Exam Master

A 33-year-old Caucasian man with a history of severe type 1 diabetes presents with a red and swollen pinky toe on his left foot. Further details from the patient include that he was running to answer his phone at home 2 days ago and stepped on an exposed carpet tack. He washed it out and covered it as soon as he could, but he has noted a significant increase in redness and severe restriction of movement of this toe, worsening significantly over the last 12 hours. He admits to "feeling feverish" for the past day and experiencing significant night sweats the previous night. He denies formally measuring his temperature. He has tried to take acetaminophen 500 mg 2 tablets every 8 hours without any noticeable relief. Pertinent physical examination findings include an oral temperature of 102.8°F, significant erythema and edema extending the entire fifth toe of the left foot, and restricted range of motion due to tenderness and swelling. There is a small amount of purulent drainage at the site of the wound.

6 weeks

A 54-year-old woman with diabetes mellitus presents with a 3-week history of vaginal spotting. An endometrial biopsy is performed and the pathology indicates endometrial cancer. The patient has a history of 12 years of amenorrhea and considers herself postmenopausal. She denies pelvic pain and cramping. She cannot identify any health changes that relate to the new vaginal bleeding. She has not seen a medical provider for preventive services for over 5 years due to a lack of health insurance. She is currently on metformin 500 mg TID; the patient admits poor compliance with the second and third doses each day. She has no known allergies, and her past medical history is significant for a cholecystectomy and tonsillectomy. The patient does not smoke or drink alcoholic beverages and denies illicit drug use. Menarche was at age 15; her menses were generally regular in her teens and 20s. She was amenorrheic while using depot medroxyprogesterone acetate, then menses returned but were irregular in frequency in her 30s. She believes her LMP to have been around age 42. She denies significant dysmenorrhea, menorrhagia, or premenstrual syndrome throughout her menstrual history. She is a G8P6Ab2, with her first child delivered at age 19; she had 6 spontaneous vaginal births with two first-trimester spontaneous abortions. She has had 9 sexual partners and has no history of sexually transmitted diseases. Previous methods of contraception included oral contraceptives (briefly) in her 20s and depot medroxyprogesterone acetate (DMPA) for 5 years in her early 30s. She discontinued the use of contraceptives in her mid-30s and has rarely been sexually active since.

A progestin during times of amenorrhea if the patient was not already on contraceptives

A 55-year-old woman presents with poor appetite and nausea. She has vomited 2 times over the past week and lost 4 pounds in the past month. Past medical history is significant for 20 years of alcoholism, 5 years with diabetes, and hypertension. She takes no medications; she is not involved in any therapy for her alcoholism. She has been drinking 4 12oz beers almost every day for the past 20 years, consuming greater quantities on weekends. Her vitals include a heart rate of 102 BPM, blood pressure of 140/100 mm Hg, respiratory rate of 20/min, and a temperature of 99.8°F. Physical exam reveals hepatomegaly. A liver biopsy reveals macrovesicular fat, spotty necrosis, and polymorphonuclear infiltration.

AST>ALT by a factor of 2

A 35-year-old man presents after several episodes of vomiting in the last 24 hours; there is loose stool and strong pain localized in the upper middle region of the abdomen. Physical examination indicates a temperature of 101°F and a tender epigastrium. Lab tests reveal an initial WBC count of 18x109/L. C-reactive protein level is 325 mg/L, and amylase is 130 U/L. There is a lactate dehydrogenase level of 816 U/L. The patient has no history of pancreatic disease and denies alcohol use. He is overweight. He has a history of type 2 diabetes and hypertension. He takes medicine to control his high blood pressure and obesity.

Abdominal computed tomography scanning

A 64-year-old man presents with progressive weakening of his urinary stream, nocturia, post void dribbling, and the sensation that he is not emptying his bladder. Annual screening blood work recently revealed a serum prostate-specific antigen of 4.3 ng/mL.

Abdominal examination, including digital rectal exam

A 41-year-old man presents with right upper quadrant pain. His pain began gradually, following a meal, but it has now become constant. He notes that he has had previous episodes of similar pain, but it has never been quite this severe. The pain radiates to his right shoulder and is worsened with inspiration. He has experienced nausea and vomiting, and he notes feeling chilled. Examination reveals an overweight man in moderate distress. He develops rigors during the physical exam. He has scleral icterus, and his skin has a yellow hue. Heart and lungs are clear. His abdomen is soft and non-distended with positive Murphy's sign. Vital signs reveal BP 109/62 mm Hg, pulse 112, respirations 18, and temperature 102.3°F. Laboratory studies include:

Abdominal ultrasound

A 28-year-old man presents with diplopia and the inability to move the right eye outwards. He was hit by a ball on the right side of his face while playing volleyball 2 hours ago. His symptoms are non-progressive. On examination, his visual acuity is normal in both eyes. Right eye is medially deviated and cannot be moved laterally; otherwise, there is no abnormality detected.

Abducens

A 42-year-old woman presents with a 1-month history of severe worsening pain in her right foot, ankle, and lower leg. The pain is constant and burning. She reports some initial swelling and warmth in the leg, which has lessened. Now, her right lower extremity is always cool to the touch. Hair growth has dramatically decreased on her right leg. She has tried multiple over-the-counter pain medications and topical analgesics with no relief. She denies trauma to the affected limb and reports her symptoms just "came out of the blue." Her sleep is poor, and she reports fatigue secondary to unrelenting pain, but she denies any other symptoms.

Abnormal autonomic nervous system activity

A 65-year-old man presents to the office due to 6 months of bilateral buttock and thigh cramping pain. It occurs after walking 20 feet and is completely and quickly relieved with resting. His past medical history includes hypertension treated with atenolol, and he had a stroke 3 years ago. He also reports impotence for approximately the same duration of time.

Absent femoral, popliteal, pedal pulses

A 17-year-old male football player is being evaluated for fatigue and a sore throat. He denies coughing or fevers. He does not smoke or drink. In addition, he denies blood in his stool or urine and any dysuric symptoms. He practices safe sexual intercourse with his girlfriend. Physical exam demonstrates a blood pressure of 130/65 mm Hg, a pulse of 72/minute, respirations of 16/minute, and a temperature of 98°F (36.6°C). Lung and heart sounds are normal. There is no cervical adenopathy. When you look at the pharynx, there is tonsillar enlargement with evidence of exudates. The abdominal exam demonstrates a spleen tip that is easily palpable 1.5 cm below the left costal margin. Results of a Monospot test are positive.

Acetaminophen or NSAIDs

A 30-year-old man presents with excessive thirst for the past few days. He consumes 3-4 liters of water per day but is still thirsty. He has also been passing urine very frequently. He gives a history of a road traffic accident 1 month ago where he hit his head against the dashboard. Urine specific gravity and osmolality are 1.002 and 180 mOsm/kg, respectively. There is an increase in urine osmolality with exogenous antidiuretic hormone (ADH) administration.

Acquired central diabetes insipidus

A 17-year-old high school football player was tackled and forcefully slammed onto his right dominant shoulder 2 hours ago during a game. He had immediate pain but was able to continue playing. He has full active and passive range of motion but some pain (4/10) with abduction. There is no obvious deformity, and the skin over the shoulder is intact and not tented. There is no crepitus on palpation while moving the arm. Most tenderness seems to be on the superolateral right shoulder.

Acromioclavicular separation

A 65-year-old man is being treated at the dermatologist for a lesion on his face for the past 5 weeks that will not go away. Additionally, the patient has a history of staying out in the sun, as he lives in Florida. Upon physical exam, a 0.6 cm macule that appears flesh-colored and slightly hyperpigmented is present on his right cheek. Upon palpation, the macule feels like sandpaper and is tender to the patient. All labs are within normal limits.

Actinic keratoses

A 70-year-old woman presents with shortness of breath at rest over the past 3 days. She has found it difficult to walk short distances due to shortness of breath. Additionally, she is experiencing confusion, orthopnea, nocturnal dyspnea, and lightheadedness. She denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, nausea, abdominal pain, vomiting, diarrhea, rashes, and syncope. On physical examination, the patient is short of breath, requiring numerous pauses during conversation. She is afebrile, but she is tachycardic, diaphoretic, and her extremities are cool. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, and dullness to percussion and expiratory wheezing noted. An elevated JVD and 2+ pitting edema of the lower extremities is evident.

Activation of the renin-angiotensin-aldosterone system occurs.

A 6-year-old boy with Down syndrome is brought to the emergency department after a drowning accident in a lake. Submersion time is unknown, but he was missing for some time. He was resuscitated and intubated by emergency medical technicians during transport. On arrival, his heart rate is 76 beats/min, BP 104/72 mm Hg, and rectal temperature is 81°F (27°C). He remains comatose, exhibiting non-purposeful flexion withdrawal to pain. His pupils are equal and reactive.

Active internal warming

Early one afternoon, a 15-year-old boy presents with abdominal pain, nausea, and vomiting. The pain has been worsening since the onset of symptoms in the morning. There is no known gastrointestinal disease in the history; no one in the immediate environment has one, either. Physical examination finds no abdominal tenderness, but Psoas sign and tenderness on rectal examination are detected. Temperature and pulse are slightly elevated. Skin turgor is reduced, and there is a 10 mm Hg drop in postural blood pressure. Laboratory studies find 18,000 white blood cells per microliter.

Acute appendicitis

A 44-year-old premenopausal Caucasian woman with a BMI of 36 presents with persistent upper right quadrant abdominal pain that radiates to the back. It has gotten so bad that she has difficulty eating any food and needs to force herself to eat. She has nausea with some episodes of vomiting. She denies bulimia but admits to anorexia. On exam, the patient has a positive Murphy's sign and tenderness to palpation in the epigastric and upper right quadrant area. Patient has a slightly elevated temperature. The physician assistant is awaiting labs and imaging.

Acute cholecystitis

An 18-year-old woman presents to the emergency department with her mother due to pain in her right leg after a car accident. She points to her lower leg and describes the pain as severe. Upon physical exam, there is extreme pain with passive movement of right leg with diminished sensation. When asking the patient to stand on the leg, she reports weakness and extreme tenderness. Upon use of the Stryker IC pressure monitor system, the patient's pressure was 35 mm Hg.

Acute compartment syndrome

A 5-year-old girl is brought to her pediatrician by her mother. Her mother notes that the patient has been bruising easily for the last few weeks, but she does not recall any major injury. The patient began feeling tired around this time as well. The mother initially thought she had the flu, but she brought the patient in when it became apparent she was not improving. On examination, the patient is pale and appears fatigued. Her skin has multiple areas of bruising and petechiae. She is febrile. A CBC/Diff is significant for the following:

Acute lymphocytic leukemia

A 43-year-old man arrives at the emergency department via ambulance. His wife indicated that she found him lying on the living room floor when she came home from running errands around town. She also stated that he seemed "fine" before she left approximately 2 hours prior. He has a history of acid peptic disease. Upon arrival, he is conscious and indicates that he became dizzy upon standing. For the last couple of days, his stools have been coffee ground in color and he has had increasingly worse upper middle abdominal pain and nausea. His vitals are BP 90/48 mm Hg, pulse 145/min and thready, respirations 24/min, and pulse oximetry 88%. You order a hemoglobin and hematocrit, and the results are 8.2 g/dL and 24.8%, respectively. You review his records and find that 2 weeks ago his H&H was 15.6 g/fL and 48.2%, respectively.

Acute massive hemorrhage due to perforation

A 54-year-old man presents with chest pain. He has a past medical history of hypertension and diabetes mellitus. The pain is located in the middle of his chest and radiates to his jaw. The pain began about 20 minutes ago, and he rates the pain as a 10 on a 0-10 point scale, with 10 being the worst pain he has ever felt. He has had 3 similar episodes, but they have always resolved after 5 minutes or so of rest. He has smoked 1 pack of cigarettes a day for the past 36 years. He drinks 2 or 3 beers on Friday nights. Review of systems (ROS) is positive for diaphoresis, acute dyspnea, and sense of impending doom. ROS is negative for fever, chills, and malaise. Physical exam shows an obese, middle-aged man in moderate distress. BP is 148/80, pulse is 100, and respirations are 26. Except for tachycardia and tachypnea, heart and lung exams are normal. He has no pedal edema. Electrocardiogram (ECG) shows ST elevation in leads II, III, and AVF; this is a new finding when compared to an ECG from 3 months ago.

Acute myocardial infarction

A 13-year-old girl presents to the emergency department with febrile episodes (Tmax 102°F), joint aches in her knees and wrists, chest pain, and a raised red rash. She denies sexual activity or intravenous drug use. Vital signs are BP 90/60 mm Hg, HR 115/min, T 101°F, RR 25/min. Physical exam is remarkable for diffuse scattered ring-shaped macules on her extremities, a III/VI systolic ejection murmur, and guarded passive range of motion in wrists and knees bilaterally with no apparent swelling. Laboratory findings: WBC 16,000 mcL, Hematocrit 35%, Platelets 350,000 mcL, ESR 65 mm/h, positive antistreptolysin O titer.

Acute rheumatic fever

A 28-year-old woman receives a lung transplant due to cystic fibrosis. 2 months later, she is readmitted with left-sided paralysis. CT scan is consistent with basal ganglia stroke. After 2 weeks in the hospital, she develops cardiac failure and is intubated. A posterior mitral valve leaflet vegetation with severe regurgitation is identified by transesophageal echocardiography (TEE). She is referred for mechanical mitral valve replacement. Colonies of Aspergillus fumigatus are detected in the excised mitral valve leaflets. Intravenous antifungal therapy with amphotericin B is started. A week later, she presents with fever, shortness of breath, and edema. Laboratory results include elevated creatinine and increased fractional excretion of sodium epithelial casts on urinalysis.

Acute tubular necrosis

A 27-year-old woman presents due to labial pain and burning and reportedly noticed a cluster of blisters in the area 2 days ago. She had myalgia, malaise, and a temperature of 100.5°F a few days prior to appearance of the blisters, which kept her home from work. She is monogamous and her partner denies similar symptoms. On physical examination, inguinal lymphadenopathy is noted in addition to the presence of multiple vesicles on the labia and perineum; some are ruptured and some are crusted. There is no vaginal discharge, and the rest of the pelvic exam is unremarkable.

Acyclovir

A 5-year-old Latino boy with acute lymphoblastic leukemia presents with fever and rash. He is currently on induction chemotherapy that includes dexamethasone. He was exposed to a friend with varicella 2 weeks ago; he has never had the varicella vaccination and his mother cannot recall that he ever had a varicella infection. Blood tests prior to initiation of chemotherapy showed the absence of antibody to the varicella virus. He now has 10 small vesicles and several red macules on his face and chest. Temperature is 38.5°C. Exam is otherwise normal.

Acyclovir 500 mg/m2 IV every 8 hours

A 20-year-old man has had a 1-month duration second-line acne therapy; he now presents with skin that looks worse and has more inflammation and cystic development. This patient has now progressed to severe acne.

Add oral isotretinoin after stopping medication for 2 weeks.

A 28-year-old man with a history of crack cocaine abuse is rushed in to the emergency room. His mother found him in his apartment; he was cyanotic and severely short of breath. No other history is available. Examination reveals a young man in severe respiratory distress with temperature 99.2°F, pulse 102/min, respiration 40/min, BP 165/95 mm Hg, and pulse oximetry of 66%. He was intubated at his apartment by EMS personnel because of lack of improvement of his pulse oximetry on 100% non-rebreathing mask. His chest X-ray shows bilateral alveolar and interstitial infiltrates. The arterial blood gas on the mechanical ventilation (set at a rate of 12 cycles/min, tidal volume 500 mL) shows the following: PAO2/Fi02 ratio = 100 mm Hg, pH 7.52, PCO2 30, PO2 55, and O2 saturation 88%.

Add positive end-respiratory pressure

A 31-year-old woman presents due to being "really tired." In addition to this extreme fatigue for the last several months, you note the patient has had unintentional weight loss of 20 lb, decreased appetite, salt cravings, nausea and mild vomiting, irritability, and loss of sexual interest. Physical examination reveals a hypotensive female patient who appears her stated age but fatigued. She has multiple areas of hyperpigmented skin located in her bilateral palmar creases, both axillary regions, and areas in the oral mucosa. She has noted thinning of body hair throughout.

Addison's disease

A 75-year-old African American woman presents for follow-up of osteoarthritis, diet-controlled type 2 diabetes, and hypertension. She has taken ibuprofen PRN x 10 (osteoarthritis) and lisinopril (hypertension) for 15 years. Her last urine albumin to creatinine ratio was 180 mg/g. Her osteoarthritis is currently asymptomatic, and she has not taken ibuprofen for 2 months. In review of her laboratory results from earlier this week, you note that her most recent serum potassium was 5.8 mEqdL. Her blood pressure is 147/90.

Addition of diuretic to lisinopril and follow potassium

A 54-year-old man has had long-term GERD symptoms. He has been on proton pump inhibitors and has had fair control of his symptoms. Other past history is unremarkable. He is a non-smoker and drinks socially. Family history is significant for hypercholesterolemia in his father. Physical examination is unremarkable. An endoscopy a few years ago revealed Barrett's esophagus by biopsy of the esophageal mucosa. He was recommended to have follow-up endoscopy every 2-3 years with mucosal biopsy.

Adenocarcinoma of esophagus

A 16-year-old African American girl with hemoglobin S disease has experienced several complications, including multiple acute splenic sequestration crises that resulted in a splenectomy when she was 14. She no longer receives antibiotic prophylaxis. Her last polyvalent pneumococcal vaccine was 2 years ago. She presents to the emergency department with a 2-day history of fever up to 104.3°F without localizing symptoms. She notes malaise, abdominal discomfort, and one episode of vomiting. Examination reveals a temperature of 103.2°F; pulse 110; blood pressure 116/76 mm Hg; and respirations 21. Hydration is normal, and no localizing findings are present.

Admit patient, obtain cultures, and begin IV ceftriaxone and vancomycin.

A 25-year-old sexually active woman presents with a 2-day history of pain and swelling of her dorsal right wrist and fingers. For the past week, the pain and swelling have been in different joints of her body, including her left knee, left elbow, and right ankle. On exam, you note edema, effusion, and erythema over the dorsal right wrist with the wrist held in 15° of extension. It is very tender on palpation and has virtually no range of motion secondary to the pain. You aspirate synovial fluid for lab studies. The lab studies reveal the following information: Synovial fluid: WBCs - 57,000 cells/mcL Gram stain: too numerous to count WBCs with no bacteria seen Culture: pending

Admit to the hospital for IV ceftriaxone.

A 32-year-old Gravida 4, Para 4, Ab 0 woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications. Vitals: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. The patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The next morning, the patient is found to be alert, oriented, and afebrile.

Albendazole with IV prednisolone

A 43-year-old man presents with jaundice, weight gain, enlarged abdomen, and peripheral edema in his legs for the last several weeks. He reports fatigue, malaise, and insomnia. His wife and adult son are with him. They tell the ER physician assistant that his oral intake has been limited to excessive alcohol ingestion and very little food in the last few weeks. He has a history of hypertension being treated with amlodipine 5 mg. Family history is significant for his father having hypertension and having an older brother with alcoholism. He has smoked 1 pack of cigarettes daily since he was 18 years old. He has been drinking 12-24 cans of beer daily for the last 15 years. On examination, his temperature is 99.2°F, BP 140/86 mm of Hg, pulse 86/minute, respiratory rate 18/minute. His sclerae are icteric. Lungs have decreased air entry at the bases. Heart sounds are normal. Abdominal exam shows ascites and caput medusae without hepatomegaly. He has pitting pedal edema bilaterally and a fine tremor in his hands. He is alert and fully oriented. Labs are ordered and are pending.

Alcohol abstinence

A 43-year-old Caucasian woman, previously in good health, presents to the emergency department with headache, blurred vision, and dizziness. Symptoms started 3 days ago and progressively worsened. Past medical history: hypertension, hypothyroidism, prior cholecystectomy. No known drug allergies. Medications: HCTZ 25 mg daily, Diltiazem CD 120 mg daily, and Levothyroxine 88 mcg daily. She ran out of all medications 2 weeks ago. Vital signs were normal, except for blood pressure 210/114 in the right arm, 215/115 left arm, 220/100 right leg, and 215/112 left leg. Physical exam: Heart - no visible or palpable PMI; normal S1 and S2 without murmur, rub, or gallop. Pulmonary - few faint RLL crackles, which cleared upon coughing. Remainder of the physical exam, including neurologic exam, was unremarkable. CBC and BMP were unremarkable except for K+ 2.3 mEq/L. EKG - NSR with one PVC. Chest X-ray - clear lung fields; normal pulmonary vasculature. CT head - no evidence of intracranial pathology. Renal artery sonogram - Unremarkable. Patient was treated with IV Nitroprusside and IV KCl 40 mEq x 2 doses and was admitted for further treatment. Over the next 2 days, patient's blood pressures gradually normalized with medical therapy; potassium levels remained low despite treatment.

Aldosterone-renin ratio

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Vitals are as follows: pulse is 94/min; BP is 110/70 mm Hg; temperature is 101°F. Direct fiberoptic laryngoscopy is performed and shows an edematous larynx. Cultures are taken, and an endotracheal tube is placed. The epiglottis cultures reveal Haemophilus influenzae, and the diagnosis of acute Haemophilus influenzae epiglottitis is made. The mother is worried about her 1-year-old child living in the same house and is currently not vaccinated for H. influenzae.

All family members, including the patient, should receive prophylactic rifampin.

A 4-year-old boy has had intermittent rhinorrhea, nasal congestion, and cough for about 3 weeks. His mother says he had felt warm at night when his symptoms started, and he sneezes occasionally. He goes to a large daycare 4 days a week. Otherwise, he has been healthy except for an occasional dry itchy rash that he has had on and off for "a long time." Mom has been treating this with OTC moisturizers. On exam, his temperature is 98.4°F, respirations 24, pulse 86 beats/min. He appears somewhat tired, with dark circles under his eyes. There is slightly cloudy nasal drainage, turbinates seem a little boggy, lungs are clear, ears and throat are normal and his neck is supple without any lymphadenopathy. His skin exam reveals a fine roughened slightly hyperpigmented maculopapular rash in elbow creases with a few healing excoriations.

Allergic rhinitis

An 8-year-old girl presents with a 3-month history of hair loss. Except for usual minor childhood illnesses such as colds and ear infections, she has been in good health since birth. 3 months ago, her mother noted small bald areas developing on the girl's scalp when she brushed her hair. The child denies any pain or itching of the scalp, and she denies pulling at her hair. There have been no other symptoms. She has not taken any medications, and she has no known allergies. On exam, you find three round smooth silver dollar-sized areas of complete hair loss. The scalp is normal.

Alopecia areata

You have been asked to do a house call on an 88-year-old woman who is bed-bound and lives at home with her private home health aide. She has had no medical follow-up for the past year. Approximately 3 weeks ago, she appeared to be having "headaches." 2 weeks ago, she developed a rash on the left of her forehead that developed into "little blisters that popped and crusted over." She has a history of coronary artery disease and was diagnosed with "senile dementia" 6 years ago. The home health aide says she is occasionally combative and resistant to care. On exam, she is awake and mumbles several words but is not responsive to verbal commands. BP is 118/68 mm Hg, P 84/min R 20/min. Skin exam reveals clusters of vesicles with crusts on her left forehead. There are no other significant lesions noted on the body.

Aluminum acetate solution

A 66-year-old man with a past medical history of myocardial infarction 2 years ago, aortic regurgitation, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease is presently being monitored in the hospital. Myocardial infarction has been ruled out. An EKG performed upon admission revealed significant Q waves in the anterior leads but no evidence of an acute myocardial infarction. A diagnostic echocardiogram confirms moderate aortic and mitral valve regurgitation and a left-ventricular ejection fraction of 30%. He denies any complaints upon bedside evaluation. His physical exam reveals a blood pressure of 95/55 mm Hg and tachycardia. Continuous bedside ECG monitoring notes wide monomorphic QRS complexes with a heart rate of 160 beats per minute that spontaneously resolve within 20 seconds, reverting to the pattern identified upon admission.

Amiodarone

A 66-year-old woman with a history of a multinodular goiter presents to the office after a recent hospitalization for a newly diagnosed cardiac arrhythmia. She relates that she has continued to see the cardiologist and is being treated with an oral medication. She denies any symptoms of hyper or hypothyroidism. She denies any change in the size of her gland or associated dysphagia or dyspnea. Thyroid function studies continue to remain in the normal range.

Amiodarone (Cordarone)

A 47-year-old man presents to an urgent care center with 18 hours of abdominal pain, nausea, vomiting, and chills. He is a single construction worker, denies smoking, and has at least a 10-year history of drinking 2-4 alcoholic beverages daily. A series of lab work is performed on the patient to evaluate his abdominal pain prior to abdominal imaging.

Amylase 310 U/L and lipase 760 U/L

A 28-year-old man presents with rectal bleeding. The patient has noticed blood with bowel movements 3 times. The blood is described as bright red in color and small in amount. He also complains of rectal pain, especially with passing hard stools. He has tried some over-the-counter hemorrhoid creams without relief. The patient admits episodic constipation. He denies dark, tarry stools, easy bruising, and prior episodes of rectal bleeding. He has not noticed blood in his urine or with brushing his teeth. He denies nausea, vomiting, diarrhea, fevers, and weight loss. He has no known medical conditions. Family history is negative for gastrointestinal disorders. Social history reveals he is in a heterosexual relationship, and he denies anal intercourse. On physical exam, his abdomen is normal. The anus has no visible protrusions or rash, but there is a very small erythematous and tender area that appears like a "paper cut" or crack in the skin. The patient experiences pain with digital rectal exam (DRE). No masses are noted in the rectal vault.

Anal fissure

A 35-year-old Hispanic man presents for an appointment but is too embarrassed to tell the nurse his chief complaint. You enter the room and coerce him to give you the reason he has come in to seek medical treatment. He admits to severe, intense itching around his anus that has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10 on a pain scale and it lasts hours afterward. This intense pain makes him not want to have any bowel movements. He admits to only 1 episode of a small amount of bright red blood on the toilet paper as well as on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease.

Anal fissure

A 65-year-old man with a past medical history of hypertension, chronic arthritis, and herniated lumbar discs presents with a 1-week history of severe, tearing pain to his rectal area that occurs while he defecates. Following his bowel movement, he notes relief of the tearing pain, but he feels a throbbing sensation in the area. He has noted small drops of bright red blood on the toilet paper. He presently takes amlodipine and hydrochlorothiazide for hypertension as well as hydrocodone-acetaminophen for pain. He has noticed a reduced frequency of bowel movements of late due to pain. The physical examination is notable for a 5-mm midline crack-like lesion at the anus in the 6 o'clock position. The remainder of the physical exam is unremarkable.

Anal fissure

A 35-year-old Hispanic man presents due to a sore that will not heal around his rectum and anal area. This lesion has been draining pus consistently for the last week. He has had intermittent pain with this lesion (4/10 on a 0-10 pain scale) that is made slightly worse when he has a bowel movement (ranking it a 6/10). More recently, especially in the last few days, he has noted pain increases with just sitting. The patient also admits to intermittent periods of itching. He denies fever or diarrhea. No past medical history of inflammatory bowel disease. Physical examination of the anorectal area reveals excoriated and inflamed perianal skin with a palpated induration.

Anal fistula

A 41-year-old woman is found to have anemia with Hb of 10 g/dL on a routine physical exam and labs. Patient has a history of hypercholesterolemia, depression, and rheumatoid arthritis. She is on a low cholesterol diet, escitalopram (Lexapro) 10 mg daily, and diclofenac 50 mg twice daily. Physical examination was essentially unremarkable except for mild arthritic changes at the proximal interphalangeal joints of both hands. Further labs reveal normal MCV and MCHC on peripheral smear. Serum iron and TIBC levels are low, percentage saturation with iron is normal, and ferritin level is moderately high.

Anemia of chronic disease

A 65-year-old woman presents after being on hemodialysis for the past 1.5 years for diabetic nephropathy. Despite stable subcutaneous erythropoietin and intravenous iron doses, her hemoglobin level has decreased from 12 g/dL to 10 g/dL over the past month. Oral lanthanum doses have been stabilized. Diabetes is treated with glyburide. She developed a foot ulcer 2 weeks ago and was treated with antibiotics. Additional tests include:

Anemia of chronic disease

A 25-year-old man presents with back pain and stiffness. He has noticed an increasing presence of stiffness and general fatigue along with the pain. The pain is much worse first thing in the morning, and he rates it a 7/10. Radiation occasionally occurs into the buttocks, and the symptoms improve with activity. Physical examination is remarkable for forward stooping of the thoracic and cervical spine and decreased lateral flexion in the lumbar spine.

Ankylosing spondylitis

A 19-year-old man presents with pain and deformity of his right dominant shoulder after a sudden jerking movement to the same shoulder from a wrestling competitor approximately 1 hour ago. He states he felt a clunking sensation when it happened. He was unable to continue wrestling and has pain with movement of the right shoulder.

Anterior/posterior, scapular lateral, and axillary radiographs

A 42-year-old female IV drug user experiences vague symptoms consisting of fatigue, aches and pains, and nausea. She has developed a distaste for her cigarettes. She appeared jaundiced for a few days, but the condition spontaneously resolved. She goes to the free clinic and they run preliminary blood tests. The staff at the free clinic tell the patient she does not have hepatitis B.

Anti-HBc

A 42-year-old man presents with a 3-day history of intermittent sharp stabbing chest pain that has become progressively worse and more continuous over the past 24 hours. The pain is aggravated by deep breathing and lying flat; it is relieved by sitting and leaning forward. He has no previous cardiac history. Upon further questioning, he mentions that he recently "had the flu." Physical examination reveals an anxious patient in moderate distress. Vital signs are as follows: BP 138/90 mm Hg Left Arm, HR 104 bpm and regular, RR 18/min and shallow, T 99.8°F. Normal breath sounds and a pericardial friction rub are noted upon auscultation of the chest. A stat ECG reveals diffuse ST elevation.

