department after falling while getting out of bed. She sustained an intertrochanteric fracture of the right hip. Preoperative chest x-ray before repair of the hip reveals that she had existing asymptomatic vertebral fractures before her fall.
Osteoporosis
A 50-year-old male diabetic smoker presents with leg pain on exertion for 6 months. He notes bilateral calf cramping with walking. He states that it is worse on his right calf than his left and that it goes away when he stops walking. He has noticed that distance is more limited on an incline or if stairs are present.
Peripheral arterial disease
A 75-year-old woman with hypertension and hyperlipidaemia presents with abnormal ankle brachial index on a routine screening. She is able to walk without any discomfort and is active.
Peripheral arterial disease
A 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 a 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 38°C (100.7°F), blood pressure is 130/78 mmHg, and pulse is 110 bpm. He looks unwell 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.
Pleural effusion
A 70-year-old woman presents with slowly increasing dyspnoea. She cannot lie flat without feeling more short of breath. She has a history of hypertension and osteoarthritis, and she has been taking non-steroidal anti-inflammatory drugs with increasing frequency over the previous few months. On physical examination, she appears dyspnoeic at rest, her blood pressure 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 oedema to the knee.
Pleural effusion
A 20-year-old man presents to the emergency department with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he might have strained a chest wall muscle, but because the pain and dyspnoea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular examination is normal.
Pneumothorax
A 65-year-old patient with COPD presents to the emergency department with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the colour or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.
Pneumothorax
A 65-year-old man presents to the emergency department with acute onset of shortness of breath 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 38.0°C (100.4°F), heart rate 112 bpm, BP 95/65 mmHg, and an O₂ saturation on room air of 91%.
Pulmonary embolism
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 taps on and off 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.
Rheumatoid arthritis
A 57-year-old woman who is typically sedentary presents complaining of shoulder pain after a trip and fall onto her outstretched hand. She has no prior history of shoulder injuries. She has pain on the lateral aspect of her shoulder and weakness with external rotation and forward elevation.
Rotator cuff injury
A right-handed 65-year-old man presents after painting a room in his house. He complains of pain in his right shoulder, which worsens with overhead lifting, and some night pain since the onset of symptoms. He has no past history of shoulder problems and no other medical conditions. He has no neurological symptoms and does not complain of weakness.
Rotator cuff injury
A 54-year-old man with a medical history of hypertension, diabetes, dyslipidaemia, smoking, and family history of premature coronary artery disease presents with retrosternal crushing chest pain (10/10 in intensity), radiating down the left arm and left side of the neck. He feels nauseated and light-headed and is short of breath. Examination reveals hypotension, diaphoresis, and considerable discomfort with diffuse bilateral crackles on chest auscultation. ECG reveals convex ST-segment elevation in leads V1 to V6.
ST-elevation myocardial infarction
A 70-year-old woman is 2 days post-operative for knee replacement surgery. Her past medical history includes type 2 diabetes and a 40 pack-year history of smoking. She reports feeling suddenly unwell with dizziness, nausea, and vomiting. She denies any chest pain. On examination she is hypotensive and diaphoretic. ECG shows convex ST-segment elevation in leads II, III, and aVF with reciprocal ST segment depression and T-wave inversion in leads I and aVL.
ST-elevation myocardial infarction
A 25-year-old man who is a known intravenous drug misuser presents with a 5-day history of pain and swelling in his right leg. On examination there are multiple sites of intravenous puncture. His right leg is swollen from the knee downwards. There is a large effusion on the right knee together with significant cellulitic changes of the overlying skin.
Septic arthritis
A 55-year-old woman presents with a 1-week history of pain and swelling in her left wrist. She was diagnosed with rheumatoid arthritis at the age of 36 years but the rest of her joints are currently asymptomatic. Her rheumatoid arthritis is well controlled on her current medication. On examination her left wrist is found to be hot, swollen, tender, and highly restricted in its range of movement. There is no sign of inflammation in any of her other joints. She has a temperature of 37.5˚C (99.5˚F).
Septic arthritis
A 13-year-old boy presents with hip, groin, thigh, and medial knee pain. He is overweight and recently experienced an adolescent growth spurt. On physical examination, the affected leg is externally rotated and there is limited range of motion in the hip joint. He is unable to bear weight on the affected leg.
Slipped capital femoral epiphysis
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain, or haemoptysis. Past medical history is significant for chronic obstructive pulmonary disease and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy was palpable on examination and breath sounds were diminished globally without focal wheezes or rales.