Anti-inflammatory medications

A 10-year-old girl presents with chest pain and joint aches. Her mother says that about 2 weeks ago, her daughter had a sore throat with fevers and pus around her tonsils. She was prescribed a 14-day course of penicillin on the initial visit, but her mother stopped the medications after 2 days because the fever subsided. She also experienced chest pain and recurrence of fever. Her vital signs: blood pressure 120/80 mm Hg, heart rate 110 beats/min, temperature 102.3°F. On physical examination, normal S1/S2 and a II/VI short mid-diastolic murmur are heard. Her EKG shows a sinus tachycardia with a prolonged PR interval.

Antibiotic compliance

A 72-year-old man presents with low-grade fever, nausea, confusion, and lethargy. His past medical history is significant for hypertension, hypercholesterolemia, and diabetes. He had sinusitis approximately 1 week ago; otherwise, he has been healthy. Laboratory workup shows a CSF with elevated opening pressure and low blood glucose levels. A Gram stain on the CSF shows gram-positive cocci. CBC shows an elevation of PMNs, but it is otherwise normal.

Antibiotic therapy

A 31-year-old female nurse who works at a local hospital presents with a purpuric rash covering her arms, legs, and abdomen, as well as fever, chills, nausea, abdominal tenderness, tachycardia, and generalized myalgias. Prior to the development of the rash, the patient noted that she had a headache, cough, and sore throat. Laboratory studies were positive for gram-negative diplococci in the blood, along with thrombocytopenia and an elevation in PMNs. Urinalysis showed blood, protein, and casts. Vital signs are as follows: BP 92/66, P 96, RR 14, T 39. The patient denies any foreign travel and does not have any sick contacts. She is admitted to the hospital and placed in respiratory isolation.

Antibiotics

A 40-year-old African American woman presents with diffuse headache and joint pain. The headache started few days ago; it is dull and becoming progressively worse. Joint pain is localized in fingers, starts in the morning, and improves during the day; it returns when she gets tired. 2 months ago, she was treated in the ED because of several weeks of lasting fatigue, low-grade fevers, joint pain, hair loss, and oral ulcers. Her laboratory tests were normal, except for positive VDRL and antinuclear antibody tests results. Urine and blood cultures were negative for evidence of infection, and her chest X-ray was normal. Because she felt better after a 10-day tapering course of prednisone, she did not follow up with a healthcare provider at that time. She did not appear to the scheduled control. Today, your examination reveals an ill-appearing woman in distress. Her temperature is 39°C. Her fingers are swollen and red, and she has a malar rash and oral ulcers.

Antibodies to the Sm antigen

A 44-year-old man starts to notice that his eyelids are drooping. Some time afterward, his jaw becomes weak. He has difficulty swallowing and experiences weakness in his limbs. He is quite embarrassed when he eats because he must use his hand to help support his jaw. His weakness gets progressively worse. Finally, he seeks medical attention. His physical examination demonstrates the weakness in his limbs, but no sensory defects are present. A Tensilon test is done and is positive.

Antibodies to the acetylcholine receptor

A 58-year-old man presents to the emergency department for a 4-hour history of chest pain and shortness of breath. He is a long-haul truck driver and noted the symptoms started while he was driving. He admits a mild cough with some blood in his sputum. The chest pain seems to be associated with breathing and gets worse with deeper inspiration. He denies fever or chills. He is a smoker. He reports no known medical conditions, no medication use, and no prior surgeries. On physical exam, the patient is mildly obese, tachypneic (respiratory rate of 22), and tachycardic (pulse of 112). He appears to be in mild distress. Lungs are normal to auscultation and percussion. Heart exam is normal. His left lower leg has some dependent edema and tenderness. The patient thinks he strained a muscle or bumped it, but he had been too worried about his shortness of breath and failed to mention this in his history. The remainder of his exam is normal. He was immediately placed on oxygen at arrival. Several tests results are available. TestResultOxygen saturation92% on oxygenComplete blood countNormalComprehensive metabolic panelNormalElectrocardiogram (ECG)NormalTroponin and CK-MBNormalChest X-rayNormalD-dimerElevated

Anticoagulation

A 52-year-old woman presents to her gynecologist's office with a 6-month history of hot flashes, night sweats, mood swings, and vaginal dryness that interferes with intercourse. The symptoms seem to be worsening and are now interfering with her productivity at work and with her relationships with family and friends. Her last normal menstrual period (LNMP) was 8 months ago. She denies tobacco use, and she drinks one glass of red wine daily. She has a history of coronary heart disease (CHD) with stent placement 2 years ago. She recently read an article about hormone replacement therapy (HRT).

Antidepressant therapy is indicated for menopause-related mood swings.

A 21-year-old man reports intermittent sneezing, runny nose, itchy nose and eyes, and cough. His symptoms typically occur after exposure to pollen or pet dander. He has a history of a fractured clavicle but is otherwise healthy. He has no known drug allergies and takes Tylenol for occasional headache. He is a full-time engineering student and denies any alcohol or drug use. Physical exam reveals an alert Caucasian male with dark circles under both eyes. Physical exam is remarkable for erythematous injection of the conjunctiva, pale boggy nasal mucosa, and postnasal drainage.

Antihistamine

A 66-year-old man presents with a history of recurrent episodes of chest tightness and shortness of breath that originally occurred with exertion but are now happening at rest. Dizziness also occurs with exertion. The pain is retrosternal, 6/10 in intensity, lasts for 10 minutes, and radiates to the neck, jaw, and shoulders. On examination, pulse is 65/min and low in volume; BP is 100/80 mm Hg. On auscultation, a loud mid-systolic murmur is heard at the second right intercostal space and radiates to the carotid arteries bilaterally. There is a single second heart sound.

Aortic stenosis

A 13-year-old girl presents with a painful reddened lesion on the inside of her cheek. She noticed this lesion a few days ago and it will not go away. Upon physical exam, the inside of her right cheek has a yellow-grey appearance with an erythematous halo surrounding the lesion. Patient overall feels well besides this specific issue, and no other rashes or lesions are noted. All laboratory findings are within normal limits. HSV-1 and HSV-2 are both negative.

Aphthous ulcers

A physician assistant arrives 45 minutes late to work due to traffic caused by a car collision. The PA forgot to notify the office of their tardiness. The PA arrives to find their first patient has been waiting 60 minutes in the examination room. The patient yells from the room, "This is how you treat your patients? Give me a different provider!"

Apologize to the patient and explain the delay.

A 48-year-old Caucasian woman with a chronic history of inability to tolerate oral intake is admitted to the hospital for J-tube placement. The patient also reports a rash that has developed on her upper extremities. Examination reveals diffuse petechiae and perifollicular hemorrhage.

Ascorbic acid

During a routine X-ray examination for employment insurance purposes, the radiologist notices a rounded lesion in a pulmonary cavity on the right upper lobe of the pulmonary X-ray of a middle-aged man. The patient was treated for pulmonary cavitary tuberculosis (TB) 2 years ago; he has completed treatment, and he has not had any problems since.

Aspergilloma

A 40-year-old man with chronic alcoholism presents with a cough that produces of large amounts of fetid sputum. He developed the cough about 4 weeks ago, and it has gradually worsened over time. The sputum is now foul-smelling and copious. He has had high intermittent pyrexia for 4 days. His vitals are: T 102°F, PR 98\min, RR 24\min, BP 140\80 mm Hg. HEENT exam shows poor dentition with multiple missing teeth, mild erythema to the nasal muscosa with clear drainage. RRR without a murmur. On lung auscultation, there is pleural rub and diminished air entry on the right side. The chest X-ray shows a large, irregularly shaped, dense opacity on the right side with a fluid level.

Aspiration is the most common cause

A 21-year-old man presents with acute onset of pleuritic chest pain accompanied by 2-3 days of fever, chills, arthralgias, and myalgias. Upon further questioning, the patient notes that he had a severe sore throat and fever 4 weeks ago, but he was not evaluated for these symptoms. Physical examination reveals a febrile patient in mild distress. A systolic murmur is noted in the left fourth/fifth intercostal space that radiates to the left axilla. A friction rub is also appreciated on exam. Laboratory results reveal an elevated erythrocyte sedimentation rate (ESR) and antistreptolysin antibodies.

Aspirin

A 7-year-old boy presents with his mother with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. Total lung capacity (TLC) is 111% on spirometry. Pre-bronchodilatorsPost-bronchodilatorsFVC%4963FEV1%4146FEV1/FVC4955

Asthma

A 33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a productive cough most mornings. He has no other symptoms or exam findings. He smokes on a social basis. His CXR is normal and most recent pulmonary function tests reveal a reversible airflow limitation.

Asthmatic bronchitis

A 60-year-old man presents for routine follow-up. He has no present concerns. He denies fevers/chills, changes in vision, headaches, chest pain, shortness of breath, PND, orthopnea, peripheral edema, dizziness, and syncope. Past medical history is significant for a coronary artery bypass grafting x 4 approximately 3 years ago, GERD, and obesity. He is currently on isosorbide mononitrate, metoprolol, and aspirin. Routine lipid panel: Triglycerides: 145 mg/dL HDL: 34 mg/dL LDL: 135 mg/dL

Atorvastatin, 80 mg daily

A 42-year-old woman with a history of dizziness and difficulty exercising presents seeking help. She reports fatigue, shortness of breath, and weakness for the past month. Upon physical exam, an EKG is conducted and an irregularly irregular heartbeat of 90 beats a minute. Laboratory findings showed no abnormal findings. Upon ECHO, there do not appear to be any abnormalities.

Atrial fibrillation

A 32-year-old man with no significant past medical history presents with a 2-month history of increased dyspnea upon exertion; the dyspnea becomes apparent after walking 10 city blocks. He denies associated symptoms, such as fever, chills, changes in weight, chest pain, abdominal pain, nausea, and vomiting. He also denies any history of cigarette smoking, occupational risk factors, sick contacts, and recent travel. His physical exam reveals normal vital signs and no distension of his jugular vein, but there is a prominent right ventricular impulse along the lower-left sternal border that is associated with a palpable pulmonary artery. There is also a mid-systolic ejection murmur at the upper left sternal border that does not vary in intensity with respiration. There is a fixed split second heart sound. The remainder of his examination is normal.

Atrial septal defect

A 47-year-old Caucasian woman presents for evaluation of a 4-week history of dyspnea. Symptoms started when on vacation in Colorado. She initially attributed the symptoms to the altitude, but she continued to have shortness of breath with mild activity after returning home: walking more than 100 feet, walking up one flight of stairs. Symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope. Past medical history includes usual childhood illnesses, no previous surgeries, and no known allergies. She takes a daily multivitamin and occasional Tylenol for headache. She does not smoke, rarely drinks alcohol, and denies use of recreational drugs. Physical exam shows temp 96.9°F, pulse 80 and regular, respirations 16, and BP 136/82. O2 sat is 96% on room air. The patient is an alert Caucasian woman in no acute distress, with no obvious jugular venous distention; non-labored respirations; lung fields clear to auscultation and percussion; and no rhonchi, rales, or wheezes. Heart shows RV heave present; normal S1 with fixed, split S2 with prominent P2 component; and grade II/VI systolic murmur at the left upper sternal border at the second intercostal space. The remainder of exam is within normal limits. CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2.

Atrial septal defect

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class, he is frequently in trouble for being disruptive, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are worsening. The teacher reports the patient often seems distracted. He rarely sits still at his desk, fidgets often, and blurts out comments without waiting his turn. Physical examination is remarkable for increased motor activity but is otherwise normal.

Attention deficit hyperactivity disorder Father reports similar symptoms into adulthood. Initiate stimulant medication.

An 18-month-old boy is brought in for a well-child visit. His mother states that he does not say any words, not even "mama" or "dada." He does have monosyllabic babble and points to objects that he wants. The remainder of the child's development is within normal limits, including gross and fine motor skills. He was born full-term via normal spontaneous vaginal delivery with no complications. He has always been healthy. He is currently not on any medications; he has no known drug allergies and all of his vaccinations are up to date. On observation, the child plays with the mother and makes good eye contact with her. The physical exam of the child is normal. The head circumference is normal. There is no cleft lip or palate, and the neurologic exam is within normal limits.

Audiology consultation for a hearing evaluation

Parents bring their 3-year-old son for evaluation of a recently diagnosed intellectual disability. The test for intellectual disability was performed primarily because of delayed speech. The mother states that her child started to babble at about 9 months of age and then learned a few words such as "dada" and "boo" at 18 months. Despite the efforts of his parents to stimulate his language (reading to him, singing, exposing him to sounds, teaching him to mimic their speech, etc.), his speech has remained far behind other children his age. He is not interested in playing with the other children, always looks serious, and behaves more independently than other children. His prenatal and past medical history is unremarkable; he was always healthy, and his immunizations are up to date, including MMR. While you are taking the anamnesis, he does not seem interested in the conversation. Instead, he started spinning himself, an activity that he enjoyed so much that he did not respond when parents tried to stop him. When asked, his parents left the room, but the child did not pay attention to them leaving. Then he saw fancy colored wooden sticks and started sorting them out by colors because nobody could interrupt him. Developmental screening today is impossible because he simply ignores you, so you decide to schedule a follow-up evaluation.

Autism spectrum disorder

A 35-year-old woman presents with a 2-month history of palpitation and nervousness. She mentions that she always feels hot, even if the weather is cold. Her menses have been irregular lately, and she has had no fevers recently. She was also told that her eyes are "weird-looking." On examination, blood pressure is 150/70 mm Hg, and pulse is 89 beats per minute. Her eyes show exophthalmos, and she has lid lag when looking down.

Autoimmune

A 12-year-old girl becomes comatose and is rushed to the hospital by her parents. She went to school feeling ill 2 days before the admission. She vomited that evening. Her vomiting persisted with only an 8-hour pause during sleep. She is breathing deeply and rapidly; her breath has a fruity odor. Her parents mention that her appetite has increased. She has also been drinking a lot of fluids; subsequently, she has been urinating more than normal. Urinalysis reveals 3+ glucose levels and 2+ ketone bodies.

Autoimmune destruction of B-cells of the pancreas

A 60-year-old man with hypertension presents with constipation. He states that he has not had a bowel movement in the past 2 days. He was hospitalized with a myocardial infarction 1 month ago, but he is now stable on a low-fat, low-salt diet. He refuses a docusate sodium enema and is prescribed oral docusate tablets.

Avoid long-term use of docusate.

A 32-year-old man is working on his farm when a wild horse suddenly jerks the bridle, forcing the man's right arm over his head and backward. There is a "clunking" sound, and the man is in immediate pain and unable to move his arm. There is a deformity of the shoulder with a depressed area (dimple) noted in the anterior shoulder.

Axillary

A 50-year-old man presents with multisystem failure secondary to bilateral pneumonia. He recently traveled from a work conference last week and presented to his primary care physician with fever, cough, and malaise 4 days ago. He was given a broad-spectrum antibiotic and he progressively became worse over the course of the antibiotic treatment. On exam, his body temperature is 40°C, respiration is 35/min, and pulse is 100/min. Laboratory examination is significant for impaired liver and renal function. Chest X-ray shows patchy infiltrates without evidence of consolidation. A sputum culture is performed and is significant for the presence of WBC in the Gram stain, but there are no organisms present. The culture result is negative.

Azithromycin

A 25-year-old woman presents for her annual gynecological visit. You review her history and note menses onset at age 12 and duration of menses is typically around 6 days and occurs every 30 days. She is G0P0 and has no history of abnormal pap smears or diagnosed STIs. The patient is a non-smoker, is single, and is in a monogamous relationship with one partner for the past year. A pertinent positive the patient mentions is a whitish-gray vaginal discharge that increases after intercourse and is accompanied by a distinct musty odor; she denies any pain from this discharge. Physical examination and a positive result of a whiff test support your suspected diagnosis.

Bacterial vaginosis

A 65-year-old man presents because a morsel of meat he had eaten 3 days ago reappeared on his pillow this morning. About a year ago, he noticed difficulty swallowing—particularly solid foods—which seems to be worsening. His wife complains about his bad breath, and he notes that people avoid being close to him. He does not drink, does not smoke, and was in a good health before. His physical examination is within normal range for his age, except that you notice that he is repeatedly clearing his throat as if he is embarrassed.

Barium study

A 22-year-old woman presents due to clogging of the right ear, hearing loss, dizziness, ringing of the ear, and ear pain. She was scuba diving in Florida last week. A thorough ear exam was conducted. The eardrum appears slightly pushed outward from where it normally sits. Laboratory results showed no abnormal findings.

Barotrauma

A 32-year-old woman presents with a 2-day history of having a vaginal "bump"; the bump is painful to sit on. She has never had this problem before, and she has been monogamous with the same sex partner for 7 years. On physical exam, you notice a solitary 2 cm smooth, slightly tender mass at the introitus. A KOH/wet mount demonstrates squamous cells with no white blood cells (WBCs), hyphae, or motile organisms. Whiff test is negative. Refer to the image.

Bartholin gland cyst

An 85-year-old woman with active vascular dementia is brought into the emergency department by her son after a fall. She is only able to groan. Her son says that she "tripped over a cat." She has mobility issues and depends on her family for her activities of daily living. Vitals are within normal limits. Her arms exhibit bruises of various stages of healing, and she is malnourished.

Begin a physical exam.

A term newborn is apneic at birth. After providing warmth and positioning and clearing the airway, the infant is still apneic and has central cyanosis; heart rate is 80 beats per minute.

Begin positive pressure ventilaton

A 28-year-old African American man presents with dyspnea associated with mild substernal chest pain and dizziness. Symptoms are provoked by sporting activities, and they are relieved with rest. His physical exam reveals a harsh murmur best heard at the left lower sternal border; it decreases in intensity upon squatting. There is also an S4 gallop. A bedside electrocardiogram was remarkable for left ventricular hypertrophy and septal Q waves in the anterolateral leads. An echocardiogram noted asymmetric LVH and a septum that was twice the thickness of the posterior wall.

Begin this patient on a beta-adrenergic blocker.

An 80-year-old woman with metastatic bladder cancer presents to the office for review of her most recent imaging. Her computerized tomography (CT scan) reveals pelvic lymphadenopathy suspicious for metastasis. She requires oral narcotics for pain control and has become progressively weak with poor oral intake. She vocalizes she no longer wants to consider any further treatment.

Beginning after stopping treatment

An 18-year-old woman has been afraid of dogs ever since she was bitten as a child. You begin therapy by having the client do relaxation exercises while looking at the word "dog." Once the client is comfortable with this process, you have her do relaxation exercises while looking at a picture of a dog. The next step is to have the client do relaxation exercises while watching a dog from a distance. You then have the client do deep breathing exercises while sitting in the same room as a small dog. The final step is to have the client sit in the same room as a big dog while performing deep breathing exercises.

Behavioral therapy

A 37-year-old woman presents with a history of right-sided facial paralysis and periauricular discomfort since she awoke this morning. She is afebrile. She had a "cold sore" 1 week prior to her symptoms, but this resolved without complications. During her neurologic exam, she was discovered to have an inability to raise her right eyebrow and close her right eye completely. She also has drooping of the right corner of her mouth. The rest of her neurologic exam is normal. There are no masses or rashes evident. She denies history of prior CVA or neurologic illnesses. She does not take any medications.

Bell's palsy

A 61-year-old woman presents a 1-week history of intermittent episodes of feeling like she was spinning. She states the episodes are brief, but they occur 2-3 times per day. It is worse when she turns to her right side while lying in bed. Even when she is not dizzy, she feels off balance. She denies tinnitus, decreased hearing, fever, syncope, nausea, vomiting, diplopia, or any other related symptoms. During the Dix-Hallpike maneuver, the patient exhibits nystagmus, with her eyes beating laterally when the right ear is turned downward. The nystagmus diminished with each time the maneuver was performed.

Benign paroxysmal positional vertigo

A 65-year-old Caucasian man presents with a 3-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first 2 days of his illness but successfully eats breakfast on the day he is seen in the clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms. The otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg and Fukuda testing indicate right-sided pathology. Other than a crisp left-beating nystagmus, cranial nerve examination is normal. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.

Benign positional vertigo

A 28-year-old man presents with a 2-week history of a non-painful non-pruritic rash. He is negative for any other rashes, dysuria, urinary frequency, penile discharge, erectile dysfunction, diarrhea, constipation, change in stool, nausea, or vomiting. He does recall having had a penile "scab" approximately 4 weeks ago that healed; he never sought medical attention. He is not aware of having been exposed to anyone with any illnesses in the past few months. Social history is positive for unprotected anal sex with multiple male partners in the past 6 months, with the last sexual encounter occurring 4 days ago. He states that he has not engaged in any recreational drug use or cigarette smoking. Skin exam reveals a pink-red papulosquamous eruption with scattered discrete coppery papules on the palms of his hands.

Benzathine penicillin G 2.4 million units IM once

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate 120 bpm, and respiratory rate 34/min. Physical examination findings include lungs clear to auscultation, heart regular rhythm, normal S1/S2 with an S4 present, and grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. Neck is negative for JVD and no carotid bruits present. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray shows a widening of the mediastinum.

Beta blocker

A 74-year-old man presents with progressive exertional shortness of breath, lower extremity edema, and lightheadedness over the past 7 months. He has a past medical history of HIV, hepatic cirrhosis secondary to chronic alcohol abuse and hemochromatosis, obesity, and thiamine deficiency. His symptoms improve with rest. Blood pressure 108/68 mm Hg, heart rate 90 bpm regular, oxygen saturation 92% on room air, and respirations 18/minute. The physical examination reveals rales, elevated JVP, cardiomegaly, S3 gallop rhythm, high-pitched, blowing holosystolic murmur at the apex, peripheral edema, and abdominal distension suggestive of ascites. A bedside EKG notes sinus tachycardia with nonspecific ST-T wave changes and Q waves. An echocardiogram shows a dilated left ventricle, thinning of ventricular walls, and decreased systolic function.

Beta-blockers

A 68-year-old man with a history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with a 3-day history of shortness of breath at rest. He has found it difficult to walk short distances due to shortness of breath. He reports orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is acutely dyspneic. He is afebrile but tachypneic and diaphoretic. There is a diminished first heart sound, S3 gallop, and laterally displaced PMI. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. A bedside chest X-ray revealed pulmonary vascular congestion and Kerley B lines.

Bibasilar rales

A 78-year-old woman presents with behavioral changes over the past few months. Her daughter feels that her mother is depressed, as she talks less frequently with her family members. She was a regular at various social gatherings, but the patient has been avoiding them lately due to some difficulty in communication. She has been spending more time painting portraits and has been watching television at a higher volume than usual. She has no suicidal thoughts. She is well oriented to time, place, and person; her mood today seems good. Ear examination and tests indicate sensorineural hearing loss. The rest of her physical examination is within normal limits.

Bilateral hearing aids

A 74-year-old man presents with a 90-minute history of severe pain and blurred vision in his left eye. He reports headache and some nausea along with halos surrounding lights. Upon examination, his left eye is erythematous with a steamy cornea and a poorly reactive mid-dilated pupil. An ophthalmologic consult is ordered and tonometry is completed, revealing an elevated intraocular pressure. Gonioscopy was used to confirm the diagnosis and examine the fellow eye, showing narrow anterior chambers in both eyes.

Bilateral laser peripheral iridotomy

A 35-year-old man presents by EMS after MVA that occurred 24 hours ago. He was found lying by the road by a local citizen after the MVA. Emergency department evaluation shows a fractured pelvis, acute kidney injury, and bilateral hydronephrosis near the upper ureters. His kidneys are of normal size with normal cortical thickness. He was previously well, and his only medications were multivitamins. He has not yet voided, and he notes decreased urine output after his accident.

Bilateral ureteral stents

A 21-year-old woman is markedly thin, and she describes being worried she is going to fail her college finals and not graduate. She presents because she cannot eat or sleep; she feels like she would be better off dead. She was doing well in classes until after a spring break trip to Europe. When queried about previous psychiatric treatment, she tells you that she went "a little nuts" when she was a freshman; it was her first semester and the first time she had lived so far from home. She stayed up for a week trying to write a novel, and during that time she bought two computers and a whole new wardrobe with her father's credit card.

Bipolar I disorder

A 25-year-old woman is brought in by her sister. The woman has had increasingly frequent incidences of bizarre behavior, and her family is concerned. The most notable episodes occurred within the past week. She seemed sad and distant for a couple of days, then she left abruptly and returned home after being gone for 2 days. During that time, the woman told her sister that she had driven for 3 hours for no particular reason and spent much of her time partying and spending money. The normally intelligent woman was unable to remember where she had gone, and she could not explain why she left in the first place. After running out of money and sleeping in her car for 2 nights, she called her sister, who came and got her. Her sister found her dirty and speaking quickly about nothing in particular. She was brought home, and she now looks quite calm and seems a bit solemn. On examination, the woman's vital signs are within normal limits. Lab work reveals nothing abnormal. The patient did not display any unusual behavior. She was quite pleasant and cooperative. Her score on the mini-mental state exam was 29, but she does not seem to recall much about what happened a few days ago.

Bipolar disorder

A 44-year-old male salesperson presents after driving cross-country in a rural part of southern Ohio. His car had broken down and he found a local farmer who let the salesman spend the night in his farmhouse. His car was repaired the next day, and he promptly returned home. Several weeks later, he experienced an abrupt onset of a fever, non-productive cough, shortness of breath, and mild chest pain. Believing he has just caught a cold, the salesman thinks nothing of it. A few days after the onset of symptoms, he is much better, but he presents to your office for an opinion. You order a CXR that reveals airspace consolidations.

Blastomycosis

A 22-year-old woman presents with a 1-year history of flaking and scaling around her lashes, along with itching and a burning sensation. She has also noted her lid margins are red, and some of her lashes are missing. Her history is significant for diabetes and for seborrheic dermatitis of the scalp, eyebrows, and external ears.

Blepharitis

A 52-year-old man presents with a burning sensation in both eyes. He denies recent trauma and contact with individuals who have similar symptoms. On examination, his eyelid margins are red and inflamed. His eyelashes are greasy and adherent with a surrounding dandruff-like scale. Conjunctivae are clear.

Blepharitis

A nurse in your office may have been exposed to blood from a patient with AIDS. She was administering an antibiotic injection intramuscularly to an HIV-positive patient and accidentally sustained a needle prick injury. As part of her post-exposure prophylaxis therapy, you instruct her to begin daily tenofovir.

Blocks the viral enzyme in reverse transcriptase

A 28-year-old man with no significant past medical history is rushed to the local trauma center following a stab wound to his chest. Paramedics report that there was significant blood loss. The patient has lost consciousness. He is oliguric and his extremities are cool and moist to touch. His physical exam is also remarkable for tachycardia, tachypnea, a depressed systolic pressure, an immeasurable diastolic blood pressure.

Blood products

A 13-year-old boy presents with right breast development over the last 5-6 months. He is on the swim team, so this has caused him much consternation. The breast swelling is slightly tender and without any drainage. He has been healthy and denies taking any medications, he denies any substance abuse or trauma, and he is doing well at school. On exam, his height is 63 in (160 cm) and weight is 115 lb (53kg), which are both 75th percentile, BP is 94/68, pulse 68 beats/min. There is slightly tender 7-8 cm of right breast elevation and swelling extending from the areola that is non-erythematous. The left side is normal. There is no axillary lymphadenopathy. The testes are descended bilaterally and measure 3 cm in size. Pubic hair shows sparse growth of long downy hair at the base of the penis. There is no axillary or facial hair. He does have scant acne. The mother is very anxious and wants laboratory tests.

Blood work Serum testosterone, estradiol, FSH, and LH levels

A 33-year-old man presents with sudden onset severe chest pain for the past 6 hours. He is mildly febrile and states that he has had 4-5 episodes of forceful vomiting after which the severe chest pain started. He does not have a significant past medical history. On exam, the patient appears ill and diaphoretic. Blood pressure is 80/60 mm Hg, heart rate is 128/min, respiratory rate is 30/min, and temperature is 39.8°C. Cardiac exam shows tachycardia with no murmur. Lung sounds are decreased in the left base with dullness to percussion. On abdominal exam, there is mild tenderness in the epigastric region, but there is no guarding or rebound. ECG changes show sinus tachycardia without ST segment changes or Q waves. Chest X-ray reveals left-sided pleural effusion.

Boerhaave syndrome

A 65-year-old man presents with watery diarrhea and mild abdominal pain. He has had 8-9 non-bloody bowel movements per day for the last 10 days; he currently feels a general abdominal discomfort. On examination, his pulse rate, blood pressure, and oral temperature are normal. There is no abdominal tenderness. The stool guaiac test is negative. He does not travel. He eats home-cooked meals most of the time, and he reports using water from his private well for all of his needs.

Boil water before using.

A 45-year-old Caucasian man was employed to demolish several painted structural steel railroad trestles. The project was scheduled to take 2 years. He was not given protective masks or clothing. Towards the end of the project, he started to develop abdominal pain, so he sees his family doctor. On questioning during the medical history, he comments that he frequently drops things with his right hand. On physical examination, his lungs are clear to auscultation and no abnormal breath sounds are heard. His cardiac exam is unremarkable. His skin exam is normal other than a pigmentation at the gingivodental margin. His extensor muscles of the wrist and finger are weak. A CBC is done.

Bone

A 30-year-old African American man is admitted to the hospital to undergo stapedectomy for the treatment of otosclerosis. He had been experiencing increased hearing loss in the right ear over the past few years. His mother had suffered from the same condition when she was in her 40s and had been successfully operated upon. You perform an assessment using the Weber and Rinne tests.

Bone conduction of the affected side is greater than air conduction.

A 40-year-old woman presents occasional constipation that she relates to her diet. She is married with two sons. Aside from mild anxiety, she is dealing appropriately with her duties as a librarian. She does not smoke, she consumes alcohol only recreationally, and she weighs 187 lb. She is well-nourished and communicates well. Lung, cardiac, abdominal, and neurological examinations are unremarkable. Thyroid is normal in size and consistency. Menses are normal, and drug history is negative except for "hormone pills" for contraception.

Bone densitometry at age 65

A 19-year-old female student is referred for psychiatric assessment after an attempted suicide 2 days ago. On questioning, the patient informs that the precipitant to her attempted suicide was a recent breakup with her boyfriend. Her history is significant for multiple suicide attempts since the age of 12. On further questioning, the patient informs that she has a chronic feeling of emptiness and sometimes feels disconnected from reality. She also gets into fights with her boyfriends, as she has difficulty controlling her anger. The patient admits that she has had highly problematic relationships with men and that she falls quickly in and out of love. Examination reveals several cuts on the wrists and arms.

Borderline

A healthy mother with no known medical illnesses presents her 6-month-old male infant due to a 1-day history of poor feeding, lethargy, and weak cry. At first, the infant had difficulty sucking and swallowing and was not opening his eyes. This was followed by loss of head control, weakness of the trunk, arms, and then legs. The infant is constipated and has had decreased tears and saliva since yesterday. The infant was healthy before the onset of these symptoms. There is no history of fever, vomiting, cough, seizures, or difficulty in breathing. The infant has weak gag and pupillary reflexes, generalized hypotonia, loss of head control, ptosis, and diminished deep tendon reflexes. Blood counts and CSF examination are within normal limits.

Botulism

A 57-year-old white man presents to the emergency department reporting a syncopal spell 1 hour ago. He was in his normal state of health until approximately 7 days ago, when he developed acute diarrhea that lasted 4 days and then resolved. For the past 3 days, however, he has had progressively worsening nausea and vomiting. Past medical history is significant for congestive heart failure secondary to non-ischemic cardiomyopathy, atrial fibrillation, hypertension, chronic renal insufficiency (with baseline creatinine 2.0), and benign prostatic hypertrophy. Previous surgeries include laser surgery for a detached retina and transurethral retrograde prostatectomy. He has no known drug allergies but indicates an intolerance to diltiazem due to hypotension. Current medications include furosemide, digoxin, enalapril, carvedilol, and tamsulosin. Review of systems is as follows: General—Admits to decreased appetite for the past 3 days. Admits to fatigue and malaise. HEENT—Admits to visual disturbances for the past 3 days described as yellow and green halos around lights. Cardiovascular—Admits to chronic dyspnea on exertion at 3 blocks. A complete review of systems was otherwise negative. On physical examination, temp 98.8°F, pulse 40 and slightly irregular, respirations 16, blood pressure 108/60. The patient appears alert with nausea and some vomiting during interview and exam. Bradycardia is present with slightly irregular heart rhythm. Normal S1 and S2 without obvious rub, murmur, or gallop. Lungs fields are clear without rales, rhonchi, or wheezes. The remainder of complete physical examination is unremarkable. Lab: Notable for K+ of 5.8 mEq/L, BUN 40 mg/dL, creatinine 4.2 mg/dL, digoxin level 4.8 ng/mL. EKG demonstrates complete AV dissociation present, while CXR shows no acute disease and abdominal X-ray displays normal findings.

Bradycardia with complete AV block

A 15-year-old girl with a history of mild asthma has had worsening episodes of cough, wheezing, and increasing bloody sputum over the past 5 months. She denies weight loss, decreased appetite, lethargy, or travel. She has increased her bronchodilator use, but she had not sought further care. Her mother has noted facial flushing with sweating that sometimes appears when she feels stressed—brief at first but lasting longer now. On exam, her respiratory rate is 32 breaths/min, temperature is 98.6°F, heart rate 84 bpm, BP 114/76 mm Hg, oxygen saturation is 94%. Her throat is clear, RRR without murmur; on auscultation, breath sounds over the left hemithorax are diminished without retractions or wheezes; there are few fine crackles at the base. Right side is clear. Remainder of the exam is normal. Chest X-ray reveals a round area of increased opacification near the right hilar region. CBC shows normal white count and differential.

Bronchial carcinoid tumor

A 67-year-old man was cleaning out his garage and noticed a "bug" crawling on his leg. The bug bit him before the patient killed it. He discarded it and went about his business. 2 days later, he presents with pain, itching, and swelling of the affected leg. The bug had a violin-shaped pattern on its back.

Brown recluse spider

A 13-year-old girl has a history of being found by her mother consuming large amounts of high-calorie food on several occasions and then vomiting what she ate. For the past 2 days, the patient has experienced pain in her throat, which was diagnosed as esophagitis. Upon physical exam, the patient is dehydrated, has abnormal electrolyte imbalances, and appears to have eroding front teeth.

Bulimia nervosa

A 26-year-old woman presents with 8 weeks of gastric reflux that does not improve with medication along with bloating, constipation, vaginal bleeding, and weight loss. Past medical history is significant for father with hypertension and coronary artery disease, mother with breast cancer, aunt with hypothyroidism, and sister with breast cancer. Complete physical examination is significant for an adnexal mass. CBC is significant for hemoglobin 11.5 g/dL and hematocrit of 38%. Urinalysis is negative.

CA125

An 8-month-old boy is admitted due to possible middle ear infection and chronic diarrhea. He has episodes of frequent loose stools since birth. He had two episodes of lower respiratory tract infection with bronchospasm, treated with intravenous antibiotics and bronchodilators. Parents are not related, and their firstborn died of pneumonia at age 8 months. The patient appears irritable, screams, shakes his head, and tries to rub the right ear. Signs of dehydration are noted. Weight is <5th percentile, height is 5th percentile, and head circumference is 50th percentile. Temperature is 38°C. Mucocutaneous changes suggestive of a fungal infection are noted. Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic otoscopy. Left tympanic membrane appears clear with good mobility. Throat is erythematous. Thyroid, heart, lungs, genitalia, and nervous system are within normal limits; abdomen is tender. You cannot palpate lymph nodes, and there are no signs of hepatosplenomegaly.

CBC with differential

A 3-year-old girl presents with a 1-day history of irritability and weakness in her legs. Neurologic exam reveals an ascending symmetrical paralysis with cranial neuropathy. A lumbar puncture is performed and cerebrospinal fluid is found to have a normal glucose level, <10 leukocytes/mm3, and elevated protein. Medical history shows the child recently recovered from a mild diarrheal illness.

Campylobacter jejuni

You have been working as a physician assistant with a neurosurgeon for several years and you have developed a strong professional relationship. Recently, the surgeon informed you their mother passed away. Since this disclosure, you have noticed the surgeon has become more withdrawn and less interactive with you and the staff. Despite this change, the surgeon continues to provide high-quality patient care. The two of you are scheduled to perform a lumbar laminectomy on a patient with significant spinal stenosis. Before the operation, the patient informs you they have been waiting over 6 months for this surgery. While preparing and draping the patient, you smell alcohol on the surgeon's breath. Upon questioning, the surgeon admits to having consumed a glass of whiskey in their office. The surgeon does not appear intoxicated and is conversing appropriately with you.

Cancel the surgery and report the surgeon for intoxication.

A 30-year-old woman presents with lower abdominal pain; she is thought to have pelvic inflammatory disease (PID). She admits to prostitution and recreational drug use. Labs on admission reveal blood glucose of 260 mg/dL, a positive HIV screen, and a non-reactive RPR. Aside from the abdominal/pelvic pain, the admitting physical is also notable for moderate obesity, the absence of pronounced lymphadenopathy, and an erythematous macerated rash in the intertriginous distribution. The patient reports her rash is "really itchy and wet all the time," and it began within the last 3 months; it is now at its worst. She also reports intense itching of the vulva over the last few weeks.

Candidiasis

A 35-year-old woman who recently finished a round of oral antibiotics for pneumonia presents due to her tongue having "a thick white coating"; she adds that it is "also red and irritated." She is able to "scrape the white stuff off" some areas of her tongue, which she reports have become raw and more erythematous.

Candidiasis

A 27-year-old man underwent pre-employment urine drug testing of hospital employees after recently being hired for a full-time position. Although the patient admits to using both legal and recreational drugs in the past, he claims he has not used anything for at least 2 weeks. The urine test returns positive.

Cannabinoids

A family presents in the middle of winter. They live in a low-income housing development. Due to their gas furnace being broken, they have been using a kerosene heater at night for the past week. For the last 3 days, both parents and the two siblings have been experiencing varying degrees of headache, dizziness, nausea, vomiting, and fatigue; symptoms are particularly severe at night and have been increasing in intensity each night they occur. The 4-year-old daughter has been very lethargic; occasionally, she seems to black out or fall asleep very soundly. She and her 9-year-old brother have also had a cough, runny nose, and sore throat for the past week. On exam, other than seeming tired, findings are nonspecific. Both children have a runny nose but their lungs and ears are clear.

Carboxyhemoglobin level

A 35-year-old woman comes to your office due to frequent flushing and chronic diarrhea that started a few months ago. She also notices progressive edema of her lower limbs and enlargement of her abdomen. On examination, she looks cachexic with congested neck veins, lower limb edema, and a palpable tender liver with an irregular surface. A pansystolic murmur is heard inside the apex that increases in intensity with inspiration. Chest X-ray shows cardiomegaly with dilated right atrium and clear lung fields. ECG shows right atrial abnormality (P pulmonale). Echocardiography shows thickened, fibrotic, and fixed tricuspid valve in a semi-opened position and right atrial and ventricular enlargement. 24-hour urinary excretion of 5-hydroxy-indole-acetic-acid (5HIAA) is grossly elevated. Liver ultrasonography shows multiple small nodules.

Carcinoid syndrome

A 77-year-old man presents to the emergency department with chest pain and difficulty breathing. His heart rate is 120 beats/minute and blood pressure is 70/45 mm Hg. Physical examination is remarkable for cool extremities, and urinary output is minimal. Despite aggressive fluid resuscitation, the patient's symptoms appear to be worsening. Bedside ECG indicates ST elevation in leads II and III and aVF. Hemodynamic monitoring indicates large V waves on PCWP tracing.

Cardiogenic shock

A 23-year-old man presents with a 2-day history of burning urine. He also reports a slight purulent urethral discharge. He denies any fever, malaise, or chills. He smokes 1 pack of cigarettes daily and drinks socially; he has multiple sexual partners. On exam, his vitals are normal and lungs are clear; abdominal exam is unremarkable, without any renal angle or suprapubic tenderness, and external genitals reveal only slight urethral discharge. Labs show WBC of 6500/uL, and urinalysis has 5-10 WBC and 0 RBC. Gram stain of the urethral discharge shows neutrophils and intracellular gram-negative diplococci.

Ceftriaxone 250 mg IM plus azithromycin 1g PO each single dose

A 5-year-old African American girl with sickle cell disease presents due to right leg pain. She began to experience right thigh pain and a slight limp following a playground injury 2 weeks ago. Upon sustaining the injury, she was taken to a local ER; X-rays were negative for evidence fracture. She was diagnosed with and treated for a leg contusion. Over the past 2 weeks, the pain has become more severe and she has experienced fever; temperatures have been as high as 102°F, and she has experienced episodic chills. On physical examination, her temperature is 101°F; her right leg is swollen, tender, and erythematous over the anterior aspect of the thigh. The remainder of the PE is unremarkable. CBC with differential reveals a leukocytosis; there is a predominance of neutrophils and a bandemia.

Ceftriaxone and vancomycin

A 64-year-old African American man presents to the emergency department after he went blind in his right eye "out of the blue" 20 minutes ago. There is no pain associated with his symptoms and he is not nauseated. Past medical history is positive for type 2 diabetes mellitus for the past 10 years. The pupil reaction on the left side is normal with pressure of 17 mm Hg. Right pupil evaluation reveals no reaction to light or accommodation with pressure of 20 mm Hg. Right eye ophthalmoscopy reveals arteriolar narrowing, vascular stasis, and "boxcar" pattern.

Central retinal artery occlusion

A 78-year-old Caucasian man presents with unilateral painless loss of vision in the right eye of 3 hours duration. Examination reveals an elderly man who is anxious but in no acute distress. Visual acuity is light perception only in the right eye and 20/30 in the left eye. Pupillary examination is significant for an afferent pupillary defect on the right side. Penlight examination of the eyes is otherwise unremarkable. Retinal examination of the right eye reveals a cherry-red spot. Retinal examination of the left eye is unremarkable.

Central retinal artery occlusion

A 25-year-old woman presents with pelvic pain for the last 3-4 menstrual cycles, the most recent episode with increasing symptoms for approximately 2 weeks. She has tried over-the-counter pain relievers without relief. She admits deep dyspareunia, and she has been with her current sexual partner for about 6 months. She does not use barrier contraception every time with her current and previous partner, although she is on an oral contraceptive pill. She has no chronic medical conditions. There are no allergies to any medications. She denies urinary issues. She admits to nausea, but no vomiting or diarrhea. She reports a negative home pregnancy test this morning. Her last pelvic exam was over 1 year ago. LMP was 1 week ago.

Cervical motion tenderness

A 70-year-old Latinx man with a past medical history of hyperlipidemia presents with recurrent chest pain that has been occurring over the past month. This pain is provoked with activity, especially of his upper torso and left arm. The pain is described as sharp and generally located in the left pectoral area. He denies any weight changes, fever, or chills. He also denies cough, wheezing, pleurisy, calf pain, wheezing, vomiting, diarrhea, changes in bowel habits, cigarette, drug or alcohol use, sick contacts, and travel. Physical exam reveals an elderly Latinx man in no acute distress. Vital signs, skin, cardiopulmonary, abdominal, and peripheral vascular exams are found to be within normal limits.

Chest pain that is reproduced with palpation

A 25-year-old man with no significant medical history presents due to sudden onset of shortness of breath associated with right-sided chest pain. The pain is worse with inspiration but is unaffected by position. He states he was grocery shopping when it started. He denies chest trauma. Patient admits to an upper respiratory infection earlier in the month that had resolved without incident. He smokes 1 pack of cigarettes per day. On examination, he is afebrile, BP is 138/80 mm Hg, pulse is 124, respiratory rate is 24, and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is midline. He has increased resonance to percussion with no breath sounds on the right anterior apex; the other lung fields are clear to auscultation. Heart is tachycardic with normal S1 and S2; no murmur, rubs, or gallops are present.

Chest radiograph

A 2-month-old girl presents with rapid breathing and a staccato cough, appearing otherwise well; she is afebrile. Physical examination detects fine rales over the lungs and a thickened red tympanic membrane. A chest X-ray shows bilateral patchy interstitial infiltrates. Laboratory studies indicate eosinophilia. Her mother received limited prenatal care.

Chlamydia trachomatis

A 5-week-old male infant presents with a 2-week history of prominent cough, nasal congestion, and wheezing. His symptoms have been getting progressively worse. Yesterday, the patient's mother took her son to her primary care doctor. The doctor started albuterol nebulizers every 4 hours and told her that the child had a viral infection and would get better. His mother is now particularly concerned that her child has had dry diapers for over 15 hours. The child has been irritable during this time. He has not had any fevers, vomiting, or diarrhea. The child is not tolerating breastfeeding or bottle-feeding well. The physical exam shows that the child is acyanotic and alert. The temperature is 97.8°F (36.5°C), respirations are 40/minute, and the pulse is 119/minute. There are no lymph nodes observed, and his tympanic membranes appear normal. There are rales noted diffusely on auscultation. The mucous membranes are moist and the skin has good turgor. You also detect conjunctivitis. Blood work is obtained; including a set of blood cultures, and a urine culture. The following lab values return: Hemoglobin12.6 mg/dLHematocrit37.1%Platelet count204 x 109Eosinophilia count6% The chest film demonstrates interstitial infiltrates and hyperinflation.

Chlamydia trachomatis

A 37-year-old man presents with a feeling of constant left ear fullness. His hearing has not been as sharp out of his left ear for the past 3 months. The patient had multiple middle ear infections as a child and had myringotomy tube placements on four separate occasions. He has a history of severe perennial and seasonal airborne allergies, but he is not seeking treatment currently. Weber test findings lateralize to the left ear. During otoscopic inspection, a sac filled with a cheesy white material is located on a retracted tympanic membrane. A small perforation of the tympanic membrane is suspected; there is the presence of the same cheesy white debris behind the membrane.

Cholesteatoma

A 55-year-old man presents with a 1-week history of fatigue, night sweats, and abdominal fullness. On physical examination, you note a palpable spleen. You order a CBC; the results indicate a white blood count of 105,000 cells/mcL with a left shift of the myeloid series. The red blood cell count and morphology show anemia, and he has an elevated platelet count. To help confirm your suspicions, you order genetic studies, and the results come back with the BCR/ABL gene detected.

Chronic myelogenous leukemia

A 52-year-old man presents with vomiting and epigastric distress for the past few hours. He has been drinking alcohol for over 20 years, and he has been a moderate-to-heavy drinker. 5 years ago, he was diagnosed with a "gastric/duodenal ulcer," for which he has been taking cimetidine and antacids. The pain now radiates towards the left along the costal margin. He has noticed his appetite has been reduced lately, and his stools are bulky and foul smelling. His friends have commented on his sickly look and weight loss.

Chronic pancreatitis

A 67-year-old man presents with a subacute onset of lower urinary tract symptoms. He cannot discuss his past medical history or current medications. An initial genitourinary workup is started, and microscopic urinalysis reveals granular and waxy casts.

Chronic renal disease

A 29-year-old man presents with a chronic respiratory infection; he is seeking the advice of an ear, nose, and throat specialist. He reports a history of recurrent respiratory infections. A biopsy of his respiratory epithelium reveals an alteration in certain epithelial structures.

Cilia

A 57-year-old man presents with progressive dyspnea on exertion and left lumbar colic. He has a history of hypertension as well as a 40 pack-year history of smoking. He denies cough, orthopnea, and paroxysmal nocturnal dyspnea. He has some mild ankle swelling, but he has no history of congestive heart failure. The only medication he is on is amlodipine. His vital signs are as follows: temperature 99.8°F, pulse 92/min, respiration 22/min, BP 128/88 mm Hg. Of significance on physical examination is the absence of breath sounds in the left lower lung zone. Laboratory data reveals WBC 1000/μL with 70% segmented neutrophils, serum glucose 106 mg/dL, sodium 138 mmol/L, chloride 102 mmol/L, potassium 4.2 mmol/L, bicarbonate 22 mmol/L, BUN 32 mmol/L, creatinine 1.2 mmol/L, protein 8.2 g/dL, amylase 56 U/dL, and LDH 250 U/mL. Thoracentesis is done and pleural fluid analysis shows WBC 910/μL, RBC 14/μL, LDH 108 U/mL, protein 2.6 g/dL, glucose 82 mg/dL, and creatinine 1.2 mmol/L.

Cirrhosis

A 29-year-old woman presents to an urgent care clinic due to abdominal pain and bloody diarrhea that has worsened in the last 36 hours. She also reports nausea, vomiting, and a low-grade temperature of 100.1°F. She attended a neighborhood block party 2 days ago and ate various home-cooked foods. She has no relevant past medical history. A physical exam reveals dry oral mucosa and epigastric pain upon deep palpation of the upper abdomen. Stool studies for bacteria, ova, and parasites were collected and sent for analysis. Several more people appear later in the week reporting similar symptoms.

City health department

A 15-year-old Caucasian boy presents with a 2-week history of recurrent breakouts on his face. His mother states that the condition is worse during football season. He currently uses over-the-counter products with no improvement. Examination of the face reveals a combination of inflammatory papules, pustules, and comedones on the face, with a concentration on the forehead and temples.

Clean football helmet after use.

A 27-year-old woman followed by your practice for several years has recently undergone genetic testing for von Hippel-Lindau disease. The test showed that she has a mutation in the VHL gene. She does not have von Hippel-Lindau disease yet, but she is at risk for developing it. The patient has a 24-year-old brother who was diagnosed with von Hippel-Lindau disease 6 months ago. The patient asks you where she might find information regarding ongoing investigational studies of patients with von Hippel-Lindau disease.

ClinicalTrials.gov

A 53-year-old man presents with a 2-week history of severe headaches that occur primarily at night. The patient is pacing while he is talking. The pain surrounds one eye and lasts for 30-90 minutes. He also states that there is ipsilateral lacrimation, conjunctival injection, and nasal congestion during the attacks. The patient states that he has had these headaches once a day over the last week. He cannot point to any one thing that causes them. On examination, the patient has features of partial Horner's syndrome. His vital signs are temperature: 97.0°F, heart rate: 80/min, respiration 16/min, and blood pressure: 126/80 mm Hg.

Cluster headache

A 6-week-old boy presents at your pediatric practice office, brought by his mother. She reports that for the past week he has not been feeding well and he breaks out into a cold sweat on his forehead while feeding. Upon further questioning, she reports that he becomes extremely breathless, irritable, and extremely pale after extended periods of crying. The mother reports a normal vaginal delivery and denies any problems with her son at the time of discharge from the hospital following his birth. She reports a family history of congestive heart failure. Vitals are as follows: pulse 130-regular, respiration 34-regular, blood pressure R arm 96/62 L arm 92/54 and R leg 70/42 L leg 74/40. Cardiac exam reveals 4+ carotid pulses bilaterally, 2+ brachial pulses bilaterally and absent femoral pulses bilaterally. A loud harsh systolic ejection murmur is noted at the base of the heart. The EKG reveals normal sinus rhythm with left ventricular hypertrophy.

Coarctation of the aorta

The Framingham Heart Study is an ongoing cardiovascular research project centered around residents of Framingham, MA. It began in 1948 with 5209 adult participants. Since then, adult children, spouses of adult children, and grandchildren of the original participants and minority residents of the community have been added to the investigation. Before initiating this investigation, little was known regarding the epidemiology of atherosclerotic or hypertensive heart disease, such as the impact of smoking, diet, exercise, or aspirin use.

Cohort study

An 18-year-old man presents 30 minutes after falling on his outstretched arm while skateboarding. He is guarding his left forearm near his wrist with his right hand, and he has his left arm against his body for support. There is a deformity similar to the image with edema and ecchymosis at the wrist. He is neurovascularly intact and the skin is closed. His left elbow and shoulder exam are normal.

Colles' fracture

A 35-year-old man has a routine physical examination with no abnormal findings. His family history, however, is positive for familial adenomatous polyposis.

Colonoscopy

A 58-year-old man presents with a recent episode of rectal bleeding. A brief history reveals that his bowel patterns have been increasingly erratic over the past 6 weeks. He reports periods of 2-6 days without bowel movements followed by copious production of thin coils of stool. He has lost 10 lb over the last month. His family history is significant for the death of his cousin from colon cancer. Physical exam reveals the patient is pale and febrile (temperature 101°F); the rectal exam is heme-positive with scant stool, and his prostate is soft and moderately enlarged.

Colonoscopy

A 34-year-old multiparous woman presents for a routine Pap smear after being "too busy" to have annual exams for the past 7 years. Three Pap smears in her 20s have all been normal. She has had one episode of venereal warts in her late teens; there was no recurrence. She had two vaginal deliveries. She does not smoke. Remainder of her history is negative. Her Pap smear is reported as "atypical squamous cells of undetermined significance." The HPV test is positive.

Colposcopy

A 2-year-old boy has a solid mass of tumor on the lower pole of his right kidney. Histopathological studies show whorls of mesenchymal cells and clusters of disorganized epithelial cells rather than renal corpuscles and renal tubules, which confirm your suspected diagnosis.

Combination chemotherapy is appropriate after surgery.

A 65-year-old man presents with a 2-day history of diffuse colicky abdominal pain originating in the RUQ (right upper quadrant). It is not aggravated by food or activity. There has been nausea, but there has not been any vomiting. His skin and eyes have turned yellow in the last several days. His urine has been dark brown, and his stools have been white and chalky. He stopped drinking alcohol about 2 years ago and has been sober since. There is no history of drug abuse. He smokes 2 packs of cigarettes a day. He had gallstones diagnosed at the time he stopped drinking, but he refused surgery. There is a history of previously diagnosed but untreated hypertension. He denies temperature elevation, but he has felt "warm." There was an episode of "shaking chills" earlier in the day. When he walks, he gets dizzy. Vital signs are: T-103°F (oral); P-115/min; BP-100/65 mm Hg; R-32/min (labored); Pulse Ox-90% (room air). He is mildly icteric. Abdomen is slightly protuberant, and there is tenderness and rebound tenderness restricted to the RUQ. No surgical scars are present. Chest examination is within normal limits except for scattered wheezes and rhonchi. Cardiac examination reveals mild cardiomegaly. On rectal examination, pale soft stool is obtained; it is guaiac negative. Good sphincter tone is present. Mild atrophy of the testicles is noted. The remainder of the physical examination, including a neurological exam, is within normal limits.

Common bile duct stones

A 35-year-old man presents with a 2-week history of constant burning and throbbing pain in his left hand. The pain also seems to affect his distant forearm. Contact with normal clothing and bed sheets worsen his hand pain. He also reports that his hand is swollen. He denies trauma to his hand, but he does report an uncomplicated left wrist fracture 3 months ago that resulted from a sports accident. By the time of cast removal at 7 weeks post-injury, he denied any pain or edema in the affected limb. He was instructed to return to normal activities, as tolerated. He was initially treated with ibuprofen and opioid pain pills. He discontinued all pain medicines within 2 weeks of the fracture. He now describes his hand pain as an 8/10. On physical exam, the left hand and forearm are noted to have some localized edema, warmer temperature, and increased hair growth compared to his right hand and forearm. No rash or skin lesions are noted. With even light palpation of the affected region, the patient cries out in pain. Range of motion is decreased, and reflexes are increased the left upper extremity (in comparison to the right). The rest of his exam is normal. X-ray of the left wrist and hand are normal, with good fracture resolution.

Complex regional pain syndrome

A 56-year-old man presents with moderately severe substernal and left anterolateral chest pain. There is some exacerbation of pain on inspiration that has been increasing in severity over the last 36 hours. He works as a truck driver and has a history of heavy cigarette smoking, hypertension, and obesity. Over the past week, he has experienced swelling and discomfort in his right calf. Examination shows BP of 90/55 mm Hg, P of 122/min, RR of 40/min, and temp of 37.6°C. The patient is mildly agitated and confused. Systemic examination reveals tachycardia, soft systolic murmur, and questionable ventricular gallop. Lungs show dullness to percussion at left base, with scattered crackles and wheezes throughout. Abdominal and neurological exams are negative. The right calf is 0.5 cm larger than left, with some deep tenderness and a trace of ankle edema. Laboratory analysis reveals hemoglobin 16.4 g/dL, Hct 51%, WBC 12,300 cells/µL, PaO2 52 mm Hg, PaCO2 38 mm Hg, and pH 7.35. Chest radiograph shows borderline cardiomegaly and a prominent aorta, scattered patchy infiltrates bilaterally, and a small left pleural effusion.

Computerized tomographic angiography

The JUPITER trial ("Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein" New England Journal of Medicine 2008) was designed to evaluate if individuals with elevated high-sensitivity C-reactive protein (hs-CRP, specific biomarker of inflammation) without hyperlipidemia might benefit from statin treatment. The trial studied 17,802 apparently healthy individuals with LDL cholesterol <130 mg/dL and hs-CRP level ≥2.0 mg/L, half randomized to treatment with rosuvastatin 20 mg daily, half to placebo. The primary endpoint of the study was combined rate of MI, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular disease. The primary endpoint occurred in 142 of 8901 in the rosuvastatin cohort and 251 of 8901 in the control group (0.77 events per 100 person-years in the rosuvastatin group vs 1.36 events per 100 in control group; p-value <0.00001; hazard ratio 0.56, 95% confidence interval 0.46-0.69). Mean LDL cholesterol was reduced by 50% and mean hs-CRP was reduced by 37% in the cohort assigned to rosuvastatin. The study was terminated after a median follow-up of 1.9 years, at which time 75% of participants were taking their study pills. The study reported a 44% decrease in new cardiovascular events in patients treated with rosuvastatin compared to placebo.

Confidence interval has 95% chance of containing true hazard ratio.

A 70-year-old woman presents with a 3-day history of shortness of breath at rest. She has been finding it difficult to walk short distances due to shortness of breath. Additionally, she is experiencing orthopnea and nocturnal dyspnea. Her past medical history is significant for hypertension, hyperlipidemia, and myocardial infarction. The patient denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, abdominal pain, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is short of breath; she requires numerous pauses during conversation. She is afebrile but tachycardic and diaphoretic; her extremities are cool. The exam reveals a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, dullness to percussion, and expiratory wheezing. There is no JVD noted, but 2+ pitting edema of the lower extremities to the level of the mid-calf is evident.