Small cell lung cancer
A 45-year-old woman presents with a burning pain in her right calf, over an existing varicose vein, for the past 3 days. She has also noticed some reddening around that area extending from just below the knee to halfway down the lateral aspect of the right leg. The varicose vein has been relatively asymptomatic and first appeared after the birth of her first child when she was 32 years old. She has no known medical conditions and does not take any medicines. She has no previous history of deep vein thrombosis (DVT). Physical examination reveals a cord-like superficial vein on the outer aspect of her right leg. The overlying skin is erythematous and warmer than the adjacent leg skin. She is afebrile and her heart rate is normal. There is no clinical evidence of DVT.
Superficial vein thrombophlebitis
A 36-year-old woman with a history of chronic sinusitis presents with nasal deformity. She has had non-specific muscle and joint aches for 2 years, diagnosed as fibromyalgia. For a few years she has regularly noted dark crusts from her nose, occasionally mixed with some blood. A few weeks ago the bridge of her nose started to collapse. She has a prominent saddle nose deformity and nasal septal defect. Sinus biopsy shows only chronic inflammation, but her cytoplasmic-pattern anti-neutrophil cytoplasmic auto-antibody titre is 1:160, consistent with granulomatosis with polyangiitis.
Systemic vasculitis
A 75-year-old man with an unremarkable past medical history presents with a complaint of new headache for the past 2 weeks. He notes that the headache is localised over the left temple. Two weeks prior to the onset of headache, he noted pain and stiffness in the shoulders and hips, which made it difficult to rise from bed in the morning, but progressively improved throughout the day. A few days prior to his evaluation, he noted jaw pain on chewing, and notes in retrospect that he had begun to avoid certain foods (such as steak) because of the associated discomfort. Laboratory evaluation demonstrates evidence of inflammation, including an elevated erythrocyte sedimentation rate, C-reactive protein, and platelets. The complaints of new headache and jaw claudication in the setting of systemic inflammation are consistent with a diagnosis of giant cell arteritis.
Systemic vasculitis
A 55-year-old female secretary with diabetes reports pain and catching of her left dominant thumb. This started over the previous few months; no other digits are involved. She denies any locking of her thumb, and can actively flex and extend her thumb, although sometimes with difficulty. On examination a tender, palpable nodule could be felt over her left thumb metacarpophalangeal joint. When asked to flex and extend her thumb she could easily flex, but her thumb clicks on the way to full extension.
Tenosynovitis of the hand and wrist
A 60-year-old male labourer presents with right wrist pain. The pain is located over the dorsal radial side of his wrist. It is exacerbated while at work and improves with rest. He has no limitation of motion, but ulnar deviation is very painful. He has local tenderness in the area of the radial styloid.
Tenosynovitis of the hand and wrist
A 3-year-old boy is seen in the accident and emergency department at 2 a.m. because he is crying. He is otherwise healthy. Earlier in the day he was playing, but his mother noted that he may have had a limp. He has no fever and otherwise feels well. On physical examination, slight movement of his hip is tolerated but excess motion causes him to cry. His full blood count and erythrocyte sedimentation rate are normal.
Transient synovitis of the hip
A 65-year-old man, who smokes and has a history of hypertension and peripheral vascular disease, now presents with increasing frequency and severity of chest discomfort over the past week. He reports that he previously had chest pain after walking 100 metres, but now is unable to walk more than 50 metres without developing symptoms. The pain radiates from his chest to the left side of the neck and is only eased after increasing periods of rest.
Unstable angina
A 45-year-old woman presents with complaints of heaviness and fatigue in her legs. She does not experience the symptoms when she first awakens, but they become more noticeable and prominent as the day progresses and with prolonged standing. When she is standing for most of the day she notes swelling in both legs. The symptoms are concentrated over her medial calf, where she has prominent tortuous veins. She first noted dilated veins about 20 years ago when she was pregnant. Initially they did not cause her any discomfort but they have progressively enlarged and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs.
Varicose veins
A 45-year-old man presents to the emergency department with upper abdominal pain and a history of peptic ulcer disease. He reports vomiting blood at home. He is otherwise well, takes no medications, and abstains from use of alcohol. While in the emergency department he vomits bright red blood into a bedside basin and becomes light-headed. Blood pressure is 86/40 mmHg, pulse 120 bpm, and respiratory rate 24 per minute. His skin is cool to touch, and his skin is pale and mottled.
shock
A 72-year-old man presents with progressive malaise, weakness, and confusion. He suffers from hypertension but this is well controlled with a thiazide diuretic and an ACE inhibitor. He has diabetes, treated with metformin, but no other medical problems, and he is able to perform all activities of daily living independently. The patient's wife reports general deterioration over the last 2 days. The patient appears severely ill, weak, and obtunded, and is unable to speak. His skin is mottled and dry with cool peripheries, and he is mildly cyanotic. Respiratory rate is 24 breaths/minute, pulse rate 94 beats/minute, blood pressure 87/64 mmHg, and temperature 35.5°C (95.9°F). Auscultation yields coarse crackles over both lung bases.
shock