Congestive heart failure

An 84-year-old woman presents with a 6-hour history of dyspnea, non-productive cough, hemoptysis, and a "sharp, stabbing" pleuritic chest pain. Her review of systems is negative for any fever, chills, palpitations, wheezing, abdominal pain, nausea, vomiting, diarrhea, and rashes. She has a past medical history of myocardial infarction, congestive heart failure, dyslipidemia, asthma, and lung cancer. Social history is significant for a 50 pack-year smoking history, but she quit 10 years ago. She denies any alcohol or recreational drug use, sick contacts, or recent travel. She also denies any recent hospitalizations or surgeries. On physical exam, skin is warm and dry without rashes. There is abdominal distension, hepatosplenomegaly, supraclavicular lymphadenopathy, and 2+ lower extremity pitting edema (right greater than left) noted. The cardiac exam reveals tachycardia, jugular venous distension of 6 cm, and an S3 gallop. Pulmonary exam reveals tachypnea, diffuse dullness to percussion, decreased tactile fremitus, and absent breath sounds. She undergoes diagnostic thoracentesis. Laboratory findings of pleural fluid are listed below. AppearanceClearPleural fluid LDH160 units/literPleural-to-serum protein0.2Pleural-to-serum LDH0.3Pleural fluid glucoseNegativePleural fluid WBCsNegativePleural fluid pHWithin normal limitsPleural fluid RBCsNegative

Congestive heart failure

A 12-year-old boy presents for evaluation of short stature. His height is 54 in (136 cm, 5th percentile) and weight is 76 lb (35 kg, 25th percentile). He uses a nasal inhaler for seasonal allergies and denies other medications. He is physically active and an only child. His mother is 5'4" and his father is 5'10". He has healthy eating habits and denies constipation, fatigue, or any other digestive or urinary problems. His birth history was normal: full term, weight 7 lb 3 oz, height 20 in. On exam, he appears shorter than his stated age. He has normal-appearing facies. His heart, lung, and abdominal exams are all normal. He is at Tanner stage 1. His growth charts show him starting around the 50th percentile for height and weight; there is slow linear growth during the first 3 years of life, with both parameters crossing percentiles downward. Linear growth occurs at a near-normal rate below but parallel to the 5th percentile in the last couple of years. A bone age shows delayed skeletal maturation. Upper-to-lower body segment (U/L) ratio is proportionate.

Constitutional growth delay

You are a PA working in the emergency department of a community hospital. A 65-year-old man presents with left lower quadrant abdominal pain associated with nausea, vomiting, diarrhea, and fever for 3 days. Abdominopelvic computed tomography (CT) reveals sigmoid diverticulitis with microperforation. The patient is now comfortable after receiving intravenous (IV) fluids, morphine for pain control, and ondansetron for nausea.

Consult attending physician and on-call GI to request admission.

A 12-year-old boy presents with itching and redness between his toes. The mother notes that this is his second visit in 2 weeks, adding that her son had the same symptoms previously. She states that the child was prescribed an antifungal cream on the previous visit. They still have cream left. On examination, the interdigital spaces are macerated and erythematous.

Continue the antifungal cream and give health education advice.

A 62-year-old man presents with a 2-month history of worsening fatigue and shortness of breath. He has a past medical history of emphysema attributable to his 85 pack-year smoking history. The patient complains of nearly passing out while climbing the stairs in his house. He tells you that he feels like his heart races. He reports chronic shortness of breath and cough, but he now he feels like his dyspnea is dramatically worse; he can no longer sleep in his bed. He has been trying to sleep propped up in a chair at night. He is also experiencing fatigue. He has gained about 15 pounds, and he notes that he can no longer lace up his shoes. He denies fever, chills, and chest pain. His cough produces some mucus, but no hemoptysis. His vitals are shown in the table. Weight212 lbHeight69"Body mass index31.3Pulse108Blood pressure140/88Temperature98.2°FPulse oximetry88% On physical exam, you see a man in mild respiratory distress; he is sitting upright and leaning forward, and he uses accessory respiratory muscles for breathing. The exam is significant for reduced air movement and mild rales bilaterally in the lungs; distended neck veins; mild tachycardia with prominent P2; lower extremity edema; and right upper quadrant abdominal tenderness with hepatomegaly.

Cor pulmonale

A 69-year-old man presents with dyspnea on exertion (climbing stairs and walking short distances) that has slowly progressed over the last year. He has fatigue, palpitations, intermittent retrosternal chest pain, lower extremity swelling, dizziness, and "feeling faint." Associated symptoms occur upon exertion. He denies fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes in urine color/odor, flank pain, hematuria, or dysuria. No cigarette, alcohol, or drug use. Cardiac exam shows increased pulmonic component of the second heart sound (P2), wide inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, left parasternal lift, loud diastolic murmur increasing with inspiration and diminishing with Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. Enlarged liver with hepatojugular reflux, peripheral edema, and ascites. EKG reveals peaked P waves, rightward axis deviation, and prominent R waves in the early V leads.

Cor pulmonale

A 32-year-old woman presents with malaise, excessive urination, and palpitations. Her symptoms began approximately 2 months ago and have been getting more pronounced with time. She finds herself craving ice-cold water and drinking on an almost continual basis. No matter how much she drinks, she never seems to satisfy her thirst. The patient had been very healthy until recently. She has no significant past medical or family history, with the exception of an auto accident approximately 2 years ago; she hit her head on the steering wheel and spent a night in the hospital for observation. She had no problems after she was discharged until now. She reports no deficits of vision and no history of syncope or seizures. On physical examination, the woman is anxious, pale, and appears dehydrated. Her vital signs are: blood pressure 100/54 mm Hg, temperature 99.8°F, pulse 112 beats per minute, respiratory rate of 24 per minute. Laboratory tests show dilute urine with a specific gravity of 1.000 and a urine osmolality of 198 mOsm/kg. Her plasma osmolality is 299 mOsm/kg.

Idiopathy

A 39-year-old woman presents with a rash. The rash started 5 days ago; it is pruritic and located primarily on her arms and legs, with a few sores in her mouth. Her husband described the rash as like a "bullseye." She has felt mildly "flu-like," but she denies fevers. She denies any changes in soaps, detergents, or diet. She has not been around anyone with a similar condition, and she denies travel. Otherwise, she reports feeling better than usual, with more improved control of her migraines since her neurologist started her on topiramate about 3 weeks ago. She has not needed to use her sumatriptan for over 1 month. Her review of systems is negative. She suffers from migraines, but she has no other chronic health conditions. Her current medications are topiramate daily, with sumatriptan as needed. She is allergic to amoxicillin. She has regular menses; she had a tubal ligation as contraceptive. On physical exam, a few small oral lesions are noted. The lesions on the extremities are primarily on the dorsal surfaces, with a ringed appearance, similar to a target. The remainder of her exam is normal, including vital signs.

Immediate discontinuation of the new medication

A 33-year-old woman presents for an annual physical. She has past medical history of GERD, asthma, and irritable bowel syndrome. She drinks 1-2 alcoholic beverages per week and has never smoked; she does not use illicit drugs, and she consumes a vegetarian diet. Her past surgical history includes an appendectomy at age 14. Her father passed away from a heart attack at age 63. Her mother is alive with history of colorectal cancer, which was diagnosed at age 41.

Immediate screening colonoscopy

A 48-year-old Caucasian man is evaluated for palpitations by a PA in an internal medicine clinic. He presents with a several-week history of episodes of irregular heartbeat and tachycardia. PMH: kidney stones, childhood asthma; lithotripsy 3 years ago. NKDA. No daily medications. Extensive travel for work and 1-2 alcoholic beverages a few times weekly. Denies recreational drugs. Review of systems negative for chest pain, shortness of breath, dizziness, or syncope. Pulse: 108 and irregular. Vitals otherwise stable. Heart: irregularly irregular, mild tachycardia. No murmurs. Lungs: clear to auscultation and percussion. Remainder of physical exam unremarkable. EKG: atrial fibrillation, rate 110. Patient is started on sotalol (Betapace AF) 80 mg twice daily, and Holter monitor is placed. Cardiologist appointment is scheduled for 2 weeks. 2 days later, the patient dies of sudden cardiac arrest wearing the Holter monitor, showing runs of torsades de pointes (form of polymorphic ventricular tachycardia). 2 months later, a wrongful death and medical practice lawsuit is filed against the PA and supervising physician on behalf of the family.

Immediate verbal discussion while patient still in office

A 56-year-old man presents with a painful lump on his neck that has been bothering him for the past 2 weeks. He denies other symptoms or recent illness. He has a past medical history of hypertension and kidney stones. Nursing staff reports that his temperature is 97.9°F, heart rate is 65, respirations 12, and blood pressure is 140/88. During your examination, you palpate an enlarged lymph node on his left suboccipital region that is soft and about 1 cm in size. The lymph node is non-movable, non-erythematous, and without warmth or fluctuance.

Immobility

A 47-year-old woman with a history of obesity presents to the emergency department due to pain in her right ankle after a fall 2 days ago. Upon physical exam, she has pain and tenderness at the tip of the medial malleolus and has the inability to bear weight for at least 4 steps. The patient does not present with pruritus or any rashes, but the ankle appears swollen. The patient's foot appears to be neurologically intact. She does not present with a fever or erythema of the ankle. According to the Ottawa Ankle Rule, she qualifies for X-rays.

Immobilization

A 36-year-old woman presents with fatigue and diplopia; symptoms started in the morning and worsened during her time at work. On examination, the patient has ptosis bilaterally and decreased ocular muscle power. A CT scan of the chest shows a thymoma.

Immune-mediated destruction of the acetylcholine receptor

A 5-month-old infant presents in the winter months with wheezing, rapid respirations (>45 breaths/min), and chest retractions. The patient has a 2-day history of rhinorrhea and low-grade fever. Breath sounds are normal, and there is no cyanosis.

Immunofluorescence of nasal secretion

A 24-year-old man presents with a painful ulcer on his left leg and systemic symptoms. The lesion started 1 week ago as a small pustule that developed at the site of a mosquito bite and rapidly developed into a painful ulcer. The patient describes the pain as "stabbing" and debilitating. He also develops symmetrical joints pain, muscle pain, fever, and malaise. His past medical history is significant for ulcerative colitis, which is currently in remission. On examination, you find a deep exudative ulceration with a well-defined violet border and a worn erythematous indurated edge. There are also signs of pathergy.

Immunosuppressant (systemic corticosteroids)

You have been employed as a PA for a hospitalist group for several years. You have recently been invited to serve on a hospital committee taskforce. The mission of this taskforce is to make recommendations regarding system-wide initiatives likely to improve patient outcomes and reduce costs for the healthcare system. These recommendations will be forwarded to the CEO of this large healthcare system. If the Board of Directors approves, it is fully expected that the initiatives will be funded and implemented.

Implementation of a telehealth program

You are working at the Centers for Disease Control and Prevention, assigned to the National Center for Chronic Disease Prevention and Health Promotion. You are asked to prepare a report describing the impact of atrial fibrillation in the US. You learn that: An estimated 4.4 million persons (estimate 2.7-6.1 million persons) had atrial fibrillation in the US in 2010. 1.2 million cases of these cases of atrial fibrillation were newly diagnosed in 2010. The US population in 2010, according to the official government census, was approximately 323 million. In order to prepare a table displaying measures of population morbidity of atrial fibrillation in 2010, you make the following calculation: 1.2 million new cases of atrial fibrillation323 million US population=0.0037=0.37%1.2 million new cases of atrial fibrillation323 million US population=0.0037=0.37%

Incidence proportion

A physician assistant sees 20 patients a day in a primary care clinic. These patients are all follow-up patients initially seen by the physician. The PA is supervised by a physician who is physically present in the office during the PA's clinic hours.

Incident-to services

A 28-year-old man presented 4 days ago for evaluation of a 101.8°F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat has worsened. He has not been able to drink fluids or eat, and he has excruciatingly severe pain when swallowing. You recognize the patient speaking with a muffled "hot potato" voice. Upon re-examination today, you identify a right medial deviation of the soft palate with 4+ right tonsillar swelling.

Incision and drainage

A 35-year-old man presents with a painful perirectal lump. It began 6 days ago as a small firm mass and has gradually increased in size. As the mass has grown, it has become more tender. On examination, there is a 4 cm fluctuant red perirectal mass.

Incision and drainage

A 48-year-old man presents with a logbook of home-recorded blood pressure readings between 125-185/75-100 mm Hg. His past medical history is significant for hypertension and obesity (BMI 31 kg/m2). He is a non-smoker and does not drink alcohol. He has been adhering to a sodium-restricted diet and tries to walk 2 miles at least twice a week. For the past 2 years, he has been taking hydrochlorothiazide 12.5 mg daily with no apparent side effects. Physical exam is unremarkable, and vital signs reveal a heart rate of 85 beats per minute and blood pressure of 150/85 mm Hg.

Increase hydrochlorothiazide dose to 25 mg daily.

A 14-year-old boy presents due to embarrassment after an incident in school: while undressing before the class in physical education, the other boys laughed at him because of his "underdevelopment." His personal and family history is non-contributory.

Increase in size of testes

A 48-year-old Caucasian woman presents due to feeling like she is losing her mind. She wants some tests done. Upon further questioning, she reports she is having multiple episodes daily in which she suddenly becomes very hot, flushed, and diaphoretic. These episodes last about 1 minute, then resolve. She has not measured a fever. The patient reports that the episodes occur during the day and at night, causing her to wake up drenched in sweat. As a result, her sleep has been poor, and she feels fatigued and irritable at both work and home. She has noticed these symptoms for about 2 months, and they seem to be increasing in severity. The patient has not had a period for 3 months; she recently did a home pregnancy test, which was negative. Prior to that, she had regular menses. This patient denies weight changes, palpitations, cold intolerance, bowel changes, as well as changes in her nails, skin, and hair. Although she admits irritability, she denies anxiety, depressed mood, and suicidal ideation. Her family history is remarkable for diabetes in her maternal grandfather and hypertension in her father. She is a G4P3Ab1. She denies any major psychosocial stressors recently. She drinks alcohol rarely, and she denies use of other drugs. Vitals and a urine specimen for hCG were obtained prior to the physical exam.

Increased follicle stimulating hormone (FSH)

A 27-year-old Caucasian man returns to the emergency department with unbearable left lower leg pain approximately 6 hours after initial discharge. While playing lacrosse, the patient sustained a closed mid-shaft tibial fracture. After casting and an anti-inflammatory, his pain was noted to be mild (2/10) at time of discharge. He reports his pain is increasing dramatically (it is now rated 9/10) and is unresponsive to his prescribed narcotic, acetaminophen, icing, and elevating his leg. He also describes a feeling of tingling and numbness throughout the lower left extremity. The patient arrived on crutches and appears in obvious pain. He is afebrile; he has a pulse of 105. The cast is intact and the remainder of the left leg and foot is examined. The patient is tender to palpation of the left foot and ankle, with swollen firm tissue. The skin appears shiny. Pulses are normal, but capillary refill and sensation are decreased on the left foot compared to the right. With passive movement of the patient's left toes, he cries out in pain. There is no ecchymosis or visible skin lesions on the left foot or ankle.

Increased pressure within the tissue space, leading to venous obstruction

A 24-year-old woman presents with severe diarrhea that she has been experiencing for 3 days, with no medical issues before then. She now feels dizzy upon standing, her tongue is dry, and her eyes appear glazed. Her serum sodium concentration is 130 mEq/L. What finding is most likely?

Increased serum ADH concentration

A 50-year-old woman presents for her annual pelvic examination. She states her last menstrual period was over 12 months ago; the last few occurrences of menses were extremely irregular. The patient also describes having the sensation of intense heat in her face and trunk; the sensation is accompanied by sweating. She further states that these "heat episodes" have been occurring 1 or 2 times a week for the last several months. She reports no other issues at this time. She has received her annual pap and pelvic examination yearly, as well as a clinical breast exam, without any issues. During the pelvic examination, you note obvious vaginal thinning and excessive dryness; there is also apparent vaginal wall atrophy.

Increased serum follicle-stimulating hormone (FSH)

A 32-year-old man presents with a severe headache; he has had 2 similar headaches within the past week. He describes a burning, "hot poker" type of pain located primarily behind his right eye. He notes that his eye waters profusely with the headache. His nose is initially congested, then it starts running. Only his right side is affected. The headache is so severe that he cannot work or sleep through it, and he is unable to concentrate on anything else. The headaches have been unresponsive to over-the-counter pain medications. The episodes seem to last about 1 hour. He denies any other symptoms. This patient has no chronic medical conditions, and he takes no regular medications.

Increased trigeminal nerve and parasympathetic activity, leading to vasodilation

A 45-year old Caucasian woman complains of an oval growth on her forehead. She noticed the growth 2 weeks back, and it has gradually grown in size and now bleeds occasionally. She works as a secretary at a dentist's office. She often visits tanning parlors to get a tanned look. She has also had several cosmetic procedures done, including liposuctions in the past to treat her obesity. She gives a history of cocaine abuse in her 20s. She is a hypertensive on treatment with thiazides. On exam, there is an erythematous papule about 3 x 3 cm in size, which bleeds on touch. Her BMI is 30. Biopsy of the lesion reveals squamous cell carcinoma (SCC) of the skin.

Indoor tanning

A 42-year-old man with a past medical history of hypertension presents with a 6-week history of intermittent fever. He has an associated cough, dyspnea, anorexia, arthralgias, abdominal pain, diarrhea, a widespread rash throughout his body, and back pain. He has come to see you because he has experienced painless hematuria since this morning. The patient admits to a dental extraction approximately 6 weeks ago. He denies chills, a history of travel, sick or confined contacts, exposure to animals, bites, stings, cigarette smoking, otalgia, sore throat, swollen glands, drug use, dysuria, preceding GI or GU infections, previous surgeries, or sexual contact in the past year. Physical exam is remarkable for low-grade fever of 101°F, a generalized petechial rash and petechiae of the mucous membranes, dark red linear lesions of the nailbeds, tender subcutaneous nodules of the digital pads, and nontender maculae on the palms and soles. His heart is notable for a new harsh, medium pitched pansystolic murmur at the apex with radiation to axilla, and splenomegaly.

Infective endocarditis

A 57-year-old man presents with a 6-month history of a daily productive cough. The patient is a non-smoker, and he has worked in a local coal mine for the past 39 years. He very rarely comes in to see a healthcare provider. When asked if he is up to date with his vaccinations, he does not recall the last ones he received; he also does not recall when these may have been given.

Influenzae and pneumococci

A 14-year-old boy presents with two episodes per week of shortness of breath exacerbated by playing soccer. His mother has given him her albuterol inhaler on several occasions, and his cough and shortness of breath improve significantly. He also wakes up 1-2 times per month with coughing episodes. He has a strong family history of asthma. He denies fever, chills, and chest pain and has no known drug allergies.

Inhaled corticosteroids

A 32-year-old man presents due to occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symptoms occur 1-2 days a month. He is otherwise healthy and does not smoke. Blood pressure is 128/74 mm Hg, pulse is 76, respirations are 14, pulse oximetry is 100% on room air. FEV1 is 96%.

Inhaled short-acting beta-agonist

You are currently on an inpatient hospitalist team in a local pediatric hospital. First thing this morning, your team is called in to evaluate an infant born at 27 weeks gestation 50 minutes ago. Upon initial inspection of the newborn, you observe rapid labored grunting respirations, flaring nostrils, and retractions that are present above and below the breastbone. Auscultation reveals diminished air movement, and a chest radiograph reveals a ground glass appearance in the lung fields bilaterally.

Inhaled surfactant replacement

A 38-year-old Caucasian man with a long-standing diagnosis of acromegaly has come to you with a concern. He read some articles suggesting that patients with acromegaly have an increased incidence of developing colon cancer, and this has caused him tremendous worry. The patient has no known personal or family history of diverticular disease, colon polyps, or colon cancer. He had a successful selective transsphenoidal surgical resection of a pituitary microadenoma over 20 years ago and has had routine periodic serum insulin-like growth factor-1 (IGF-1) levels drawn that have always been within normal range.

Initial colonoscopy at age 40 and every 5 years

A 71-year-old woman presents with her daughter for dizziness. The daughter is worried about a potential fall; her mother recently had surgery for a right ankle fracture. The patient denies syncope but feels lightheaded when trying to stand. She lives alone and is in a walking boot with crutches. She has not had to use her narcotic pain medicine for 5 days, stating her ankle pain is controlled with ibuprofen alone. She is limiting fluid intake to minimize bathroom trips. Past medical history is remarkable for stable overactive bladder and hypothyroidism. Medications: oxybutynin, ibuprofen, levothyroxine. Only surgery is the recent ankle fracture repair. She denies allergies and use of tobacco, alcohol, and recreational drugs. On physical exam, the patient is wearing the boot and reports dizziness as she moves to the exam table. Exam is remarkable for mild tachycardia and decreased skin turgor, remainder is normal. BP 94/58, Pulse 110, Wt 117 lb, Ht 63".

Initiate IV fluids.

A 7-year-old boy presents for evaluation of behavior problems in school that have been occurring for over 6 months. The boy's teacher recommended he be evaluated. The teacher reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction. He does not finish his homework, and he often loses his homework, pencils, and books. The boy is often seen fidgeting at his desk. He blurts out answers and has difficulty waiting his turn. The parents tell you that they have seen similar traits at home, such as forgetting to do daily activities. For the past several years, he has been easily distracted. They view him as a happy, bright boy, and they report that he is very active. He has had normal vision and hearing screenings. The father self-reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he has never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams, has always met milestones, and has had normal exams. Today, he is quickly moving about the exam room. He looks at a book for a few moments, and then he looks out the window for a short time before interrupting his parents.

Initiate medication.

A 48-year-old man presents with fatigue, weakness, and nausea—symptoms progressively worsening over 6-8 months. He reports fatigue despite adequate sleep, overall feeling of muscle weakness, nausea with occasional vomiting, 12 lb weight loss, headaches, and muscle aches. His wife thinks he appears tan year-round, despite lack of sun exposure. He admits feeling anxious and irritable, but he denies any major psychosocial or traumatic events. Before symptom onset, he was healthy and active. Past medical history reveals no chronic medical conditions, medications, surgeries, or allergies. Family history is significant for thyroid disease in sister and mother, type 1 diabetes mellitus brother. He denies tobacco, alcohol, and recreational drugs. On physical exam, he is hypotensive and hyperpigmented. Remainder of his physical exam is normal.

Initiate steroids.

A 20-year-old primigravida presents at 30 weeks gestation with a 2-day history of a headache, decreased urine output, and facial puffiness. On examination, vitals are as follows: pulse 90/min, blood pressure 164/116 mm Hg and 166/114 mm Hg (taken 6 hours apart), RR 20/min. There is generalized edema and exaggerated deep tendon reflexes with presence of clonus. Abdominal examination reveals a fundal height corresponding to 30 weeks gestation and the presence of good fetal heart sounds (FHS). Urine dipstick for protein reveals 3+proteinuria (300 mg/dL) on 2 occasions.

Injection of betamethasone

A 44-year-old woman is referred to a hospital because of occasional headache accompanied by irritability, confusion, sweating, and hunger. She states that symptoms appeared approximately 3 months ago; they frequently tend to appear early in the morning before breakfast or between meals. On one occasion, during the crisis period, a decreased blood glucose level (55 mg/dL) was detected despite the fact that she consumes a diet rich in glucose. She admits to excessive abuse of alcohol, and she occasionally used aspirin for headaches up to 6 days before admission. Her medical records suggest she was previously treated as a psychopath who was prone to malingering. The patient herself confirms that she was haloperidol-treated for more than 1 year, but she discontinued haloperidol use 2 weeks ago. Her general physical findings are unremarkable. Routine laboratory tests taken on admission reveal no abnormalities. During echosonographic examination of abdomen, no abnormalities were noted. Fasting test was attempted, but it had to be discontinued due to a fall in blood glucose level from baseline value of 75-33 mg/dL 8 hours later. It required intravenous glucose administration and termination of the test. Laboratory analyses taken at the time of test termination also revealed elevated serum insulin (9 uU/mL), elevated serum proinsulin (6.3 pmol/L), and elevated C peptide (0.3 mmol/mL) levels. Insulin receptor antibodies are not present in the patient's serum, and sulfonylurea is absent in the patient's sera and urine.

Insulin-producing tumor

A 40-year-old man presents with a 2-year history of severe, burning epigastric pain. A detailed history reveals that the pain is greatest in the early hours of the morning and wakes him up from sleep. The pain is also felt 2-3 hours after meals. He reports diarrhea for the past 2 years. On examination, his pulse is 74/min and blood pressure 136/84 mm Hg. There is slight epigastric discomfort on palpation. Lab examination shows hyperchlorhydria.

Intestinal ulcers

A 24-year-old woman is evaluated in the endocrinology clinic. She is on 100 mcg of thyroxine per day for treatment of Hashimoto's thyroiditis and receives oral steroids for autoimmune adrenal insufficiency. In addition, she complains of fatigue, numbness, and tingling in her feet. When routine labs were drawn, the following values were noted:

Intramuscular injection of B12

A 25-year-old woman presents due to sneezing episodes that have progressively worsened over the last few months. She has symptoms on most days, and it is affecting her daily life. The symptoms are worse in the spring and fall and improve in the winter. She also reports rhinorrhea, cough, and fatigue. Physical examination is remarkable for boggy nasal mucosa and pale nasal turbinates.

Intranasal corticosteroids

A 31-year-old woman presents with her husband to discuss methods of temporary contraception. They explain that they want to have children in the future but would like to wait a few years. They are both in good health. The woman's routine pelvic and physical examinations show a healthy young woman; her past medical history is unremarkable. She is a non-smoker and there is no family history of breast, ovarian, or uterine cancer.

Intrauterine device

A 70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, or rashes. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. General assessment reveals the patient is tachycardic and diaphoretic Cool extremities. Heart exam reveals a diminished first heart sound, S3 gallop, and laterally displaced PMI. Lung exam reveals dullness to percussion, bibasilar rales, and expiratory wheezing. 2+ pitting edema of the lower extremities to the level of the mid-calf. There is no JVD noted.

Intravenous diuretic

A 30-year-old Caucasian man presents with a 3-day history of fever with chills and severe weakness. There are no other complaints. The patient has had multiple sex partners in the past. He also gives a history of travel to South America and consumption of street food while working there 1 month before presentation. He admits to intravenous drug abuse and cocaine abuse (snorting) in his early 20s. He often ventures out into the woods and has been bitten by several insects in the recent past. Abdominal exam reveals mild hepatomegaly. You send for routine lab investigations, including CBC, comprehensive panel, and serology of HIV and Hepatitis B and C. Liver enzymes are elevated and anti-HCV comes back positive. Anti-HIV and HBV are negative.

Intravenous drug abuse

A 6-week-old male infant presents with a 2-day history of vomiting after every feeding of cow's milk-based formula with iron, 4 ounces per feeding. There has been no fever, diarrhea, or other symptoms except increased crying. The child appears alert and hungry. The mother describes the vomiting as forceful, traveling about 2 feet. Physical evaluation reveals minimal tear production with mild skin tenting. Bowel sounds are decreased. BUN 29 mg/dL; serum sodium 129 mg/dL; serum potassium 3.4 mg/dL; serum chloride 89 mg/dL; serum bicarbonate 34 mg/dL.

Intravenous fluids and abdominal ultrasond

A 7-year-old African American girl presents with a 6-hour history of severe pain in her hands and feet that started spontaneously. She has been having bouts of excruciating pain since she was 6 months old. She is an only child, and her parents have recently discovered that they are both carriers of her condition. On examination, her HR is 115 bpm and blood pressure is 90/50 mm Hg; she is also jaundiced. She has a mildly enlarged spleen but no source of infection. Laboratory investigations reveal hemoglobin of 8 g/dL.

Intravenous hydration

A 55-year-old man presents with severe central chest pain that started suddenly and radiates to the back and neck. He feels sick but has not vomited. He has no major illnesses and knows of none that run in his family. He does not use alcohol, tobacco, or recreational drugs. He is allergic to sulfa drugs. On exam, he appears in extreme pain and lying on his side. Temperature is 98.6°F, heart rate is 110 bpm, blood pressure of 180/105 mm Hg in left upper arm and 156/86 mm Hg in right upper arm, and respiratory rate is 20. Cardiac exam reveals normal S1 and S2 without rubs or gallop. The top of his internal jugular venous column is present at 2-3 cm above the sternal notch. Chest auscultation shows normal vesicular breathing. He has normal active bowel sounds tympanic to percussion. ECG shows left ventricular hypertrophy. Chest x-ray shows widened mediastinum.

Intravenous labetalol

A 23-year-old man with no known significant past medical history is brought in by emergency medical services in an unconscious state. He was reported by friends to be out partying, carrying a prescription bottle. His father has a known history of severe spinal stenosis, for which he takes prescription opioid analgesics. His physical exam reveals slow and shallow respirations, bradycardia, hypotension, cyanosis, and miosis of both pupils. He is comatose, has diminished bowel sounds and distension with dullness to percussion over the suprapubic abdominal area, and has flaccid musculature.

Intravenous naloxone

A 3-day-old male newborn starts to have mild epistaxis after vaginal delivery at home. The mother is a 38-year-old G2P2 who had diet-controlled gestational diabetes. She took a prenatal vitamin and iron supplement. Active labor lasted 3 hours. The midwife who examined the newborn after the delivery declared the newborn healthy. Since the delivery, the mother has been exclusively breastfeeding. The baby is eating every 1-2 hours and has had several wet diapers and 3 stools.

Intravenous vitamin K

A 2-year-old boy presents with acute abdominal pain. The boy has passed stool with blood and mucus and has vomited. He has had intermittent severe abdominal pain, which has caused inconsolable crying and drawing up of his legs in episodes of 15-20 minutes. On examination, the abdomen is tender diffusely with guarding and bowel sounds are absent. He has a fever of 100.5°F. The boy is taken to surgery. Refer to the image.

Intussusception

You are a PA working with an international aid organization in sub-Saharan Africa. A local community has developed an outbreak of an apparently contagious illness with a high (approximately 50%) mortality rate. Symptoms of the illness include fever, weakness, headache, diarrhea, vomiting, abdominal pain, myalgias, and unexplained bleeding. Lab tests for Ebola virus coordinated through the country's health ministry and the World Health Organization report that the outbreak is due to Ebola.

Isolation of infected patients

A 30-year-old male immigrant worker presented 4 weeks ago with a chronic cough, blood-stained sputum, and night sweats. His PPD was 15 mm and pulmonary tuberculosis was diagnosed. Treatment was started at that time. Today, he is back for a checkup with the presenting problem of "pins and needles" sensation in his hands.

Isoniazid

A 26-year-old African American man with no significant past medical history presents with a history of dyspnea on exertion that occurs after running. The dyspnea is associated with mild substernal chest pain. All symptoms are relieved with rest. He denies fever, chills, cough, wheezing, pleurisy, calf pain, abdominal problems, peripheral edema, cigarette, drug, or alcohol use, sick contacts, or travel. His physical exam reveals a harsh murmur best heard at the left lower sternal border and an S4 gallop. A bedside electrocardiogram was remarkable for left ventricular hypertrophy and septal Q waves in the inferolateral leads. An echocardiogram noted asymmetric LVH, anterior motion of the mitral valve during systole, a small and hypercontractile LV, and delayed relaxation and filling of the LV during diastole. The septum was twice the thickness of the posterior wall.

It decreases with squatting.

An approximately 10-year-old Latinx boy is brought by paramedics to the emergency department after a motor vehicle accident. He is unconscious and has sustained severe trauma. He has a subdural hematoma, multiple fractures, contusions, and a tension pneumothorax. He is treated with needle thoracentesis and subsequent chest tube placement. A neurosurgeon is consulted regarding the subdural hematoma. The driver of the car, a Latinx woman in her mid-30s, did not survive the accident. Efforts are made to identify the boy and to locate his next-of-kin. The patient's father arrives at the hospital, but he does not speak English. The next day, the patient's sister (who speaks English) arrives and asks you why the family did not have to give consent before the chest tube was placed.

It was an emergency situation.

A 16-year-old girl presents to her primary care physician after having discovered a breast mass while bathing. She reports no symptoms of any kind; the mass was discovered while taking a shower. There is no history of chest trauma. Exam reveals Tanner stage IV breast development, appropriate to age, and a 2 cm mass in the upper outer quadrant of the right breast. The mass is rubbery in character, mobile, with distinctly palpable borders, non-tender, not fixed to adjacent tissue, and without change in surface anatomy of the breast.

Juvenile fibroadenoma

A 27-year-old woman presents at your family practice clinic for management of her anxiety. She reports that her home situation is unsafe, and she is afraid of her husband; he is physically and emotionally abusive to her and her children. She does not want this information shared; she fears he may retaliate for her telling anyone. She is also afraid that any diagnosis of psychiatric disease will affect her ability to have custody of her children.

Keep records electronically password protected.

A 48-year-old HIV-positive man starts to develop headaches. At first, he attributes the headaches to stress, but they persist and become worse over the next few weeks. He develops nausea and vomiting, and he thinks he has a fever. He starts to become confused, so he seeks medical attention. On physical examination, his temperature is 100°F.

Kernig's sign

A mother brings her 16-year-old son to your medical office for a comprehensive history and physical examination. She tells you she is concerned about his immature physical development and insecure behavior. She thinks these characteristics are markedly different from her other children. His IQ is 70, and he is in special education for a language-based learning disability. On physical examination, he is tall and thin; he has sparse body hair and a high-pitched voice. Heart, lungs, abdomen, and neurologic exam are unremarkable. Pertinent positive findings include disproportionately long arms and legs, gynecomastia, as well as small testes and phallus.

Klinefelter syndrome (XXY)

A 38-year-old woman presents with a skin rash. She indicates that she has a history of psoriasis, but she has not had a serious outbreak for several years. You note salmon-pink papular lesions involving the flexor surfaces of the patient's wrist. The patient has no other lesions. The lesions appear to follow a linear pattern of distribution. She indicates that the lesion has been present about 3 days. You ask her if she was exposed to any type of agent, and she tells you that she scratched the area and then the lesions appeared the next days upon awakening.

Koebner phenomenon

A 2-year-old boy presents to your office. He is from a poor rural family and has not had regular healthcare since birth. He is experiencing a childhood exanthematous disease that involves a maculopapular rash and a fever. It started 7 days ago. He now has corneal ulcers and pneumonia.

Koplik's spots, coryza, fever, cough, and conjunctivitis

A 13-year-old girl presents for her school physical. On examination, you notice the posterior curvature of her thoracic spine to be very prominent and bulging backward.

Kyphosis

A 45-year-old African American man with no significant past medical history presents with a 1-hour history of left retro-orbital headache. The headache was of a sudden onset, and it began upon waking this morning. It is described as excruciating, stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any preceding infections, nausea, vomiting, fever, chills, focal weakness, numbness, tingling, hearing, gait, or speech changes. He recalls a similar episode several months ago; it lasted about 3 hours and dissipated without complications. His physical exam is remarkable for painful distress, nasal congestion with rhinorrhea, left ocular miosis, and left forehead flushing diaphoresis.

Lacrimation and conjunctival injection

A 76-year-old man presents with acute myocardial infarction. He quickly develops hypotension, altered mental status, cold clammy skin, and metabolic acidosis evident on laboratory tests.

Lactate levels

A 58-year-old man presents with a 1-day history of severe abdominal pain, nausea, and vomiting. He initially thought he had some indigestion with pain located in the epigastric region and tried some calcium carbonate (Tums) with no relief. The pain and vomiting progressed through the night and kept him from sleeping and going to work. He feels the pain boring through to his back. He denies hematemesis, fever, diarrhea, out-of-the-country travel, and contact with sick people. Prior to onset of pain, he reports good health. He has no known medical conditions and takes no medications. He has had no surgeries. He smokes cigarettes (40 pack-years), admits "moderate" alcohol use, and denies drug use. He is married and works as a welder. Vitals are: BP: 102/56 mm Hg; HR: 116 bpm; RR: 15; Temp: 98.9°F; O2 Sat: 95% on room air. On physical exam, the patient appears uncomfortable on the exam table and grimaces when changing position for exam. He is cooperative, alert, and oriented. Abnormal physical exam findings include distended abdomen, decreased bowel sounds, and epigastric region tenderness with guarding. He is tachycardic. No jaundice is noted. The remainder of the exam is normal.

Lactated Ringer's

A 52-year-old man presents with heartburn associated with reflux of sour-tasting material in the mouth. Some episodes are accompanied by increased salivation, coughing, and regurgitation of food. Episodes have become more frequent during the past 6 months despite treatment over several years with various treatment combinations, including antacids, histamine 2 receptor antagonists (H2RAs), and proton pump inhibitors (PPIs). He denies bleeding or abnormalities in his stool. He is slightly overweight and has mild hypertension, which is well-controlled with antihypertensive medication. Vital signs are within reference ranges, and the physical examination is unremarkable. Upper endoscopy reveals a large hiatal hernia and coalescing linear erosions throughout the esophageal circumference and a 5.5 cm circumferential cherry red patch above the gastroesophageal junction. Biopsy of the patch reveals columnar metaplasia, but no dysplasia.

Laparoscopic fundoplication

A 4-year-old boy presents with poor weight gain, small size for his age, and dyspnea upon feeding. His mother notes that the child suffers from frequent upper respiratory tract infections. On physical exam, the child is underweight for his age. You note a precordial bulge, a prominent right ventricular cardiac impulse, and palpable pulmonary artery pulsations. You also find a widely split and fixed second heart sound as well as a mid-diastolic rumble at the left sternal border.

Lasix (furosemide)

A 24-year-old man presents with head trauma received in a motor vehicle accident (MVA) 30 minutes ago. Paramedics relate that the patient experienced a loss of consciousness for 1 minute with a complete recovery. At the subsequent evaluation, the physical exam reveals a patient with a Glasgow Coma Scale (GCS) of 12, right hemiparesis, and a left fixed dilated pupil.

Left epidural hematoma

A 55-year-old woman with no significant medical problems presents with a CC of pink urine, stating, "I think I have blood in my urine." She states she has no pain with urination, but the hematuria is persistent. On questioning, she states that she has had a 1-month history of some progressively worsening left flank pain. The pains are not debilitating, but they are nagging. She admits to a 50 pack-year smoking history, and she states she is currently retired from her job as a teacher. Vital signs: T 98.6°F, BP 118/76 mm Hg, P 78/min, R 14/min. Abdominal exam reveals a left side abdominal mass. Urine dipstick only shows too numerous to count RBCs, and urine cultures are negative. CT scan of the abdomen and pelvis with and without contrast reveals a 4.2 cm solid enhancing lesion in the left renal parenchyma.

Left nephrectomy

A 74-year-old woman presents for management of an ischemic stroke. She reports difficulty seeing objects on her right side. You perform confrontational visual field testing as part of your neurological examination and you discover she has a right inferior homonymous quadrantanopsia.

Left parietal lobe

A 42-year-old man presents with a 10-day history of worsening headache, stuffy nose, greenish nasal discharge, and a low grade fever. He has body aches and facial pain, as well as a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a temperature of 100.9°F taken orally. Pulse is 86/min, BP is 120/76 mm Hg left arm sitting, and SPO2 is 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates.

Length of time the symptoms have been present

A 58-year-old Caucasian man presents to his primary care physician's office reporting lethargy. His heart rate is 44 beats per minute.The patient is sent to the emergency department where he is treated with atropine 0.5 mg x 1 dose. Heart rate then increases to 57 beats per minute, and the patient is admitted to the hospital for further evaluation. Cardiology consultation is requested. The patient reports no previous history of cardiac disease. He denies symptoms of chest pain or pressure but admits to intermittent lightheadedness and mild dyspnea on exertion with moderate activity in the last 2-3 months. He denies paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema, and palpitations. He denies frank syncope. He admits to fatigue and lethargy for approximately the past 3 months. He had an exercise tolerance test 10 years ago that was reportedly normal. His last physician's office visit was 2 years ago. His past medical history is notable only for high cholesterol and history of tonsillectomy. He has no known drug allergies. His only daily medication is Lipitor 20 mg once daily. He does not smoke, drink alcohol, or use recreational drugs. Review of systems reveals cold intolerance and episodes of constipation. Physical examination reveals an alert Caucasian man who is somewhat slow to speak and respond. His voice is moderately hoarse. He has coarse facial features and dry skin. Mild periorbital puffiness is noted. Deep tendon reflexes are delayed. 12-lead EKG reveals sinus bradycardia, rate 52, without evidence of prior myocardial infarction, ischemia, left ventricular hypertrophy, or bundle branch block. The EKG is otherwise within normal limits.

Levothyroxine Thyroid stimulating hormone and free T4 level

A 68-year-old woman presents with a several-month history of feeling dizzy and lightheaded. She admits brief syncope once. These episodes often occur when she gets out of bed and after dinner. She admits some general weakness but feels well. She denies seizures, headaches, numbness, paresthesias, and gait or balance disturbances. She did some routine labs for a health fair last month and reports all values returned normal. PMH is non-contributory. She is menopausal, with no medications, surgeries, or allergies. She is retired, lives with her husband, and does not exercise regularly. On physical exam, her blood pressure is taken both lying supine and then again 3 minutes later standing upright. Readings are 110/78 mm Hg supine and 82/63 mm Hg standing. Mucous membranes are moist, and skin turgor is good. The patient's physical exam, including cardiovascular, pulmonary, and neurological, are normal. Electrocardiogram is normal.

Liberal salt and fluid intake

A 50-year-old man with a history of DM and CKD presents to your office for a follow-up appointment for his hypertension. He reports some non-specific muscle weakness, so you decide to perform an ECG. The ECG demonstrates peaked T waves in several leads without any other abnormality. His labs reveal BUN 12, CO2 22, creatinine 1.0, Glucose 97, K 7.2, Cl 101, and Na 137.

Lisinopril

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and ankle swelling. Symptoms started 6 weeks ago; she dismissed them as stress-related, but they have worsened in intensity and frequency. She becomes short of breath with any exertion, such as climbing stairs. She feels like she may pass out and has to sit when she gets lightheaded. Her breathing is worse when lying down. She denies productive cough, fever, or chest pain. She notes she has had no medical care in the past few years and is post-menopausal. She denies any other past medical or surgical history. Social history is unremarkable. Vitals are notable for pulse 101, BP 158/98, and BMI 28.5. Exam reveals bibasilar crackles and 2+ pitting edema of the lower extremities.

Lisinopril

A 70-year-old woman presents after collapsing at work. She has a medical history significant for a mood disorder that causes her to have wild mood swings and reckless behavior. She was diagnosed with this disorder 1 year ago and has been taking her prescribed medication. She was recently hospitalized for acute gastroenteritis that was complicated for acute renal failure. Shortly after this, she reports experiencing nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevation in BUN and creatinine and elevated serum drug levels, but the results are otherwise normal.

Lithium

A 67-year-old man presents with the complaint of a "tender bulge in his right dominant arm" following an attempt at lifting his couch 2 days ago. He admits to having mild chronic shoulder pain and taking ibuprofen (Motrin) for relief. While attempting to lift the couch, he felt a snap in his shoulder and noticed a bulging in his anterior arm.

Long head of the biceps brachii tendon rupture

A 12-year-old boy with cystic fibrosis (CF) presents for a periodic evaluation visit. Weight gain has been stable, but he has had three pulmonary exacerbations in the past year. His participation in physical activity has decreased during that time because his parents believe that exercise will be detrimental to him in his weakened condition. He has many friends who participate in athletics and physical activity, however, and he would like to join them. Past medical history is otherwise unremarkable except for occasional episodes of sinusitis. Vital signs reveal a respiratory rate of 20 at rest, with scattered crackles and wheezes at both lung bases. Pulse oximetry is 93% at rest.

Long-term exercise training should be initiated.

A 16-year-old boy presents following the striking of a wooden door with a closed fist an hour ago when he was angry at his mother. He is neurovascularly intact, and the skin is closed. There is an obvious deformity with a loss of small finger metacarpal knuckle. Radiographs reveal an oblique mid-shaft fracture of the fifth metacarpal with a palmar angulation of 45°.

Look for finger malposition when the fingers are flexed into the palm.

A 31-year-old man with a known generalized seizure disorder is brought to your emergency department. His friends tell you that the patient had a seizure and did not wake up. When he did not wake up after 30 minutes, his friends called 911. On examination, he is breathing and his heart is beating. He is warm, dry, and pink. His basic laboratory values are within normal limits, and the computerized axial tomography (CAT) scan of his brain is unremarkable. An emergency electroencephalogram (EEG) is not available. His only medications are phenytoin and phenobarbital.

Lorazepam (Ativan)

A 12-year-old boy presents with acute onset of 3 hours of severe pain in the right testis rated 8/10, associated with nausea and scrotal swelling. He never had such pain in his life, and he denies any problem in urination. He has never been operated on, and he denies any history of trauma. On exam, he is in visible distress. Temperature 37°C, heart rate 95 bpm, and blood pressure 120/70 mm Hg. Genital examination reveals enlargement and edema of the entire scrotum. The right testicle is erythematous and tender to palpation; it appears to sit higher and lies horizontally in the scrotal sac relative to the left side. The cremasteric reflex is absent ipsilaterally, and there is no relief of pain upon elevation of the scrotum (Prehn's sign). Labs show a hemoglobin 14.5 g/dL, WBC 13,000/mm3, platelets 210,000/mm3, sodium 140 mmol/dL, potassium 3.8 mmol/dL, chloride 95 mmol/dL, urea 25 mg/dL, and creatinine 0.9 mg/dL.

Loss of cremasteric reflex

A 19-year-old man presents with pain of his right dominant shoulder. He injured the shoulder while he was trying to block a basketball. Physical examination is remarkable significant pain and resistance to passive arm movement. His arm is abducted and externally rotated to minimize pain.

Loss of normal surface contour of the shoulder

A 56-year-old woman presents with sudden onset of palpitations, trembling, sweating, anxiety, headache, and confusion that started 1 hour ago after a 5-mile early morning run. She has had similar episodes in the past, but never any symptoms this severe. Sometimes she wakes up in the morning with headaches and trembling, but they usually go away after she has gotten ready and has breakfast. On physical exam, she is found to have heart rate 114, blood pressure 125/86, respiration rate 18, weight 160 lb, and temperature 98.7°F. Patient is alert and appears somewhat anxious and diaphoretic but otherwise well. HEENT exam is unremarkable. Cranial nerves, cerebellar function, strength, sensation, deep tendon reflexes, and balance testing/Romberg are all normal. Patient is tachycardic, but S1 and S2 are normal with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. EKG shows sinus tachycardia. Lab work is significant for a glucose level of 36.

Low C-peptide levels

A 57-year-old woman presents with pain and swelling in her left leg. Her chart shows a history of osteoarthritis of the knees, mild hypertension, and type 2 diabetes mellitus that is controlled on medication. She was well until 1 week ago when she noted a bulge behind her left knee. Yesterday, she woke up with pain, redness, and swelling in her calf and stayed in bed most of the day with her leg propped up on a pillow. She has had no fever or chills, no new pain or swelling in her right leg, no shortness of breath, and does not otherwise feel ill. She denies recent travel or immobility. Vital signs are within normal limits. Significant on her physical exam is a red warm swollen left calf with trace pitting. There is no swelling in the thigh or toes, feet are warm and pedal pulses are intact. The left calf is tender to palpation posteriorly and is 1 cm larger than the right calf on measurement. The rest of her exam is unremarkable. A sensitive assay D-dimer blood test is negative.

Low due to negative sensitive D dimer test. Consider ultrasound to further evaluate knee.

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills, and obsessive and compulsive characteristics; symptoms have been evident to his mother and multiple teachers at school. There have been numerous episodes. The patient has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last 4 months.

Low frustration tolerance

A 75-year-old man presents to his pain management office for follow-up after a lumbar laminectomy 2 weeks ago. He states that he has had a fever for the past 6 days. He denies any headache, chest pain, shortness of breath, cough, abdominal pain, nausea, diarrhea, vomiting, or extremity pain. He has a past medical history of hypertension, hyperlipidemia, chronic lumbar stenosis (now status post laminectomy), and type 2 diabetes mellitus. He also has a history of intravenous drug use. He was referred for an MRI of the spine, which revealed destruction of the vertebral body of L4 with significant collapse.

Lower back pain

A 5-month-old male infant presents after a seizure involving all four limbs. His mother tells you that he was born full term without any complications, and he was well until 2 days ago when he developed a fever. He vomited multiple times yesterday and was irritable. He has not had diarrhea or a cough. He was given antipyretic medication for his fever. He has no known allergies. His immunizations are up to date. His developmental milestones have been in accordance with his age. On physical exam, temperature is 102.7°F, pulse is 154/min, BP is 90/50 mm Hg, RR is 20/min. He is lethargic and pale; there are no focal neurological deficits. Non-contrast CT of the head is unremarkable. You suspect that he has bacterial meningitis.

Lumbar puncture

A 17-year-old boy presents with pain in his wrists, elbows, and knees bilaterally. He has felt fatigued, and he has been unable to work his summer job as a cashier and bagger in his family's community grocery store for the past 2 weeks. He also reports intermittent fevers and a large rash on his back in the area of his right shoulder. All of these symptoms have emerged in the last 4 weeks after a week-long backpacking trip in upper state New York. He has no significant past medical history. His only medication is acetaminophen daily for joint pain. He does not use tobacco, alcohol, or illicit drugs. He has no known allergies. Physical examination reveals a thin male adolescent in no acute distress. Temp 99.1°F, P 100 bpm, RR 14, BP 120/70 mm Hg. Small non-tender mobile lymph nodes are palpable in the neck and axilla bilaterally. There is a large warm erythematous patch with central clearing at the patient's posterior right shoulder region; it extends across the arm and axilla and measures approximately 25 cm in diameter. There is limited range of motion in his right wrist and left elbow. There were no gross focal neurologic deficits.

Lyme disease

A 73-year-old man presents with the inability to actively raise his left non-dominant arm to reach his kitchen cabinet. This began a month ago after his shoulder pain improved. He had a history of pain in that shoulder for over 6 months that kept him from sleeping on the left side and the pain would often wake him. There was no specific injury he can recall, but he felt a pop a month ago while taking out the trash.

MRI

A 23-year-old man presents with a 2-week history of fever and back pain that radiates from the midline to one side. The patient also has a 1-week history of right lower limb weakness and urinary incontinence. The patient gives history of trauma to the back following a motor accident 1 month ago. Examination by touch and percussion demonstrates localized pain in the spine; you also note neurological losses on the right side of the body that include decreased sensation and weakness. The patient's temperature is 101°F, and his skin is moist.

Magnetic resonance imaging (MRI)

A 27-year-old man presents with knee pain that started while he was playing basketball the previous afternoon. The patient states that he twisted his left knee with his left foot still planted on the floor as he attempted to pass the ball to a teammate. He describes a popping sensation at the time of the injury, but he could still bear weight on his leg. He does not recall any immediate swelling. The morning of presentation, the patient noted swelling of the knee and pain that was significantly worse than it was the day before. He has taken 600 mg ibuprofen for the pain but has experienced only mild relief. Upon examination of the left knee, there is a limitation in range of motion, the presence of medial joint line tenderness, and an effusion. McMurray's test is positive.

Magnetic resonance imaging (MRI)

A 75-year-old man presents with a 4-month history of dyspnea on exertion and a productive cough. He also unintentionally lost 10 lb in 2 months. His past medical history is significant for coronary artery disease and myocardial infarction (MI). He has smoked the occasional cigar over the last few years. He has been retired for 12 years, but he worked odd jobs in construction for 30 years. He also helped his father in the family's auto shop. Vital signs are normal. Physical exam is remarkable for decreased breath sounds in left lower lung fields and dullness to percussion. A chest radiograph shows a left-sided pleural effusion.

Malignant mesothelioma

6 hours after delivery, a 25-year-old primigravida presents with fullness and pain in the lower abdomen. Her pregnancy was normal; labor was induced with misoprostol and progressed normally during the first stage; episiotomy was performed 2 hours after second stage had started; and the third stage of labor was normal. The newborn weighed 3800 g, and APGAR score was 9, 9, and 10 in 5 minute intervals. Postpartum visually estimated blood loss is about 550 mL (normally ≥500 mL in the first 24 hours after delivery). She did not void after the delivery. On examination, her vitals are stable and her bladder is overdistended.

Measurement of urine volume

A 45-year-old man presents with episodic attacks of headache, recurring bouts of palpitations, anxiety, and sweating. He also gives history of a severe attack 1 week ago while he was having wine and cheese with his wife. On further questioning, he comments that he gets lightheaded when he stands up too rapidly. He comments that his mother had similar problems. On physical examination, his blood pressure is 165/90 mm Hg and his heart rate is 80/min. A 24-hour collection of his urine tests positive for vanillylmandelic acid. Imaging studies showed bilateral adrenal medullary hyperplasia. Further workup showed hypercalcemia, hypophosphatemia, and increased parathyroid hormone levels.

Medullary carcinoma of the thyroid

A 50-year-old obese woman presents with severe left knee pain. She states the pain began about 8 months ago but has gotten significantly worse in the last 3 months. The patient denies any trauma or event that initiated the pain. She notes stiffness in the knee first thing in the morning; it only lasts around 5-10 minutes. The knee pain worsens with activity and is relieved with rest. The patient's medication list includes lisinopril 10 mg once daily for high blood pressure. She has a documented medication allergy to acetaminophen, which gives her hives. Physical examination reveals a female with a BMI of 40, limited range of motion of the left knee, and crepitus.

Meloxicam

A 42-year-old woman has a 12-month history of amenorrhea. She noticed she has been having hot flashes and night sweats, loss of libido, and vaginal dryness. Upon physical exam, no abnormal findings are found except some dry skin. Upon lab results, elevated serum FSH level >30 mIU/mL. Her TSH and prolactin are normal and her serum HCG is negative. Her 24-hour urinary free cortisol is 11 μg/24 hr, within the normal range of 10-100 μg/24 hr. Her serum IGF-1 level is in the normal range for a 42-year-old (90-360 ng/mL). Her levels of ACTH are within normal limits.

Menopause

A 50-year-old woman with no significant past medical history presents for an annual pelvic exam. Her last menstrual period was over 6 months ago, and the last few occurrences of menses were extremely irregular. The patient also describes having the sensation of intense heat in the face and trunk accompanied by sweating. She also states that her "heat episodes" have been occurring 1-2 times weekly for several months. She denies any other symptoms. She has received her annual pap and pelvic examination yearly and a clinical breast exam without any issues. On pelvic examination, you note obvious vaginal thinning, excessive dryness, and apparent vaginal wall atrophy.

Menopause

An otherwise healthy 50-year-old man is brought to your office, located in a small town in the foothills of the Appalachian mountains, by his daughter. The daughter reports that her father has been more lethargic than usual, and she states that she has seen him go into the backwoods and return obviously inebriated. You suspect that he is drinking moonshine from a homemade still and that it is leaching poisonous metals/substances into the distillate. The patient is morose and has difficulty answering questions. The rest of the physical exam uncovers no other abnormalities. The blood gas analysis shows a pH of 7.3, a pCO2 of 30 mm Hg, and a bicarbonate of 15 mEq/L. Further laboratory testing revealed sodium of 140 mEq/L and a chloride of 100 mEq/L.

Metabolic acidosis

A 50-year-old woman presents with right-sided pleural effusion. Thoracentesis shows the presence of exudative serosanguineous pleural fluid and positive cytology.

Metastatic infiltrating ductal carcinoma

A 33-year-old woman presents for routine follow-up with an abnormal computed tomography (CT) that was done due to gradual worsening exertional dyspnea. Her past medical history includes a leg amputation 4 years ago for osteogenic sarcoma treated with neoadjunctive chemotherapy. She is married and a lifelong nonsmoker. Her physical exam includes a BP 111/67 mm Hg, pulse 70/min, respirations 14/minute, temperature of 98.4°F. She is in no acute distress. Pulmonary exam reveals clear breath sounds bilaterally. There is a healed laparotomy incision for a colon resection from perforated diverticulitis several years ago. A chest CT demonstrates a new solitary irregular non-calcified 3 cm nodule.

Metastatic osteogenic sarcoma

A 68-year-old man presents with acute chest pain. He has a 20-year history of diabetes mellitus and 10 years of hypertension. He has no history of coronary artery disease, but he has hyperlipidemia. His medications include atenolol 50 mg daily, metformin 1000 mg twice daily, aspirin 80 mg daily, and simvastatin 40 mg daily. On arrival, he has a temperature of 99°F, a pulse of 106 bpm, BP 100/60 mm Hg, and a respiratory rate of 26/min. His lungs have fine crackles bilaterally, heart sounds are heard with tachycardia, and abdomen is essentially normal. The patient is diagnosed with acute myocardial infarction.

Metformin-induced lactic acidosis

A 65-year-old woman presents with fatigue, loss of energy, decreased appetite, low-grade fever, muscle and joint aches, and stiffness. She has glucose-6-phosphate dehydrogenase (G6PD) deficiency and a history of coronary artery disease. On examination, you find swollen, painful, tender small joints in a symmetrical pattern. Laboratory evaluation reveals positive rheumatoid factor and antibodies to cyclic citrullinated peptides.

Methotrexate

A 7-year-old boy presents with his parents for evaluation of behavior problems in school; the problems have been ongoing for over 6 months. The boy's teacher recommended he be evaluated. The teacher reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents agree that they have seen similar traits at home for several years, such as forgetting to do daily activities and being easily distracted. They view him as a bright happy boy who is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and he then looks to the window for a short while before interrupting his parents.

Methylphenidate

A 54-year-old man with emphysema presents with a blood pressure of 157/101 mm Hg. Over the next several months, he is prescribed angiotensin-converting enzyme inhibitors, diuretics, and calcium channel blockers, but the patient has to discontinue each agent because of undesirable side effects. He is prescribed a beta antagonist instead.

Metoprolol

A 3-year-old girl presents with a 2-week history of a pruritic erythematous excoriated rash. Her past medical history is unremarkable. Her only medications include a topical steroid ointment and oral diphenhydramine. She has no known allergies. She lives on a farm on the outskirts of her town. She does not attend daycare and lives with three older siblings and her parents. There are cats and dogs in the house, which appear to be in good health. Her physical exam is significant for small red papules in her interdigital spaces, wrist flexors, anterior axillary folds, and forearms. Scattered red-brown nodules are found in her axillary region.

Microscopic examination of skin scrapings

An 18-year-old woman presents with a history of recurrent headaches that mainly occur above her right eye. She describes them as "throbbing" in quality. During these headaches, she gets bouts of nausea and vomiting. After a nap, she typically feels better. The headaches only last a few hours, and she experiences them roughly 2 times a month.

Migraine

A 74-year-old man presents to discuss difficulty with orientation, memory, and word-finding. The orientation problems are worse at night. His problems began with mood and behavioral changes 7-8 years ago, after his brother passed away. He reports no trouble with activities of daily living. The patient has only an elementary school education, stating that he was "not smart enough to go to college." There is no family history of dementia.

Mild cognitive impairment

A 76-year-old woman presents because her children are concerned that she might have dementia. She states that she is doing reasonably well, except that she sometimes sleeps less deeply and wakes up more often than she did several years ago. According to her children, she is slower than before, and her memory has been getting worse over the last 3 years; she has difficulties recalling the specific date of an event (although she can describe the event itself). She also has a great deal of trouble with names, but she can easily recognize people. She always says, "It is on the tip of my tongue, but..." Aside from hypertension that is under control, she does not have any other health problems. She has been a widow for about 10 years. Her older brother was diagnosed with dementia. Physical examination today is within normal limits for the age, and neurological examination is non-focal.

Mini-mental status examination

A 22-year-old woman presents for a physical examination. When questioning her for medical history, you discover that she has a history of rheumatic fever. Upon listening to her heart, you detect a diastolic murmur. The murmur is low-pitched and begins with a loud snapping sound.

Mitral stenosis

A 35-year-old Costa Rican woman emigrated to the United States 5 years ago. She presents to the office due to chronic progressive dyspnea. She reports no chest pain, fever, or cough and is a non-smoker. Her daily activities are becoming increasingly limited due to her shortness of breath. On auscultation, she has an accentuated S1, a loud opening snap, and a diastolic murmur heard best at the apex in the left lateral decubitus position. She has 1+ ankle edema bilaterally.

Mitral stenosis

A 49-year-old woman presents due to gradual onset of reduced exercise tolerance while working out at the gym. She is afebrile and otherwise feels well. Cardiac exam reveals a III/VI diastolic rumbling murmur located at the apex; it is heard best in the left lateral position.

Mitral stenosis

An 80-year-old woman has a history of a myocardial infarction about 5 weeks ago. The patient now presents to the ED with a history of congestive heart failure with symptoms of shortness of breath and peripheral edema, which appear to be worsening since her MI. An ECG is conducted, which reveals a prior inferior wall infarct. Cardiology is consulted where a 2-dimensional echo is conducted, displaying severe leaflet tethering and an enlarged left ventricle.

Mitral valve

A 22-year-old woman presents due to palpitations. She denies chest pain and shortness of breath; she has not had any recent infections. Aside from a tonsillectomy as a child, she has no significant past medical history. Examination reveals a thin woman in no acute distress. Lungs are clear to auscultation bilaterally. Cardiac exam reveals a mid-systolic click.

Mitral valve prolapse

A 24-year-old woman with a past medical history of mild scoliosis presents with palpitations, occasional chest pain, and dizziness upon standing from a supine position. Her symptoms have been ongoing for a while, but the patient's parents finally convinced her to come be evaluated. On cardiac auscultation, a mobile mid-to-late systolic click and a late systolic murmur heard best at the apex is noted; no other abnormalities are found. Blood pressure was 112/68 mm Hg.

Mitral valve prolapse

A 30-year-old woman with no significant past medical history presents with a history of recurrent palpitations. These episodes occur primarily upon exertion. She recalls periodic bouts of anxiety, panic attacks, and lightheadedness. She denies fever, chills, changes in weight, chest pain, shortness of breath, rashes, diaphoresis, abdominal pain, nausea, and vomiting. She denies any history of cigarette smoking, drug, or alcohol use. Her physical exam revealed normal vital signs. The cardiac exam revealed a high-pitch late systolic click at the apex. The valsalva maneuver and a standing position result in prolongation of the murmur and a movement of the click to earlier in the cardiac cycle. The remainder of her examination is normal.

Mitral valve prolapse

A 44-year-old woman with insulin-dependent diabetes presents with a 5-day history of weakness, polyuria, polydipsia, and frequent vomiting. A physical exam reveals a pale ill-appearing woman in moderate distress. Vitals: BP 85/55 mm Hg, P 130/min, RR 18/min, T 37.3°C. She has dry mucous membranes and diffuse abdominal tenderness. Room air blood gas shows: pH 7.01, PCO2 19 mm Hg, PO2 85 mm Hg. Her glucose is 590 mg/dL, Na is 131 mEq/L, Cl is 85 meq/L, HCO3 is 10 mEq/L, BUN is 29 mg/dL and serum creatinine is 1.7 mg/dL.

Mixed anion gap metabolic acidosis and metabolic alkalosis

A 35-year-old man presents with right shoulder pain that is becoming progressively worse. He expresses concern that, although he visits the gym 3 times a week, over the past month he has not been able to increase the amount of weight he lifts secondary to the shoulder pain. He has not tried anything to alleviate the pain. The pain is at its worst at night while he is trying to sleep. He also reports pain while in the shower washing his hair or using the shoulder press machine at the gym. He denies any history of recent trauma or sports-related injury; however, upon questioning, he reports that about 1 month ago he and his wife painted their entire house in a weekend. Upon physical exam of the shoulders, no swelling, atrophy, redness, or bruising is noted. Point tenderness is noted over the right lateral deltoid muscle. Active ROM of the right shoulder at 80 degrees of abduction elicits pain. Patient has a negative drop arm test, negative apprehensive test, and a positive Neer impingement test of the right shoulder.

Modification of activity, NSAIDs, and physical therapy

An 83-year-old woman is currently in a nursing home following a short hospitalization for a CVA. She experienced a thromboembolic stroke 2 weeks ago, which resulted in right hemiparesis and dysphagia. Other medical problems include congestive heart failure, atrial fibrillation, osteoarthritis, and depression. The nursing staff contacts you to reports a sacral pressure ulcer measuring 3 x 2 cm. On physical examination, there appears to be interruption of the epidermis with an abrasion. The lesion is clean; there is no cellulitis.

Moist dressing

A 68-year-old man with a history of obesity, hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest, making it difficult to walk short distances. He also notes orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. He is acutely dyspneic, afebrile, tachypneic, and diaphoretic. There is a diminished first heart sound, S3 gallop, and laterally displaced PMI; the lungs have bibasilar rales. Abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. A chest X-ray reveals pulmonary vascular congestion.

Monitoring of hypertension and valvular dysfunction

A 60-year-old man presents with sharp pain in his ribs and sternum; he has a history of allergies and has been sneezing frequently. Except for a heart rate of 120/min, the physical examination is normal. With the exception of a tonsillectomy as a child, his medical and surgical history is unremarkable. He has chronic seasonal allergies. Family history reveals nothing significant. Radiographs on the ribs and sternum reveal lytic lesions and a significant fracture of the sternum. Neurological examination is unremarkable.

Multiple myeloma

A 65-year-old woman presents with pain in the back, chest, and at the right seventh rib. She appears to be quite pale, and she admits to fatigue. These symptoms have come on gradually over several weeks, with the back pain becoming the reason for consulting the physician. Physical examination reveals localized tenderness at the spine of T8 and ribcage with tenderness at the right seventh rib. CBC shows a normochromic normocytic anemia with hemoglobin of 8 g/dL. Peripheral smear shows marked rouleaux formation with normal platelet and white cell counts and morphology. Serum chemistry results include calcium elevation to 12.2 mg/dL with normal alkaline phosphatase. A dipstick urinalysis shows proteinuria. A bone marrow aspirate was dry. The bone marrow biopsy is pending. Plain film X-rays of the chest show a fracture of the right seventh rib and compression of the eighth vertebra.

Multiple myeloma

A 70-year-old African American man with a PMH of HTN x 23 years and type 2 DM x 20 years was admitted to the hospital due to a high-grade fever, nausea, infection, and severe back pain. Nearly 2 years prior, while walking down his steps, he fell without incurring any apparent fractures. Since then, he has been experiencing mild back pain that worsens when coughing. Physical exam is significant for pallor and hepatosplenomegaly. Skin exam is normal. Lab reports reveal low red blood cell count but normal neutrophil and platelet count. Renal function is decreased. The serum protein electrophoresis reveals the presence of paraprotein. Bone marrow biopsy reveals 50% infiltration by plasma cells.

Multiple myeloma

A 24-year-old man with HIV-positive status for 2 years presents due to an ongoing chronic cough for the past 8 months. He admits to a mild fever that comes and goes during that period. A 5 lb unintentional weight loss is also discovered since his last visit to your office, which was approximately 9 months ago. He states he has noted an increased amount of breathlessness with simple activities that were never bothersome before the cough began. The patient denies smoking, and his TB test is negative.

Mycobacterium avium complex

A 25-year-old man presents with back pain and stiffness. He states he has had longstanding issues with back pain. He denies any trauma to his back. He has noticed associated increasing stiffness and general fatigue. He feels that these issues have gradually worsened over the last several months and are more persistent recently. He notes that the pain is much worse first thing in the morning, rating it a 6-7/10. Radiation occasionally occurs into the buttock areas and the patient feels the symptoms actually lessen with activity. Physical examination shows marked forward stooping of the thoracic and cervical spine with the lower spine showing the presence of a substantial reduction in lateral flexion.

NSAIDs

A 40-year-old woman presents because of a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting but does admit to having a Colles' fracture in this arm around 2 months ago. She denies any injury to her back, neck, or other musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing with an extremely diffuse, uncomfortable aching accompanying it. She further states that this limb has become extremely sensitive to touch and to cold, and it does appear somewhat more swollen than her left arm. The patient is very upset because she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker, does not drink, and exercises 3 times a week. Physical examination conducted of the extremity reveals a slightly cyanotic, mottled right arm with generalized pain of the entire extremity. Pulses are faint (1+) and ROM is limited.

NSAIDs

A 40-year-old woman presents with a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting, but she does admit to having a Colles' fracture in this arm around 2 months ago. She denies any injury to her back, neck, or any other musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing; there is an extremely diffuse and uncomfortable aching accompanying it. She further states that this limb has become extremely sensitive to touch and cold, and it appears somewhat more swollen than her left arm. The patient is very upset because she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker, does not drink, and exercises 3 times a week. Physical examination of the extremity reveals a slightly cyanotic, mottled right arm with generalized pain of the entire extremity. Pulses are faint (1+), and ROM is limited.

NSAIDs

A 52-year-old woman who lives a non-sedentary lifestyle presents with a 5-day history of low-grade fever, flu-like syndrome, sore throat, and malaise. She has to catch her breath because of pain on inspiration and when coughing. She has no known past medical or surgical history; she is not on any medication, and she has no pertinent family history. She denies any medication use, including over-the-counter medicines. On physical examination, her vitals are: temperature 100.6°F, pulse 86/min, BP 133/75 mm Hg, and RR 20 cycles/min. She has shallow breathing, resonant percussion notes, fair air entry with vesicular breath sounds, and friction rub. Her blood gas on room air is as follows: pH 7.36 PCO2 44 mm Hg PO2 100 mm Hg HCO3 26 mEq\L O2 saturation 99.8% Her chest X-ray (CXR) and D-dimer assay are normal.

NSAIDs

A 52-year-old overweight woman has had pain in her right hand for the past month. She is employed as a pastry chef and has trouble making a fist. On exam, she is tender over the radial styloid. You have her flex her thumb into her palm and move the wrist into ulnar deviation. This movement recreates her pain.

NSAIDs and thumb spica splint

A 40-year-old woman presents with a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting, but she admits to having a Colles fracture in this arm about 2 months ago. She denies any injury to her back, neck, or other components of the musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing with an extremely diffuse and uncomfortable ache accompanying it. She further states that this limb has become extremely sensitive to touch and cold; it appears somewhat more swollen than her left arm. The patient is very upset because she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker. She does not drink alcohol, and she exercises 3 times a week. Physical examination of the extremity reveals a slightly cyanotic hue and generalized pain of the entire right upper extremity. Pulses are strong (2+), but due to the pain, the patient states ROM is limited.

Naprosyn 500 mg twice daily

A 48-year-old Caucasian man presents with severe epigastric pain radiating to the back after a bout of drinking. He seeks medical attention and receives treatment. Symptoms improve within 5 days. 4 weeks later, his symptoms return with epigastric pain, weight loss, and decreased appetite. A repeat ultrasound shows a round thin-walled hypoechoic lesion near the pancreas tail measuring 4 cm in its largest diameter and with some calcifications in its walls. MRCP visualized a communication between this cavity and the pancreatic duct, which confirms the suspected diagnosis.

Nasogastric feeding

A 7-year-old boy presents to the ED with a 2-hour history of epistaxis. He has a history of several nosebleeds, which usually respond to pinching of the nose, but this episode has continued. The patient is known to pick his nose and has had some cold symptoms recently. He did not experience excessive bleeding at circumcision, and there is no family history of bleeding disorders. On exam, he is alert and responsive to questions. Heart rate 120 bpm; respiratory rate 20/min; blood pressure 105/64 mm Hg; oxygen saturation 97% on room air. There is continuous active bleeding from his left nostril. On examination of the nose, no obvious bleeding site can be visualized in the anterior part of the nasal cavity. He receives phenylephrine and nasal packing after the initial evaluation, and his bleeding finally stops.

Nasopharyngoscopy

A 50-year-old man was playing baseball with his company team last weekend and is now experiencing severe pain in his left shoulder. He states that he has been the team pitcher for several years now. He has developed pain progressively in his left shoulder over the last few months. He denies any numbness or tingling in his arm, hand, or fingers of his left upper extremity.

Neer test

A 54-year-old man presents with acute onset of excruciating pain in his right toe. The patient states the pain began shortly after dinner, and it has progressively worsened since then to the point where he is now unable to bear weight on the affected side. In addition, he explains that aside from occasional backaches, he has never experienced pain like this before. He reports overall good health and aside from a multivitamin, he uses no medications or supplements. On exam, the patient's right foot is swollen, and the joint of the great toe is tense and inflamed. His temperature is 37°C, blood pressure is 155/85 mm Hg, and pulse is 103 beats per minute. Labs reveal an elevated serum uric acid level.

Negatively birefringent needle-shaped crystals

A 20-year-old male college student presents with fever, chills, malaise, headache, photophobia, confusion, and numerous petechiae on his extremities and trunk. On examination, he has positive Brudzinski and Kernig's signs. A CT scan of the head is within reference limits. A lumbar puncture reveals increased leukocytes, particularly polymorphonuclear neutrophils, increased protein, and decreased glucose levels. Gram staining of the CSF reveals Gram-negative cocci in pairs.

Neisseria meningitidis

A 4-year-old boy currently hospitalized with pneumonia develops vomiting and stiff neck. The new symptoms are followed by a seizure. On physical examination, he is febrile and has signs of meningeal irritation. A lumbar puncture is done to determine if he has meningitis.

Neisseria meningitidis

A 44-year-old man presents for follow-up of poorly controlled type 1 diabetes mellitus that was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist?

Neovascularization

A 13-year-old boy presents for an annual examination; he reports no problems with his health. Upon physical examination, his body temperature is 98.3°F, his blood pressure is 150/100 mm Hg, and he shows a slight periorbital puffiness. He explains that recently he has been staying up late to read and has noticed "puffy eyes" in the morning. Urinalysis indicates light brown urine, low-level proteinuria, and no bacteriuria.

Nephritic glomerular disease

A 43-year-old Caucasian man with a 20-year history of bipolar disorder presents for the first time with long-term polyuria and polydipsia. He previously took lithium for mood stabilization for 15 years before initiating divalproex sodium therapy. He stopped using lithium because of the polyuria, but he felt that the polyuria never fully subsided. His weight is stable, and he has no other urinary complaints. His blood pressure is 115/80 mm Hg, and his physical exam is normal. His urinalysis shows no blood, cells, protein, glucose, nitrate, casts, or crystals.

Nephrogenic diabetes insipidus

A 54-year-old man notices that he has very large urine output and he is constantly thirsty. In addition to urinating large volumes during the day, he awakens at night to urinate. He has a 25-year history of a bipolar disorder, which is treated effectively with lithium. His lab results are as follows:

Nephrogenic diabetes insipidus

A 40-year-old woman presents to the emergency department with unremitting left flank pain. She denies dysuria or fever. She notes that her urine output has decreased over the last few days. As you observe the patient, she is writhing on the gurney and unable to find a comfortable position. On further inquiry, the patient states that she has been trying to lose weight by increasing protein in her diet, exercising, and decreasing her normal fluid intake. On urinalysis, red blood cells are noted. All other labs are within normal range.

Nephrolithiasis

A 12-year-old African American boy presents with a 1-month history of poor appetite and has complained of overall not feeling well. When questioned, the boy cannot delineate any specific symptoms except that he feels "puffy." He denies pain, eating disorder, rash, depression, drug use, and fevers. The family denies recent travel. His PMH is unremarkable with no recent or chronic illnesses. He has had no surgeries, and he takes no medications. His family history includes grandparents on both sides with hypertension, with one of these grandparents also having died from some type of kidney problem. His ROS is entirely negative except for the above symptoms and some noted change in urine, which he describes as frothy. He denies dysuria, gross hematuria, polyuria, and nocturia in the ROS.On physical exam, his vitals are: Tem: 97.9°F; Resp 14; HR 90; BP 120/74 mm Hg right arm sitting. It is noted weight is up 2 pounds from his charted weight 3 months ago. HEENT, neck/thyroid, lungs, cardiac, abdominal, musculoskeletal, neurological and derm exams are unremarkable. Examination of extremities reveals bilateral 1-2+ edema in the upper and lower extremities, with 2+ pulses.

Nephrotic syndrome

The effect of steroid therapy is evaluated in an 8-year-old Caucasian boy being treated for fatigue and generalized edema following a "bad cold." His vitals are T 37°C, pulse 90/min, RR 20/min, and BP 110/70. Physical exam reveals the presence of mild periorbital edema and marked peripheral edema in hands and feet with the remainder of the exam within normal limits. Lab values include Dipstick urine protein 3+; urine protein 50 mg/m2/hr (<40 mg/m2/hr) Specific gravity 1030 (1008-1020) Urine protein/creatinine ratio 2.0/mg creatinine (<0.2/mg creatinine) Serum albumin 3.9 (5.9-8.0 mg/dL) Cholesterol 250 (112-247 mg/dL) Remainder of laboratory values including BUN and plasma creatinine are within normal limits.

Nephrotic syndrome

A physician assistant has just joined a family medicine practice that has been around for more than a decade. This practice consists of a family medicine physician and a nurse practitioner. The physician assistant was asked to review two candidate applications for the position of receptionist. He notices that one candidate has the same last name as the physician. The candidates are both reviewed by the physician. The next morning, the new receptionist reveals that the physician is their cousin.

Nepotism

A 32-year-old Latinx woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications and is gravida 4, para 4, Ab 0. She is married and recently emigrated to the US from Central America. Vital signs: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. Patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The following morning, the patient is found to be alert, oriented, and afebrile.

Neurocysticercosis

A 50-year-old man presents for the evaluation of a 1-year history of progressive cognitive, motor, and behavioral problems. He complains of inattention, reduced concentration, slowing of processing, and difficulty changing mental sets. What started as slow movements now is clumsiness and problems with coordination. His friend states that the patient is "not himself anymore" and has become apathetic, non-communicative, and "down." He is HIV-positive and was diagnosed with AIDS 2 years ago because of the presence of Pneumocystis carinii with CD4 of 100. He had an excellent response to antiretroviral therapy, however, and his last CD4+ lymphocyte counts were normal and viral load undetectable. On examination, you find an apathetic male in mild distress. Neurological exam shows loss of coordination, unsteadiness, generalized weakness (more pronounced in legs), ataxia, and tremor.

Neuroimaging methods

A 55-year-old male firefighter suddenly develops fever, palpitations, and shortness of breath 7 days after skin transplant for severe facial burns. He also has fever resistant to intravenous antibiotics therapy introduced at the onset of fever. Because of oropharyngeal lesions, he is on parenteral nutrition. On examination, transplant shows neither signs of infections nor signs of rejection. Patient appears lethargic, with a blood pressure of 80/40, pulse rate of 120, respiratory rate of 18, and temperature of 103.4°F. Stat CBC shows neutropenia and eosinophilia.

Neutropenia

A 30-year-old man presents with a 1-week history of a painful tongue. He has been having diarrhea and forgetting things more easily. He recently emigrated from India and lives alone on a maize-based diet. On examination, you note that the tip and margins of his tongue are a bright scarlet color. He also has a symmetrical erythematous rash on his forearms.

Niacin deficiency

A 62-year-old woman presents with extreme fatigue and shortness of breath. The symptoms began about 24 hours ago and have progressively worsened within the last 4 hours. Vital signs on arrival are as follows: HR 90 beats per minute; BP 165/72 mm Hg; RR 16/min; SpO2 98% on 4 L/min supplemental oxygen by nasal cannula. 12-lead ECG demonstrates ST-segment elevation of 2 mm in leads V4-V6.

Nitroglycerin

A 65-year-old African American man with a past medical history of hypertension, hyperlipidemia, and diabetes experiences substernal chest pain while shoveling snow. The patient says the pain started after 10 minutes of shoveling wet snow and eventually resolved after he sat down and rested. The patient described the pain as a "heaviness" that did not radiate to any other part of his body and as a 4 or 5/10 on a subjective pain scale, and he experienced this discomfort for approximately 1-2 minutes total. The patient's current vital signs are blood pressure 168/98 mm Hg, pulse 92, and respirations 16.

Nitroglycerin 0.4 mg SL

A 32-year-old man presents with pain in his back, buttocks, and posterior thighs for 2 days after lifting a heavy load at work. He denies pain when sleeping unless he rolls over in bed. He also has pain with just standing or sitting still in a chair. He denies any radicular symptoms or bladder or bowel dysfunction.

No diagnostic tests required

A 43-year-old man visits the internal medicine clinic of a university hospital presenting with a 3-week history of shortness of breath, fever, and chills. Examination shows a temperature of 38.0°C. Laboratory results suggest hypoxemia with PO2 of 74. Previous history shows the patient has been HIV-1 positive for 4 years and presently has a CD4+ T-cell count of 50/mm3. A presumptive diagnosis of Pneumocystis carinii pneumonia (PCP) is made, which is confirmed by bronchoalveolar lavage.

No findings

A 57-year-old woman is undergoing a workup by her primary care provider for abdominal pain. The pain is in her left lower quadrant, intermittent, "crampy," and has been present for about 2 months. As an initial imaging study, she underwent an abdominal ultrasound. The ultrasound was unremarkable except for the presence of a few small (<1 cm) stones in her gallbladder. She is currently following up to discuss the results of the ultrasound.

No treatment

A 21-year-old woman presents with a 3-month history of a black mole on her right calf. She tells you that the lesion is enlarging and expanding. It began to itch about 3 weeks ago, and it has bled 2 times. She thinks that there may have been a mole near the same spot previously, but she is not certain. Her general health is good; there is no history of chronic illness, hospitalizations, or surgeries. She works as a professional model for a large advertisement agency. She does not take any prescription medication; she does not use tobacco, alcohol, or recreational drugs. Although she has dark hair, she has a fair skin, and she says that she usually burns with even short sun exposure. She does occasionally use a tanning booth prior to modeling events and vacations. There is no family history of skin cancer. VS stable, she looks anxious, but she is otherwise well. There is a dark brown-black nodule on the right calf 1 cm in diameter. On the surface of the nodule, there is a tiny area of crusting. There are no hairs. The nodule is asymmetrical, and its border is sharply demarcated; the color is uniform, and the elevation is regular. There is a narrow (1-2 mm) rim of erythema around most of the nodule. She has a sprinkling (about 25-30 in all) of melanocytic nevi on her trunk and legs. There is no significant local or distal lymphadenopathy. The liver is not palpable. The remainder of the physical examination is unremarkable.

Nodular melanoma

A 43-year-old woman presents with a 6-month history of vague right upper quadrant discomfort. The patient denies any relation of pain to meals and describes it as a dull constant discomfort. The patient was diagnosed with type 2 diabetes mellitus 1 year ago, which is controlled with diet. She does not smoke but admits to drinking a glass of wine occasionally. She denies any medications except for over-the-counter acetaminophen, which she takes occasionally for joint pains. She does not have any family history of chronic liver disease. There is no history of blood transfusions in the past. On physical examination, the patient is obese with a BMI of 31; BP 140/90 mm Hg. The liver is palpable 3 cm below the right costal margin and is slightly tender. No other signs of chronic liver disease are evident.

Non-alcoholic steatohepatitis

A 50-year-old Caucasian man presents to establish care. He has no history of diabetes, hypertension, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, nephrolithiasis, or obstructive uropathy. His only problem on review of systems is musculoskeletal aches. His parents died in their 80s of unknown causes. He has never smoked, taken recreational drugs, had a transfusion, or had unprotected sex. He worked for years as a handyman. His only medication is ibuprofen, which he has taken at several times per week for the past 10 years. His exam is normal. You order some basic diagnostic tests, including a basic serum chemistry panel and a urinalysis. The urinalysis shows microscopic hematuria and a few white cells but no leukocyte esterase or nitrites. His serum creatinine is 1.5 mg/dL. His other tests are normal.

Non-contrast CT abdomen or renal ultrasound

A 36-year-old man presents with severe left flank pain that started at 4 AM. After pacing around his house for several hours and taking ibuprofen and acetaminophen (Tylenol), he comes to the office at 7:30 AM asking to be seen. He describes the flank pain as burning and steady, with some radiation to the left lower abdomen. He has had some nausea, and he unsuccessfully tried to vomit. He has not had any diarrhea or urinary symptoms. He describes his past medical history as negative for significant illnesses or injuries. Physical exam reveals normal vital signs except for tachycardia, a negative heart and lung exam, and a negative abdominal exam. There is no tenderness noted in the CVA regions.

Non-contrast computed tomography

A 48-year-old woman presents after a seizure. Before the seizure, she experienced confusion, disorientation, and poor coordination preceded by nausea, dizziness, flushing, and weakness. Symptoms appeared after bird watching several hours in her garden under the sun. Her medical history is significant for the presence of schizophrenia, for which she takes chlorpromazine at bedtime. Her temperature is 41°C, blood pressure 90/59, heart rate 110, respiratory rate 25; BUN, creatinine, and transaminases are elevated, and there is leukocytosis and lactic acidosis. There is normal urine myoglobin, PT, and PTT.

Non-exertional hyperthermia

A 30-year-old woman presents with episodic headache, palpitations, and sweating. She has had multiple episodes of approximately 20 minutes over the last few weeks. Her primary care physician noted hypertension on her last several visits, and her blood pressure today is 210/98 mm Hg. She has no past medical history.

Norepinephrine

A 19-year-old woman presents with worsening headaches. She reports a multi-year history of episodic throbbing headaches. They have intensified, and she now misses classes and work periodically as a result. The headaches occur about 4-6 times per month recently, up from 1-2 per month when she first started experiencing them. Her headaches last 2-3 days and are accompanied by nausea, vomiting, and light sensitivity. After the headache resolves, she denies any residual symptoms. She denies neurologic symptoms, such as vision or taste changes, gait disturbances, and memory loss. She has tried multiple over-the-counter pain medications without relief. Her mother and maternal aunt experienced similar headaches. She reports some increased stressors and less sleep since recently starting college. Her past medical history is unremarkable, with no known medical conditions (except for the headaches), no surgeries, no chronic medications, and no drug allergies. She has never been sexually active and reports regular menses. She denies the use of tobacco, alcohol, and recreational drugs. On physical exam, the patient appears comfortable and reports no headache at this time. Her entire exam, including neurological, is normal.

Normal magnetic resonance imaging (MRI)

A 70-year-old woman is brought to your attention because of a slowly progressive gait disorder. She has also been experiencing forgetfulness and problems with micturition. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter. She occasionally forgets where she put things and she has forgotten to turn off the oven on 2 occasions. Over the last month, she has started experiencing urinary urgency, the need for frequent urination, and the involuntary leaking of urine. She is worried about these symptoms.

Normal pressure hydrocephalus

A 2-month-old infant who is breastfeeding presents with low hemoglobin levels. The infant was born at home and the mother received no prenatal care; she did not, and does not, take any medications. Family history is unremarkable. On examination, the infant appears healthy.

Normal process

A 66-year-old man presents with vomiting. He has lung cancer, but he has declined treatment. His father died of lung cancer at the age of 65. On examination, he is confused and dehydrated with a BP of 100/50 mm Hg and HR of 100 beats/minute. Laboratory analysis reveals a calcium level of 16 mg/dL. His renal function tests are normal.

Normal saline

A 35-year-old woman just found out she is pregnant. She is experiencing polyuria, but she denies dysuria and incontinence. Her urinalysis is unremarkable. Her fetal ultrasound is normal, and her renal ultrasound shows normal physiological hydronephrosis of pregnancy. Her pre-pregnancy weight was 155 lbs, and she is 5 feet tall. Her calculated body mass index (BMI) is 30.3 kg/m2. She takes no medications. She smokes half a pack of cigarettes per day.

Normalize weight

A 26-year-old woman presents with 20 weeks of amenorrhea. This is the first time she has been to the doctor in 5 years, and she believes she is pregnant. You perform a complete physical examination and cannot auscultate the fetal heart rate. The ultrasound reports a "snowstorm" pattern with placental and fetal remnants missing. The patient tells you she has history of miscarriage "that had something to do with high blood pressure." The doctor explains that she is not pregnant and has a disease related to the proliferation of trophoblasts.

Nutritional deficiency

A 10-year-old boy presents due to a lesion on his gums. For the past 2 days, he has reported soreness around his teeth and inside his cheeks. When his mother looked closely in his mouth with a flashlight, she noted bright red areas and patches of white curd-like lesions. There are no ill contacts in the last few weeks. There has been no fever or shortness of breath. The patient's past medical history is positive for severe seasonal allergies and mild persistent asthma. Daily medications include: pediatric multivitamin, cetirizine hydrochloride 10 mg 1 tablet at bedtime, montelukast sodium 5 mg 1 chewable tablet in the morning, beclomethasone disproportionate HFA 40 mcg 2 puffs twice daily in the am and pm, and albuterol sulfate inhalation powder 2 inhalations every 4-6 hours as needed for wheezing and 15 minutes before physical activity. Examination reveals adherent thick white plaques with underlying erythematous tender mucosa on the gingival and buccal surfaces.

Nystatin suspension Beclomethasone dipropionate

A 63-year-old man presents with pain in both knee joints that began almost 1 year ago. It was mild and present only during activity, but it has worsened and is present during rest. There is no joint stiffness. He has diabetes and has been on insulin treatment for the past 10 years. BMI is 30. Vitals are within normal limits. Examination reveals pale conjunctivae. On examination of the knee joints, there is no tenderness, warmth, or erythema. Pain in the left knee joint is reproduced on walking. You suspect osteoarthritis and order lab investigations and X-ray. Meanwhile, you prescribe exercises and ibuprofen.

Obesity

A 4-year-old Caucasian boy is seen in the outpatient clinic with a 3-week history of generalized rash. Pruritus was minimal; it has resolved, and he has not had a fever. The mother noted that the rash began as a single lesion on the abdomen that grew in size as the rash progressed elsewhere. It is now the largest lesion present. Examination revealed an otherwise well and afebrile child with a generalized rash consisting of scaly reddish-pink plaques concentrated on the trunk in a Christmas tree pattern with the single largest lesion at the abdomen.

Observation

A 9-month-old female infant presents with an acute onset of a rash on her trunk. She has a 4-day history of fever up to 104°F, but the mother states her daughter has no fever today. She has had some diarrheal stools, but no vomiting. No coughing or nasal congestion has been noted. The child has previously been well. Her past medical history is unremarkable, and she is up to date on her immunizations. She attends daycare, and her mother notes that some children have been ill with non-specific febrile illnesses over the past 2 weeks. Her only medication has been ibuprofen for the fever. Physical exam shows a temperature of 98.8°F, pulse of 124 bpm, and respiratory rate of 28/min. She is alert and shows no other abnormalities. Her exam shows normal tympanic membranes in the ear and normal conjunctivae in the eye. The neck shows some shotty anterior cervical adenopathy; a normal appearing pharynx, and the skin appears with an erythematous maculopapular rash most pronounced on the trunk. Her chest is clear to auscultation, heart rhythm is regular without murmurs, abdomen is soft and non-tender, and her neurological exam is normal.

Observe the child and reassure the parent.

A 56-year-old man presents for a routine physical exam. His medical history is significant for hypertension and non-insulin-dependent diabetes for which he takes hydrochlorothiazide and metformin, respectively. His body mass index is 33 kg/m2. He states that he knows he should exercise more, but he lacks energy. Despite getting 7-8 hours of sleep every night, he wakes up feeling unrefreshed. In addition, his wife says he snores so loudly that sometimes she asks him to sleep on the couch. He deliberately limits his caffeine intake to 2 cups of coffee in the morning. He rarely drinks alcohol, and he denies non-prescription drug use.

Obstructive sleep apnea

A 73-year-old man presents with a nosebleed that will not stop. The bleeding has been present for over 2 hours. The patient's nose began dripping blood at breakfast; there was no known trauma. He denies pain. He has tried applying nasal pressure and lying down to rest. Until the bleeding began, the patient had not been experiencing any nasal symptoms, such as congestion, impaired nasal patency, or rhinitis. Because he felt too dizzy to drive, his wife drove him to the emergency department. The patient has no diagnosed medical conditions and takes no medications. He denies prior episodes of severe nosebleeds, easy bruising, and any known bleeding disorder. The patient's vitals are shown in the table.

Obtain IV access and begin normal saline infusion. Blood type and Rh

A 70-year-old African American man presents to his primary care provider with a complaint of gradual but progressive dyspnea and fatigue on exertion. He notes difficulty in climbing stairs with associated lightheadedness, increased abdominal girth, and swollen bilateral lower extremities. He admits to chronic alcohol use but denies any heart disease, chest pain or pressure, diaphoresis, palpitations, a history of diabetes, cigarette smoking, or claudication. His physical exam reveals sinus tachycardia, bibasilar rales, a laterally-displaced PMI, an elevated JVP, an S3 gallop, a mitral regurgitation murmur, peripheral edema, and abdominal ascites.

Obtain an echocardiogram

A 7-week-old boy presents with a 12-hour history of lethargy. Physical exam reveals a child who cries and becomes irritable when examined. There is edema noted on the left side of the head. There is no papilledema, and his mother denies a history of the child vomiting. There is a single faint bruise on the upper lip. A CT of the head reveals a linear skull fracture of the left parietal bone; there is no evidence of intracranial injury. On further questioning, the mother states, "My baby rolled over from the sofa onto a carpeted floor 2 days ago."

Obtain skeletal survey to rule out child abuse.

A 66-year-old non-smoking man presents to the family practice clinic due to chronic cough. He notes shortness of breath on exertion. On physical exam, an increased respiratory rate with shallow breathing is noted. Dry crackles are auscultated bilaterally over the lungs. No clubbing or cyanosis is noted. The remainder of the exam and vitals are normal. This patient has the following test results: Pulse oximetrySlightly hypoxicChest X-raySmall opacitiesPulmonary function tests (PFTs)Restrictive pattern

Occupational exposure history

A 63-year-old man with a past medical history of hyperlipidemia presents with an 8-month history of intermittent flushing and warmth sensation to his face and neck areas; alternating watery, frothy, and bulky stools associated with steatorrhea; weight loss; and wheezing. His urine demonstrates increased 5-hydroxyindoleacetic acid (HIAA) levels. Scintigraphy reveals innumerable foci of intense activity scattered throughout the liver.

Octreotide

A 48-year-old Caucasian woman presents due to feeling like she is losing her mind. She wants some tests done. Upon further questioning, she reports she is having multiple episodes daily in which she suddenly becomes very hot, flushed, and diaphoretic. These episodes last about 1 minute before resolving. She has not measured a fever. The patient reports that these episodes occur during the day and at night, during which she awakes drenched with sweat. As a result, her sleep has been poor, and she feels fatigued and irritable at both work and home. She has noticed these symptoms for about the last 2 months, and they seem to be increasing in severity. The patient has not had a period for 3 months; she recently did a home pregnancy test, which was negative. Prior to that, she had regular menses. This patient denies weight changes, palpitations, cold intolerance, bowel changes, as well as changes in her nails, skin, and hair. Although she admits irritability, she denies anxiety, depressed mood, and suicidal ideation. Her family history is remarkable for diabetes in her maternal grandfather and hypertension in her father. She is a G4P3Ab1. She denies any major psychosocial stressors recently. She drinks alcohol rarely, and she denies use of other drugs. Vitals and a urine specimen for hCG were obtained prior to the physical exam.

Offer blood tests and provide education/prescription for hormone therapy.

A 32-year-old Hispanic woman presents with a 3-day history of vaginal pruritus. She is worried she has another infection. She was treated with penicillin 2 weeks ago for group A Streptococcus pharyngitis. The patient reports occasional sinus and urinary tract infections and always struggles with vaginal symptoms afterward. She has episodes of vaginal pruritus and thick white discharge approximately 3 times per year. She usually returns to her urgent care clinic for evaluation and treatment, then her symptoms resolve. She has no chronic medical conditions. She is non-obese and is not pregnant. On exam, the vaginal mucosa is inflamed and coated with thick clumpy white discharge. On a wet mount slide treated with potassium hydroxide, you see pseudohyphae. The patient would like treatment for her current vaginal symptoms and advice in preventing her symptoms in the future.

Offer fluconazole in combination with antibiotics if indicated.

A 28-year-old man presents due to a left ankle sprain. The patient describes walking in the woods in flip-flops yesterday, inadvertently stepping into a hidden hole. The patient immediately noticed extreme pain with weight bearing on the left ankle, making it extremely difficult for him to walk out of the woods. Ambulation is extremely difficult. He describes the pain as an 8-9/10. The patient admits to previous ankle sprains, but this one has been much more severe and debilitating. He has noted significant swelling and exquisite tenderness to touch. He has treated his sprain with elevation, ice for 20 minutes at a time, and acetaminophen 1000 mg every 6 hours. Physical examination reveals a moderate degree of ecchymosis of the left ankle with substantial mechanical instability and moderate restriction of range of motion.

Oral NSAIDs

An 11-year-old boy comes in to see you due to knee pain. He notes that he started having right knee pain about 3 months ago that has increasingly become more apparent. The patient plays basketball in the winter and baseball in the spring for the last 2 years. When asked to point to where the pain is, the patient points to an enlarged area just inferior to the kneecap. Aggravating factors include participating in sports, especially when he is doing excessive amounts of running and jumping. Alleviating factors include resting the knee. Physical examination reveals a prominence and soft tissue swelling over the right tibial tubercle and tenderness to palpation of the right patellar tendon. The remainder of the musculoskeletal exam is unremarkable.

Oral NSAIDs

A 33-year-old woman presents with spider angiomas on her trunk and face. They appeared during pregnancy and have gotten worse in the 9 months since delivery. She takes imipramine for depression and resumed oral contraceptives after delivery. She had acute infection with hepatitis C virus 3 years ago. She was also frequently treated with flucloxacillin during the past few years for recurrent respiratory tract infections. Physical examination reveals spider angiomas on the patient's face, forearms, and back. Laboratory analyses reveal AST (26 IU/L), ALT (22 IU/L), and alkaline phosphatase (43 IU/L) levels within reference ranges. HBsAg, HBeAg, antiHbc antibodies, and HCV RNA are negative, and IgG antibodies are present.

Oral contraceptives

A mother brings her 5-year-old boy to the pediatrician due to multiple blisters on his cheek and nose. Physical examination is remarkable for numerous vesicles and crusted lesions containing light yellow fluid on both cheeks and around the nose. The child has similar lesions on his right wrist.

Oral dicloxacillin

A 63-year-old woman presents with a 6-month history of difficulty swallowing. Shortly after swallowing, she feels like something is getting stuck in her upper chest. The difficulty swallowing seems to be worsened when the patient is stressed and when she eats hot or cold food. She denies weight loss and night sweats and reports no other problems. Physical examination of the patient is otherwise non-contributory. An extensive gastrointestinal evaluation, including a comprehensive endoscopic evaluation, is negative.

Oral diltiazem

A 15-year-old boy presents for follow-up for acne vulgaris. He has been using benzoyl peroxide and retinoic acid for the past 4 months. He returns for a re-evaluation, as his acne appears to have worsened. He states his diet has not changed significantly, and his past medical history is unremarkable. His mother had significant acne as an adolescent. Physical examination reveals large papules and pustules on the forehead, cheeks, chin, and upper back. No nodulocystic cystic lesions are noted.

Oral doxycycline

A 45-year-old man is evaluated for a 6-month history of palpitations, easy fatigability, and chest pain on exertion. He does not smoke or consume alcohol; he has no significant past medical history. His body weight has remained stable. He has spent the last 2 years traveling the world. His wife says that he eats "unhealthily." He is a strict vegan, consumes a lot of snacks, and has never taken any vitamin supplements. Examination shows a 5'7" male with a BMI of 19. His BP is 130/70 and pulse 90/min; his temperature is 98.4°F. Conjunctival pallor is present. Auscultation shows a grade 2/6 murmur ejection systolic murmur heard all over the precordium.

Oral ferrous sulfate

A 52-year-old man is hospitalized for a left lower lobe pneumonia. The patient is HIV positive with a CD4 count <100/uL and is known to be neutropenic. He also has type 2 diabetes mellitus and diabetic nephropathy. He is started on ciprofloxacin, ceftriaxone, and clindamycin. During treatment, the physician notes a white coating of the tonsils and oropharynx. The physician obtains scrapings of the white coating. The sample is observed microscopically and confirms the presence of fungal hyphae and budding. The physician suspects a candidal infection of the oropharynx.

Oral fluconazole

A 2-year-old boy is brought to your office by his mother after she noticed that he often scratches his head. She also notes patchy loss of hair on the top of his head. She has been sending him to a daycare center for the past 2 months. On examination, you note patchy loss of hair in the right parietal area and another area of "black dot" alopecia about 4 cm lateral to it. The area of hair loss shows a grayish ring-shaped scaly lesion. A KOH preparation demonstrates branching hyphae and spores.

Oral griseofulvin

A 42-year-old man presents for evaluation of a growth on his tongue. He thinks that the lesion has been present for a few months, and it has not changed, but he generally prefers to avoid healthcare, and he has not been concerned. He is only here at the urging of his family member. The patient denies oral symptoms and changes in taste sensation; he states that he generally feels fine. The patient denies the use of chewing tobacco and cigarettes. On physical exam, there is a white patch of tissue that does not scrape off; there is a "shaggy" appearance on the left lateral tongue. No erythema is noted. No other lesions are identified. The remainder of his exam is normal. A biopsy of the lesion is obtained. The pathology shows hyperkeratosis, "balloon" cells in the upper cell layer, and Epstein-Barr virus (EBV) in the basal epithelial cells.

Oral hairy leukoplakia

An 82-year-old man presents for evaluation of an itchy hive-like rash on his abdomen. He has had it for months. Over the last few days, the patient reports the character of the rash has changed; it now resembles blisters. Other than some skin irritation, he feels healthy. He has tried multiple over-the-counter topical treatments, but they have been unsuccessful in treating the rash. He denies any changes in soaps, lotions, laundry detergents, or anything else that may have come in contact with his skin. He also denies unusual travel, pets, or hobbies. No close contacts have reported a similar condition. He takes no medications, and he does not have any chronic illnesses. On physical exam, multiple clusters of bullae are noted across the trunk bilaterally, with some distribution on both anterior and posterior surfaces. There are still some remaining pink-red lesions; they are scattered among the bullae. The bullae are 1-3 cm in size; they are tense and do not easily rupture. They do not extend into normal skin with pressure. Pressure on the normal skin does not produce a blister. The remainder of his physical exam is normal.

Oral prednisone

An 18-year-old man presents with multiple painful vesicles on an erythematous base on the right side of his lower lip. He experienced similar symptoms a month ago with an associated sore throat. He has an oral temperature of 101°F and positive tender cervical lymphadenopathy.

Oral valacyclovir

A 42-year-old man presents with lower extremity swelling. His past medical history and review of symptoms are otherwise negative. The patient looks comfortable, with vitals showing the following: BP 142/91 mm Hg, HR 90 beats/min, RR 16 breaths/min, T 98°F, height 5'9"', and weight 158 lb. His examination is only remarkable for 2+ pitting edema in the lower extremities. The patient is counseled on a low-salt diet. The abnormal laboratory values are as follows:

Order a 24-hour urine to quantitate urine protein.

A 72-year-old woman with a past medical history of COPD, deep venous thrombosis, breast cancer in remission, hyperthyroidism, and premature ovarian failure presents with sudden-onset severe lower back pain of 2 hours' duration. She states that the pain began when stepping onto the floor as she got out of bed. She denies any falls, prior injuries, genitourinary problems, or lower extremity numbness, tingling, paresthesias, or weakness. She takes a daily prednisone tablet for COPD. Her social history is notable for a sedentary lifestyle and a 40 pack-year smoking history. Her physical exam reveals a tall thin-framed woman with noticeable lid lag. Her thoracic vertebral body is exquisitely tender at T12, and she has limited mobility of all thoracolumbar planes of motion. Lateral and AP lumbar spine X-ray reveals osteopenia and collapse of vertebral body of T12.

Order a dual-energy X-ray absorptiometry test.

A 45-year-old woman presents with a 3-day history of persistent nipple discharge. She is essentially healthy with an insignificant past medical history. She quit her job to stay home with her young children in the past year; she has noted a weight gain of 15 lb, which she attributes to being at home more, leading to increased snacking as well as less activity. She also says her periods have spaced out, occurring anytime from 28-53 days. They still last about 2-3 days, as they previously had. She denies hot flashes and the possibility of pregnancy; her husband had a vasectomy. Her review of systems is otherwise negative. She takes vitamin E every day, but she takes no other medications or herbs; she denies the use of illicit drugs. On physical exam, you note a healthy-looking woman. Her breast exam is negative for lumps, dimpling, and nipple retraction. You are able to express some clear fluid from the left nipple. It seems serous. Her axillary exam is negative for any enlarged lymph nodes; the rest of her exam is normal.

Order a mammogram.

A 35-year-old man with no significant past medical history has been experiencing progressive, moderately severe right knee pain for the past 3 months. Pain was initially felt only at night, but it is now constant throughout the course of the day for the last several weeks. It is especially severe upon ambulation and during knee ranges of motion, causing him to limp. He denies fever, chills, weight changes, history of gout, sexually transmitted diseases, hip or back pain, recent instrumentation, trauma, or injuries. His physical exam reveals an antalgic gait with limp, limited ranges of motion of the right knee, and a 3 cm diameter firm, tender mass at the distal femur. There is no erythema, crepitus, alignment deformity, or effusion noted.

Order an LDH, ALP, and a plain radiograph of the knee.

An 83-year-old woman presents to the emergency department due to dizziness, blurry vision, and weakness upon moving from laying down to a standing position. She has been feeling this way for the past few weeks. She consumes two cups of coffee daily. She denies a racing heart, breathing difficulties, or feeling overwhelmed. Her blood pressure is 115/88 mm Hg lying down. After 3 minutes of standing, her blood pressure is 90/78; sitting blood pressure is 92/80.

Orthostatic hypotension

A 14-year old girl presents due to right leg pain. She is a competitive gymnast and works out in the gym 6 days a week. Upon physical exam, there is knee pain, swelling, and tenderness at the tibial tubercle. The patient's muscles are very tight in front and behind her thigh. All laboratory findings are within normal limits.

Osgood-Schlatter disease

An afebrile 76-year-old man has a history of pain and stiffness in his knees bilaterally and in his right hip. The pain is worse after an activity or first thing in the morning. Otherwise, he is healthy and has no other complaints. Upon physical exam, the patient has limited range of motion, joint line tenderness of knees, and mild swelling in the painful joints without warmth. 2 of 18 "tender points" are tender to palpation. A synovial fluid analysis was conducted and it was negative for urate crystals. X-rays of the knees and right hip do not show sclerosis of the bone. Additionally, a Gram stain was conducted and was negative for any bacteria.

Osteoarthritis

A 6-year-old boy has gradually increasing sharp pain in his left anterior hip that seems worse at night. He is moderately overweight, but he remains active and plays baseball. There is no history of trauma. There is no redness, swelling, or fever; there is no involvement of the other hip. Ibuprofen seems to help. There is no family history of any bone or joint disease. His weight is at the 95th percentile and height is at the 50th percentile. On exam, there is mild tenderness to palpation over his left anterior hip, but the rest of the exam is normal. Laboratory studies show a normal complete blood count, hemoglobin, sedimentation rate, platelets, and C reactive protein. Plain X-rays show a small round lytic lesion surrounded by mild reactive bone formation.

Osteoid osteoma

A 39-year-old Caucasian man presents with a "lump in his left ear canal." He just wants to confirm it is not a type of tumor. Otoscopic examination reveals a single discrete pedunculated flesh-colored bony mass located at the 7 o'clock position in the left external auditory canal. The right external ear canal was unremarkable. You tell the patient that the lump in his ear canal is indeed classified as a tumor but is completely benign.

Osteoma

A 33-year-old Caucasian man with a history of severe type 1 diabetes presents due to a red swollen pinky toe on his left foot. He was running to answer his home phone and stepped on an exposed carpet tack 2 days ago. He washed it out and covered it as soon as he could. Since then, he has noted a significant increase in redness and severe restriction of movement of this toe; these characteristics have worsened tremendously in the last 12 hours. In addition, he admits to "feeling feverish" for the past day, and he experienced significant night sweats the previous night. He denies formally measuring his temperature. He has tried to take acetaminophen 500 mg, 2 tablets every 8 hours without any noticeable relief. Pertinent physical examination findings include an oral temperature of 102.8°F, significant erythema and edema extending the entire fifth toe of the left foot accompanied by restricted range of motion due to tenderness and swelling. There is a small amount of purulent drainage at the site of the wound.

Osteomyelitis

An 89-year-old Caucasian man is brought in by his daughter due to pain in his left shin. He bumped his leg on a coffee table about 3 weeks ago; he developed some mild discomfort, bruising, and a small gash in the skin. It seemed as if he was healing well, but his condition has worsened over the past few days. Now he is moaning due to pain, and he says it hurts to walk on the leg. He describes the pain as "horrible" and an 8/10. The daughter reports the pain keeps him up at night and is unresponsive to ibuprofen and narcotic pain pills. He denies fever and chills. On physical exam, the patient is in obvious pain and is assisted to the exam table with limited weight bearing on his left leg. The lower extremities are examined; significant findings include healing and a scabbed lesion of approximately 3 cm in length across mid-tibia, with surrounding erythema and edema. Tenderness is elicited along the shin, extending well past the area of erythema. Homan's sign is negative. Distal pulses, temperature, coloration, knee range of motion, and lower extremity reflexes are symmetric and normal. Right lower extremity is normal.

Osteomyelitis

A 51-year-old Caucasian woman presents to the clinic to follow up on multiple tests she had requested from another practitioner. She has had what she describes as "episodes," in which she feels overheated and diaphoretic. Her coworkers note that her face turns red. These episodes seem to occur multiple times during the day; they have been occurring for the last 2-3 months, and they last about 1-2 minutes before they resolve. She is also very warm when sleeping at night. She denies weight changes, palpitations, headaches, galactorrhea, acne, bowel changes, hair loss, and any changes to her skin or nails. Overall, she reports some mild malaise and irritability, but she denies depression and fatigue. Her past medical history is unremarkable, with no known medical conditions, no allergies, no medications, and no prior surgeries. She denies the use of alcohol, tobacco, and recreational drugs. Her method of contraception is vasectomy in her husband. Her last menstrual period was about 4 months ago, but periods were regular and monthly prior to that. Physical exam and vitals are normal. Test results are shown.

Osteoporosis

A 66-year-old woman presents with back pain. She has a 5-month history of taking prednisone and has been a smoker for the last 15 years, which she has difficulty quitting. Upon physical exam, her back is very tender upon palpation. When the patient walks, she appears very bent over and unable to stand upright. A laboratory finding on her DXA was a T score of -3.1. X-ray was conducted as well, and demonstrates a small fracture in her back.

Osteoporosis

A 67-year-old woman presents; according to her, her husband says she never listens to anything he says. The patient states that occasionally she has to ask people to repeat themselves when sitting to her right. She denies any dizziness, headaches, or visual disturbances. Her current medication is furosemide. On physical examination, the Weber test reveals lateralization to the left ear. On the left ear, air conduction lasted for 15 seconds and bone conduction lasted 10 seconds. On the right ear, air conduction lasted for 22 seconds and bone conduction lasted 10 seconds.

Ototoxicity

A previously healthy 30-year-old woman G1P1 presents with amenorrhea, weight loss, shortness of breath, and increasing abdominal circumference. Menstrual irregularity started about 1 year ago, and her last menstruation was 3 months ago. She has lost around 5 kg over the last few months, but her waist has enlarged. Shortness of breath started a week ago, and it is worse when she is lying down; she now sleeps using at least two pillows. An examination of the lungs shows dullness to percussion, decreased tactile fremitus, and inaudible breath sounds bilaterally. Physical examination of the abdomen shows bulging of the flanks in the reclining position, and there is a difference in percussion in the flanks that shifts when she turns on her side. Pelvic examination shows a normal uterus and left adnexa; the right adnexum appears enlarged, smooth, and tender. Complete blood count and chemistry is normal, and a chest X-ray confirms the presence of pleural effusion on the right side. Fluid obtained from peritoneal cavity shows heterogeneously bloody content that clots; the leukocyte number is normal, and serum-ascites albumin gradient (SAAG) is 0.8 g/dL (low). The sample is negative of malignancy.

Ovarian fibroma

A 40-year-old otherwise healthy nulligravida woman presents with involuntary loss of urine that occurs after drinking a small amount of water, when washing the dishes, when hearing water running, and sometimes for no reason discernable to the patient. It is preceded by suddenly feeling the need to urinate, and it happens both during the day and at night. Urine analysis and culture, pelvic, gynecological, and neurological examinations are normal. Cystometric studies show residual volume of 45 mL (normal) with involuntary detrusor contractions, starting already with 200 mL.

Oxybutynin

A physician assistant is working in an emergency department. Their supervising physician requests a prescription for a sleeping pill because due to difficulty adjusting to shift work; the supervising physician has not been able to see their primary care provider.

PAs cannot prescribe medication to anyone who is not their patient.

A 28-year-old woman with a past medical history of well-controlled asthma presents with recurrent sneezing episodes, nasal itching, congestion, and headache. Her physical exam reveals post-nasal drip, a transverse nasal crease, and bilateral infraorbital cyanosis.

Pale bluish nasal mucosa upon speculum examination

A 22-year-old woman presents with a 2-month history of weight loss despite the woman having a good appetite. She also reports of having frequent bouts of diarrhea. On detailed questioning, she reveals a feeling of heat intolerance and menstrual irregularity. The right lobe of the thyroid is palpably enlarged, and further investigations confirm the suspected diagnosis.

Palpitations and tremors

A 43-year-old woman is found to have a palpable thyroid nodule that is 1.5 cm in size and located in the right lobe without regional lymphadenopathy. Upon questioning, the patient denies noticing this or any increase in the size of her thyroid. She denies hoarseness, a personal or family history of thyroid disease, and thyroid cancer.

Papillary

A 30-year-old man presents with a solitary firm thyroid nodule found on routine physical exam. He denies any heat or cold intolerance, palpitations, weight loss or gain, hoarseness, dysphagia, sore throat, or neck discomfort. The patient denies knowledge of previous head or neck irradiation. There is no cervical lymphadenopathy on examination. The remainder of HEENT exam is normal. TSH, thyroxine, thyroglobulin, and thyroid antibody levels are all within normal limits. Thyroid scanning with radioactive iodine reveals a 2 cm cold nodule in left lobe of the thyroid. Patient was sent for fine needle aspiration of the nodule.

Papillary carcinoma

A 3-year-old boy presents with a loud cough. He developed a runny nose and irritability 2 days ago; yesterday, he began to cough loudly and felt warm. His mother tells you that the cough sounded like a wounded animal or a dog barking. The child is diagnosed with croup, and humidification is prescribed.

Parainfluenza virus

A 6-year-old boy presents with a 2-day history of fever followed by cough, coryza, and conjunctivitis. He has also developed a rash that started behind the ear and is starting to spread downwards towards the trunk. On examination, you notice erythematous maculopapular blanching rash with coalescence in some areas. The palm and soles are spared. On oral examination, you notice 1-3 mm bluish lesions surrounded by an erythematous base. He is not up to date with his immunizations.

Paramyxovirus

A 39-year-old woman presents with a history of repeated short episodes of intensely anxious and fearful moments with physiologic manifestations, such as trembling, tachycardia, dizziness, sweating, and a smothering sensation. She has these episodes almost daily and feels they greatly impact her life when they occur. She denies symptoms of agitation, insomnia, and depression, and she states she does not have a history of recreational drug use. After an extensive workup, a diagnosis is made.

Paroxetine

A 32-year-old woman with no significant past medical history presents with a 3-month history of right anterior knee pain described as a dull and aching pain that is "right under the kneecap." Provocative activities include bending movements, descending stairs, and performing squatting maneuvers. Pain is relieved during rest. She notes that she loves the outdoors and her hobbies include running and hiking; her symptoms began following a run. She denies a history of falls, prior surgeries or instrumentation, fever, chills, malaise, myalgias, changes in weight, joint swelling, skin changes or rashes, or other joint pains. Her physical exam is normal with the exception of a tender undersurface of the patella, with crepitus upon passive range of motion of the right knee. There is abnormal patellar tracking upon right knee flexion and apprehension of the patient upon passive manipulation of the patella. Additionally, there is a positive patellar grind test. McMurray's, Lachman, the anterior and posterior drawer, Apley's compression and distraction tests, and varus/valgus tests are all negative. There is no joint line tenderness, effusion, or restriction of range of motion of the right knee.

Patellofemoral pain syndrome

A 2-month-old female infant presents for a well-child visit. Her mother states that she is concerned about the patient's lack of interest in feeding and her rapid breathing spells. You acknowledge these concerns, and during the physical examination, you note severe tachypnea, bounding peripheral pulses, and a rough machinery murmur that is auscultated best near the second left intercostal space.

Patent ductus arteriosus

A preterm female infant born to a 32-year-old woman with no known past medical illnesses presents for the infant's 1-week follow-up. The mother reports that the patient is behaving normally and is feeding well. The physical exam is remarkable for a murmur, which is located at the second left intercostal space. The murmur is continuous throughout cardiac systole; it is diastolic, non-radiating, and of a "machinery" quality. There is also a widened pulse pressure. The skin and mucosa are without cyanosis, and there is no evidence of fluid retention.

Patent ductus arteriosus

You are a triage officer for your local jurisdiction's mass casualty response team. Your team has been activated to respond following a tornado with significant infrastructure damage and multiple injured. The nearest hospital is a small community hospital with limited medical resources 30 minutes away by ground ambulance. You are asked to evaluate the following patients: 17-year-old girl with 10 cm laceration on medial thigh; significant blood pooling is noticed on the ground around patient—alert and answers questions with some delay 27-year-old man with chest pain without visible injury or disability—alert and speaking on phone with family 34-year-old woman with leg pain and a visible large glass shard imbedded in lateral right thigh—alert and answering questions appropriately 45-year-old man with abdominal pain and visible wide spread ecchymosis on abdomen and pelvis—arousable to voice but answering questions inappropriately 75-year-old man on a stretcher with blood-stroked bandages wrapped around head—unarousable to stimulation

Patient D

A 54-year-old woman with history of type 2 diabetes mellitus presents with a new foot ulcer. She has minimal pain at the site. She noticed a small fissure on the ball of her foot about 2 weeks ago, and she discovered yesterday that the lesion had become larger and was draining purulent-smelling material. Her foot has also become swollen and red. She has been on hypoglycemic medication for the last 5 years; recently, her metformin dose was increased to 850 mg twice daily; it is combined with glipizide 10 mg twice daily. She is also on benazepril 10 mg daily for mild hypertension and microscopic proteinuria discovered at her annual physical earlier this year. Physical exam reveals a temperature of 99.1°F, pulse 72/min, and respirations 20/min; blood pressure is 123/84 mm Hg. The plantar surface of the right foot has a 2 cm shallow ulcer with a film of purulent, serous drainage. There is a 1 cm surrounding band of erythema around the ulcer margin, and her foot has 2 + edema. She has greatly decreased pinprick sensation in both feet, and she cannot feel vibration. Dorsalis pedis pulses are 4/5 bilaterally. Laboratory evaluation reveals a WBC count of 17.7 X 103/ìL, with 93% neutrophils. Her HbA1c is 8.8%, and glucose is 241 mg/dL.

Patient education and risk factor prevention

One of your patients, a sexually active gay man, asks you about pre-exposure prophylaxis for HIV (PrEP). He has been reading information regarding this prevention strategy online. One document he found on the CDC website references a study where participants were given PrEP. Study participants who were given PrEP medication were 44% less likely to get HIV, but it also mentions participants who took PrEP as directed reduced the risk of HIV up to 92%. He asks for your help in interpreting this study.

Per protocol

A 52-year-old patient with a known case of renovascular hypertension presents with poorly controlled hypertension. He has been treated with both enalapril and nifedipine. He had been diagnosed with unilateral left renal artery stenosis, but recent tests have demonstrated mild changes in the right renal artery also.

Percutaneous transluminal angioplasty

An 18-year-old man with no significant past medical history presents with pain and swelling over the upper right knee for 5 months. The pain was initially insidious, dull, and achy. Over the past several weeks, however, it has gradually become progressively more severe and unremitting, often waking the patient at night. He also notes increased swelling, warmth, and erythema. He denies a history of injuries, accidents, trauma, surgeries, or sexual encounters. His physical exam reveals a noticeable limp, reduced right knee range of motion, and localized tenderness and swelling to the distal anterior femur.

Perform a right knee radiograph.

A 58-year-old woman with no significant past medical history presents with a 6-month history of "heartburn," sometimes occurring after meals. There is associated fatigue, bloated abdominal sensation, early satiety, and alternating constipation and diarrhea. She denies fever, chills, changes in weight, chest pain, shortness of breath, abdominal pain, nausea, vomiting, melena, hematochezia, and vaginal discharge. Her last menstrual period was 4 years ago. She is unmarried, and she does not have any children. Her physical exam reveals normal vital signs and a normal cardiopulmonary exam. Her abdomen is protuberant; there is a shifting dullness and a fluid wave noted. The pelvic exam reveals a solid irregular fixed lesion in the left lower abdomen.

Perform a transvaginal ultrasound.

A 34-year-old man presents with a 2-day history of right ankle pain and swelling. He reports experiencing discomfort with bearing weight, ambulation, and when driving a car. On further questioning, he denies experiencing a recent trauma, although he does recall spraining his ankle approximately 1 year ago. The patient is not married and is heterosexual; he usually uses condoms as contraception, "but not every time." On physical examination, the patient's temperature is 99.9°F. His right ankle shows swelling, is warm to palpation, and reveals an effusion. With passive range of motion of the right ankle, significant pain is elicited.

Perform arthrocentesis of right ankle with analysis of synovial fluid.

A 56-year-old man is hospitalized with sudden onset of symptoms of chest pain, sweating, palpitation and shortness of breath. ECG showed ST elevation of 3 mm above isoelectric ECG line, and troponin I of 6 ng/mL. His BP is 130/75 mm Hg, and HR is 65 bpm. The next morning, Doppler and transesophageal echocardiography were performed following new onset of chest pain, shortness of breath and systemic hypotension, which established mitral regurgitation with papillary muscle rupture.

Perform mitral valvuloplasty.

A 55-year-old man presents with a COPD exacerbation managed with a ventilator. The patient's blood pressure drops and the ventilator alarm goes off. The only medication being administered is amlodipine via nasogastric tube. This patient is afebrile. On examination, there is a middle-aged orally-intubated man with temperature 99.4°F, pulse 145/min, and BP 62/34 mm Hg; he breathes above the ventilator at a rate of 36 cycles/min. His breathing is shallow, and there are diminished breath sounds in the right hemithorax.

Perform needle thoracotomy, chest tube placement.

A 12-year-old Caucasian girl presents with a sore throat. The onset of symptoms was about 24 hours ago. The patient experiences pain in her throat, especially with talking or swallowing. She is fatigued because throat pain prevented her from sleeping last night. Throat lozenges have not been helpful. Several classmates have been out sick recently. She denies nasal congestion, rhinorrhea, and cough and is unsure of fevers. This patient has no chronic medical conditions, takes no medications, and has no known drug allergies. On physical exam, she appears slightly ill and fatigued. HEENT exam is positive for bilateral cervical lymphadenopathy and inflamed posterior oropharynx without exudate. She does have normal range of motion of the neck without eliciting pain. Her heart, lung, and abdominal exams are normal. No other lymph nodes are palpable. Weight 92 lb, height 4'8", pulse 95, BP 102/60, temperature 99.2°F/37.3°C.

Perform rapid antigen testing for group A streptococcus.

A mother has brought her 9-year-old daughter to you because the child has been suffering from a 1-week history of intense itching on her scalp since she returned from a summer camp with a group of other children. Physical examination shows a number of nits attached to the hair shafts and a few full-grown lice on the scalp. Due to scratching, there are raw excoriated areas on the scalp with a few areas of pyoderma. Occipital group of lymph nodes are enlarged.

Permethrin 1% topical

A 3-year-old boy who weighs 14 kg presents with a 2-week history of severe itching all over the body that is more severe at night. Physical examination reveals gray thread-like serpentine lines with papules at the ends. There is a generalized papular and papulovesicular rash with few pustules. The lesions are more confluent between the webs of the fingers and toes and on the flexor surface of the wrists, axilla, genitalia, feet, and buttocks. Scrapings from the skin show an arthropod with four pairs of legs, hemispheric body, and brown spines and bristles on the dorsal surface.

Permethrin 5% cream

A 4-year-old boy presents with a rash on his feet, ankles, wrists, and gluteal areas; the rash is accompanied by severe itching, particularly at night. His 6-month-old sister has a similar rash on her neck and head. On examination, you find pruritic erythematous papular and papulopustular skin changes between the web spaces of the fingers; changes are also seen on the flexor aspects of the wrists and in the genital and gluteal areas. On superficial epidermis, you find several short elevated red tortuous lines; they have a small vesicle at the tip.

Permethrin cream

A 36-year-old woman presents because she has been feeling very tired and unhappy for the past 3 years; she thinks that she has no hope of better days in the future. She states that it is amazing her boss has not fired her yet because she is one of the company's worst employees. She cannot recall the last time she was excited about anything. She denies other symptoms. Her vital signs are stable. Her height and weight are within normal limits.

Persistent depressive disorder

A mother brings in her 6-year-old daughter because the girl's teacher is concerned about behaviors at school. The teacher has noticed the girl "staring off into space" frequently throughout the day; the teacher is able to get the girl's attention only occasionally. There are also periods when she appears to be talking to herself, but there is no sound coming from her mouth. The mother states that there are times when her daughter does not seem to be paying attention to what the mother is saying. Shortly after these episodes, the child engages in conversation without any problem, so the mother did not think the episodes were an issue. There is no concern about other abnormal behavior or discipline issues at home or at school.

Petit mal (absence) seizures

State mandatory newborn screening has been conducted on an neonate born approximately 36 hours ago. An abnormality found in the screening has resulted in counseling of the parents on initiating lifelong modification to the newborn's diet. It is explained to the parents that this action must be taken to help decrease the likelihood of the infant developing severe intellectual disability, hyperactivity, and seizures.

Phenylalanine

Mandatory newborn screening has been completed on a Caucasian infant who was born 36 hours ago. The birth was relatively benign without any complications; the newborn was born at exactly 40 weeks gestation. An abnormal result found in the screening tests has resulted in you ordering required counseling for the parents to initiate lifelong modification in their child's diet to decrease the incidence of abnormal intellectual development.

Phenylketonuria

A 15-year-old boy presents for a high school basketball physical. After his mother leaves the room, he asks if you can "take a look at something." He then lifts his shirt and tells you that he is developing "man breasts." He is very embarrassed. There is firm mobile tender tissue palpable under both nipples. This tissue is approximately 75 mm in size on the right side and 1 cm on the left. There is no nipple discharge on either side. The patient's height is 66", weight is 125 lb (BMI 20.2).

Physical examination including genitalia

A 23-year-old primigravida is referred to her obstetrician by a community nurse. The nurse noted two blood pressure readings of 150/90 and 154/90 taken 15 minutes apart. Physical examination reveals a uterus at roughly 24 weeks gestation and grade 2 pitting edema. Urine analysis is 1+ positive for albumin. A sonogram at 8 weeks gestation showed a single live intra-uterine gestation. She has had regular antenatal checkups and has no past history of hypertension or diabetes. Her parents and grandparents are hypertensive. She is unaware of whether her mother or grandmother faced similar problems during their pregnancies.

Placental ischemia

A 75-year-old woman with a past medical history of hypertension, hyperlipidemia, and obesity presents with insidious but progressive bilateral knee pain for the past several months. She states that her pain is worsened with movement and relieved by rest. She reports "cracking" sounds in her knees upon ambulation and minimal stiffness lasting 10 minutes. Her physical exam is remarkable for bilateral knee crepitus, joint line tenderness, and an antalgic gait; there is no swelling, erythema, or warmth noted.

Plain radiograph subchondral sclerosis

A 24-year-old man with no significant PMH presents due to increasing pain in his right groin and buttock and difficulty walking. The pain has been present and worsening for about 1 month. He further reports that he had significantly injured himself (also near his right hip) in a fall while snowboarding about 3 months ago. He did not seek immediate care and had difficulty ambulating for a week, then saw a chiropractor to "put his lower back back in." The pain and gait problems eventually improved. Now he is concerned because the pain has returned with no new history of trauma. He denies any family history for musculoskeletal and rheumatologic conditions. On physical exam, the patient was noted to walk with a slight limp. Examination of the hip, buttock, and groin region reveals no edema, erythema, or ecchymosis. The exam does not produce one particular point of tenderness with palpation, passive range of motion is limited and painful, especially with forced internal rotation. A straight-leg raise against resistance elicits pain.

Plain radiography (X-ray)

A mother presents her 2-year-old son for a follow-up of a febrile urinary tract infection (UTI). He just finished a 10-day course of trimethoprim/sulfamethoxazole (Bactrim) and is asymptomatic. He had a UTI with fever at age 15 months. His mother is concerned because is not toilet trained. Physical examination is unremarkable. He is not circumcised. Urinalysis and renal ultrasound findings are normal.

Plan voiding cystourethrogram.

A 67-year-old male post office worker presents with a 3-week history of increasing shortness of breath; it occurs even while he is at rest. The patient was diagnosed with congestive heart failure in the past year and he has been well controlled on oral medication. He has no history of tobacco use. He has gained 10 pounds since his last exam 2 months prior to presentation. On physical exam, there are diminished breath sounds and decreased tactile fremitus bilaterally at the base of the lungs. Dullness to percussion is also noted in the same area. He has 3+ bilateral pitting lower extremity edema.

Pleural effusion

A 69-year-old woman presents with shortness of breath. She states it has been worsening over the last 3-4 days; she also is experiencing increased fatigue. The patient is not on any daily medications other than over-the-counter multivitamins, and she has no pertinent past medical history. Physical examination is significant for an oral temperature of 101.5°F, and during auscultation, there are absent breath sounds noted in the right lower lung field. Tactile fremitus reveals an absent result in that same lung field, and percussion over that area creates a dull percussion note.

Pleural effusion

A 72-year-old man presents with longstanding and increasing dyspnea and a 3-day history of shortness of breath, coughing, and unilateral sharp chest pain. Pain is worse when he takes a deep inspiration and when he coughs. PMH is significant for a smoking history of 2 packs/day for 40 years (80 pack-years). The patient has other co-morbidities, including CAD, COPD, CHF, hypertension, and dyslipidemia. He denies recent travel, sick contacts, occupational exposure, and drug or alcohol use. Vital signs are BP 150/90, HR 96, RR 26, O2 94% on room air. Chest examination of the left posterior chest reveals a dull percussion note, inaudible bronchovesicular breath sounds, decreased tactile fremitus, a pleural friction rub on inspiration and diminished voice sounds below the sixth intercostal space. Significant bilateral lower extremity edema is also noted. A chest X-ray reveals blunting of the costophrenic angle.

Pleural effusion

A 76-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, abdominal pain, nausea, vomiting, diarrhea, or peripheral edema. His physical exam reveals a widespread friction rub upon inspiration, absent lung fremitus, and reduced lung sounds over the thoracic cavity.

Pleural fluid N-terminal pro-brain natriuretic peptide levels greater than 1500 pg/mL.

A 22-year-old man presents with sudden onset of shortness of breath and right-sided chest pain. Symptoms began abruptly yesterday. He felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He smokes one pack per day; he has an otherwise non-contributory past medical history. On physical exam, the patient is in mild respiratory distress. He has a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal.

Pleural line on chest x-ray (CXR)

You are examining a 6-month-old male infant who has not received any immunizations since birth. He was born at home and has a history of multiple respiratory tract infections and chronic diarrhea since birth. His parents are not related. Family history is significant for two of his older brothers dying of pneumonia at ages 8 and 1. His 4-year-old sister is healthy. His parents moved to the US from an underdeveloped country 3 months ago. They are worried because one of their neighbors' children (age 6) developed a pruritic skin rash and fever 2 days ago; another child (age 6 months) is in the hospital because of severe vomiting and diarrhea. On examination, your patient's vitals are normal. His weight is <5th percentile, his height is at the 5th percentile, and his head circumference is at the 50th percentile. Physical exam shows an eczematous skin rash, and mucocutaneous changes suggestive to a fungal infection are noted. His thyroid, heart, lungs, abdomen, genitalia, and nervous system are within normal limits. There are no palpable lymph nodes and no hepatosplenomegaly.

Pneumococcal vaccine (PCV13)

A 30-year-old immunocompromised patient presents with a 2-week history of breathlessness and a non-productive dry cough. The patient is afebrile, pulse is 100, and BP is 110/70 mm Hg. On auscultation, scattered rales all over the chest are heard. A chest x-ray shows diffuse air-space and interstitial shadowing in both lungs.

Pneumocystis pneumoniae

A 19-year-old Caucasian man has come to see you as the last patient of the day. He presents with sudden onset of severe shortness of breath. He states that he has been an avid basketball player all his life and was practicing about 4 hours prior to his visit when he experienced sudden chest pain and immediate shortness of breath that is still bothering him currently. He describes the chest pain in the middle of the chest, more so on the right anterior side. The patient admits to smoking half a pack of cigarettes daily. Physical examination reveals a tall, thin, well-developed man in mild distress. The only other abnormalities discovered are mild tachycardia (120 beats per minute) and diminished breath sounds in the posterior right lower lobe.

Pneumothorax

A 45-year-old man is admitted to the hospital with fever, weakness, weight loss, extremity pain, and a rash on his legs. He states that his symptoms began about 1 week ago. He denies recent illness or injury and states that he has been in good health for as long as he can remember. On physical exam, the patient was well-developed, well-nourished, and in mild physical distress. His lower extremities have ulceration near his medial malleoli and a diffuse lace-like purplish discoloration on his bilateral lower extremities. His blood pressure was elevated at 152/94 mm Hg, and a chest radiograph was negative. Laboratory analysis revealed an elevated sedimentation rate and C-reactive protein, elevated BUN, and creatinine. His red blood cell count was decreased, and his ANCA was negative. Hepatitis B tests were also negative. Biopsy of the leg ulceration reveals a fibrinoid necrosis of an arterial wall with a leukocytic infiltrate.

Polyarteritis nodosa

A 24-year-old obese woman arrives at an infertility clinic accompanied by her husband. The couple has been married for 3 years, and they have been unsuccessful at conceiving a child. History and examination of the husband is unremarkable. She attained menarche at age 13 and gives history of irregular cycles for the past 5 years. There is no history of pelvic pain or discomfort. The patient's last menstrual period was 2 months ago. On physical exam, the woman has hirsutism and acne, and her pelvic examination is unremarkable. Investigations reveal elevated serum levels of dehydroepiandrosterone sulfate (DHEAS) and androstenedione.

Polycystic ovarian syndrome

A 73-year-old man has had shoulder pain for more than 6 months and it has kept him from sleeping on his left side and has often woken him up. He presents with an inability to actively raise his left arm that started 1 month ago, before which his shoulder pain had improved. There was no specific injury that he can recall, but he felt a pop in the shoulder a month ago while taking out the trash.

Positive (+) drop arm test

A 54-year-old man presents with a 2-month history of left non-dominant shoulder pain. There is no history of trauma, but the pain began about a week after shoveling wet heavy snow from his 100-foot driveway. At first, the pain seemed to come and go from day to day, but it has gotten progressively worse and more constant. Pain is worse with overhead use. He cannot sleep on his left side and will wake up if he rolls over onto his left shoulder. Drop arm test is negative.

Positive Neer and Hawkins signs

A 71-year-old male farmer presents because he is experiencing a gradual increase of frequency of urination over the previous 4-5 months. He has difficulties starting to urinate, the stream is slow, and he frequently has a sensation of incomplete emptying. He has not had a physical examination in several years. He has no history of sexually transmitted diseases (STDs) or urinary tract infections. Upon examination, his abdomen and his prostate are non-tender. His prostate seems moderately enlarged (estimated at 35 g) but smooth and symmetrical.

Post-void residual urine test

A 16-year-old previously healthy boy fell on a cemented surface while skateboarding 3 weeks ago. He lost consciousness for 2 minutes. He was not wearing a helmet. A CT scan showed no abnormalities. He is now back at school and has difficulty concentrating in class and has frequent spells of dizziness and headaches. His neurologic exam is normal.

Postconcussive syndrome

A 7-year-old girl presents with a 1-day history of bloody urine. The grossly bloody urine scared both the girl and her parents, but she denies dysuria and frequency. No trauma or sexual abuse has occurred. The parents deny recent fever in the patient, but they note that she had a fever for a few days accompanying a sore throat. She was given acetaminophen at an appropriate dosage for her weight, and about 3 days of some leftover amoxicillin; both the fever and pharyngitis then resolved. Her past medical history is unremarkable for any chronic illnesses. Her only medication is a multivitamin, and she has NKDA. She has had no surgeries, and family history is unremarkable for urinary tract disorders or any bleeding disorders.On physical exam, she appears interactive and in no apparent distress. She is well-nourished, non-obese, and perhaps mildly edematous. Vitals are a temperature of 99.0°F and a BP of 138/85 mm Hg; pulse is 98, and respiratory rate is 20. No rashes are found. Cardiac exam reveals normal rate and rhythm; there are no murmurs or rubs. On abdominal exam, her abdomen is non-distended, non-tender, and without masses or hepatosplenomegaly. She has no CVA tenderness.

Postinfectious glomerulonephritis

A 27-year-old woman is brought to the ER by her husband because of bizarre behavior 4 days after the uncomplicated delivery of a full-term healthy boy. Her personal and family history of mental illness is negative. The second day after delivery, she accused her husband of poisoning her food. She has problems falling asleep, generally sleeping only 2-3 hours nightly and complaining of unpleasant smells waking her up. She started arranging toys and the newborn's things in a specific symmetrical order and became aggressive when someone moved them. She would stop the ongoing activity from time to time with a blank expression and was found several times staring at the wall and silently counting. Even simple tasks require the help of others, and she often forgets what she started doing. This makes her irritable and sometimes tearful. She feels guilty about being a terrible mother and states that she did not deserve to have a baby. The morning when her husband asked for your advice, she told him that she hears voices telling her to take her son and jump out the window.

Postpartum psychosis

A routine EKG 5 weeks ago determined that a 59-year-old Caucasian man had developed new-onset atrial fibrillation. The atrial fibrillation was asymptomatic and was not associated with dizziness, palpitations, chest pain, or shortness of breath. He was started on warfarin 5 mg daily for anticoagulation and his Toprol dose was adjusted. Cardioversion was scheduled as a subsequent elective outpatient procedure. The patient's past medical history is notable for hypertension and coronary artery disease with prior RCA stent. He has no history of stroke or TIA. Allergies: bee stings. Usual home medications: aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, metoprolol tartrate 50 mg b.i.d., warfarin 5 mg daily. He quit smoking 20 years ago. He now presents to the outpatient cath lab for a planned elective cardioversion procedure. Patient reports no new medical problems or symptoms since his diagnosis of new-onset atrial fibrillation. He claims compliance to his medical regimen. He denies chest pain or shortness of breath. His vital signs are stable. Physical exam reveals clear lung fields and an irregular cardiac rhythm. EKG shows atrial fibrillation with a ventricular rate of 87 beats per minute. Review of his lab work from 3 days prior shows the following:

Postpone cardioversion procedure.

A 22-year-old woman has a history of being involved in a bank robbery 8 months ago. Since then she noticed she has been having loss of memory, flashbacks, disruptive sleep and nightmares recalling the event, irritable moods, and difficulty concentrating. She denies any palpitations, tachycardia, or any chest pain. She denies any repetitive behaviors or feeling uncomfortable in social settings. She also denies any need for order or symmetry, unwanted intrusive thoughts, or scrupulosity. The patient does not mention any concerns about excessive worrying. Upon physical exam, the patient appears disheveled, with poor hygiene and flattened affect. She does not present with any hair loss or baldness. Upon lab results, everything is within normal limits.

Posttraumatic stress disorder

A 21-year-old man presents with itchy skin changes. He works as a lifeguard. About a week ago, he noticed a round red patch on his belly that spread to his trunk and legs. He denies recent infections, allergies, and illnesses; he does not take any medications, and he admits that he occasionally smokes marijuana. The rest of his personal and family history is non-contributory. On examination, you find round annular scaly pruritic papulosquamous changes on his torso and legs. There are no changes on his mucosa, and the rest of physical examination is within normal limits.

Potassium hydroxide preparation

A 16-year-old otherwise healthy girl presents with cessation of her menstrual cycle. She does not take any medications or use tobacco or drugs. She has a boyfriend, but she denies intercourse. Her family history is negative for gynecologic or fertility problems, autoimmune diseases, and endocrinopathies; her mother's and female relatives' menarche presented at age 12-14. There are no syndromic features on examination. Her height, weight, and BMI are within normal range, and her vital signs are normal. Her skin is clear (no acne), and there are no signs of hirsutism. There is no thyromegaly. Her breasts are developed, and pubic and axillary hair is present. Her abdomen is benign; her external genitalia maturated; there is no clitoromegaly; vaginal mucosa is moist and pink; saline-moistened applicator swab reveals normal vaginal length. Single finger examination demonstrates the presence of uterus. Neurological examination is non-focal; sense of smell is preserved; visual fields are normal by confrontation; fundoscopic examination shows no papilledema.

Pregnancy

A 16-year-old girl presents with a history of severe nodulocystic acne. She has used topical benzoyl peroxide and topical tretinoin and has undergone numerous courses of oral tetracycline. The acne has not responded to any treatment. You decide to change her treatment plan and prescribe the appropriate next step in management to treat her condition.

Pregnancy test

A 19-year-old woman presents with a painful sore in her mouth that has been present for 3 days. She denies oral trauma. She describes a single painful lesion that feels like a bump between her cheek and gum line. She has not tried any treatments at home. She denies history of similar lesions. She has otherwise been feeling well and denies recent flu-like symptoms. Her past medical history is unremarkable, with no known medical conditions or history of surgery; she takes no medications and has no allergies. She lives in an apartment with her boyfriend; she works at a convenience store; and she denies the use of alcohol, tobacco (including chewing tobacco), and recreational drugs. On physical exam, her vitals are normal. A single tender lesion is identified on the buccal mucosa, just across from the lower right jaw. It is a small shallow ulcer approximately 3 mm diameter with a yellow-gray center surrounded by a red halo. The remainder of her exam is normal.

Prescribe topical corticosteroids.

A 75-year-old man with a history of dementia and chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. His condition deteriorates during his hospitalization, and he is now in respiratory failure and intubated. He has failed multiple attempts to wean off ventilatory support, and his prognosis is prolonged intubation and ventilation. Due to his history of COPD, dementia, and acute respiratory failure, there is concern about cognitive decline. His wife presents an advanced directive executed 7 years ago that states he does not want prolonged intubation and ventilation. His wife is uncomfortable giving consent to take him off of the ventilator despite her husband's advanced directive.

Present the case to the hospital ethics committee.

A 16-year-old girl has had recent onset of painful menstrual periods. Menarche was at age 12. Her periods were irregular for about 8-10 months. They have been fairly regular since then, with occasional mild crampy pains on the first 2 days. She rates the pains now as being 8-9 on a scale of 10. Cramps will start about a half a day before the onset of her periods, worsen the following day, and then gradually subside over the next day. She also describes having a headache, looser stools, mild nausea, and low back and thigh pain. Bleeding is moderate on the first 2 days. She is otherwise healthy without history of abdominal surgery. Privately she denies any sexual activity. She is an average student and has missed 1-2 days of school with each period for the past 3 months. She also denies any fever or dysuria. There is also no family history of gynecological problems. On exam, she has diffuse midline lower abdominal tenderness with some mild soreness to lower back and thighs, bowel sounds are normal, and there is no rebound tenderness. An external genital exam is normal.

Primary dysmenorrhea

A 43-year-old Caucasian woman, previously in good health, presented to the emergency department with headache, blurred vision, and dizziness. Symptoms started 3 days ago and progressively worsened. Past medical history: hypertension, hypothyroidism, prior cholecystectomy.No known drug allergies.Medications: HCTZ 25 mg daily, diltiazem CD 120 mg daily, and levothyroxine 88 mcg daily. She ran out of all medications 2 weeks ago.Vital signs were normal, except for blood pressure 210/114 in the right arm, 215/115 left arm, 220/100 right leg, and 215/112 left leg.Physical exam:Heart - no visible or palpable PMI; normal S1 and S2 without murmur, rub, or gallop.Pulmonary - few faint RLL crackles, which cleared upon coughing.Remainder of the physical exam, including neurologic exam, was unremarkable. CBC and BMP were unremarkable except for K+ 2.3 mEq/L.EKG - NSR with one PVC. Chest X-ray - clear lung fields; normal pulmonary vasculature.CT head - no evidence of intracranial pathology.Renal artery sonogram - Unremarkable. Patient was treated with IV nitroprusside and IV KCl 40 mEq x 2 doses and was admitted for further treatment. Over the next 2 days, patient's blood pressures gradually normalized with medical therapy, but potassium levels remained low despite treatment.

Primary hyperaldosteronism

A 29-year-old man presents with bouts of severe depression accompanied by suicidal thoughts. Although he is well-educated, he has been unable to get a job that fits his training because of his illegal status in this country. He has been doing odd jobs, and he has barely been making a living. His relationship with his girlfriend has become stormy over the last few months, and he confesses that he wants to kill his girlfriend. You believe his intent to kill his girlfriend to be serious and suspect that the underlying cause of his fury and homicidality, is untreated depression. For his own safety, you recommend he admit himself to a psychiatric hospital for further evaluation and treatment. He vehemently refuses.

Proceed with the procedure for involuntary hospitalization.

A 25-year-old woman presents to discuss her available contraception options. You review her history and note menses onset at age 12, duration of menses typically around 6 days, occurring every 30 days. She is G0P0, and she has no history of abnormal pap smears or diagnosed STIs. The patient is a non-smoker in a monogamous relationship with one partner for the past year. All other medical history is non-contributory with the exception of the patient having a deep venous thrombosis at age 19 and a pulmonary embolism at age 21. Other than anticoagulation therapy for the appropriate amount of time, no other hematological evaluation was pursued after these events.

Progestin-only oral contraception pill

A 28-year-old woman presents because she has not gotten her period in 2 months. She is worried that she may be pregnant, but she is concerned because she and her boyfriend broke up about 2 months ago. She does not want to be a single mother. The patient mentions a discharge from both breasts. She denies any significant weight loss/gain or heat/cold intolerance. You order a urinary HCG, which is negative.

Prolactin level

An 8-year-old boy sustained a puncture wound to his right foot by stepping on a nail through his sneaker 4 days ago. His mother said the wound bled profusely but the nail did not go completely through his foot. They washed the wound at home with soap and water, wrapped it in a bandage, and did not seek further care. This morning, he complained that it was very painful and his mother noted that his foot looked red and swollen. On exam, his temperature is 99°F; pulse is 114 BPM, and his BP is 104/68 mm Hg. The plantar surface of his right foot has a small 2 mm scabbed entry wound that is surrounded by a 5-6 cm area that is erythematous, swollen, and quite tender. There is a scant amount of thin seropurulent material from the entry wound on examination.

Pseudomonas

A 30-year-old woman presents to the emergency room at 7 AM with severe pain and swelling of her right eye. She was awakened early the previous evening due to the discomfort and swelling of the surrounding conjunctiva. She found it difficult to sleep due to the discomfort. She planned on going to work, but the swelling had closed her eye shut, and she developed excruciating pain in the eye that radiated internally. The patient denies recent swimming and does not recollect any previous trauma or injury to the eye. She uses contact lenses, but they were not in use due to the condition of her eye. The contact lenses were stored in a small pillbox container with some fluid that she later described as tap water. She ran out of sterile cleaning and soaking solution for the contact lenses, so she has been using tap water as a substitute for approximately 5 days. She frequently sleeps with her contacts in. The patient is afebrile. Pulse is 70/min, and blood pressure is 135/80 mm Hg. Lungs are clear, and there is no evidence of lymphadenopathy. The eye has profound conjunctivitis that is acute and follicular. Purulent drainage is present. The acute nature of conjunctivitis requires an ophthalmologist consult. The ophthalmologist obtains ocular fluid for culture and Gram stain. CBC results are unremarkable. The Gram stain reveals the following results (see image). Prompt and aggressive therapy is initiated.

Pseudomonas aeruginosa

A 9-year-old boy presents with a productive cough for the past few days. The patient also has been having fevers of 101°F. The patient has had recurrent bouts of pneumonia. His neonatal course was complicated by meconium ileus. A sweat chloride test is positive and sputum examination reveals gram-negative rods that are oxidase-positive. The culture has a greenish tint.

Pseudomonas aeruginosa

A 63-year-old man who is 2 days status post left total hip replacement begins to report chest pain. The pain is worse with deep inspiration, and it is associated with dyspnea. His heart rate and respiratory rate are both elevated. EKG is significant for sinus tachycardia.

Pulmonary angiography

A 33-year-old African American woman with no significant past medical history, who is in her 38th week of a normal pregnancy, presents with a 1-hour history of shortness of breath. She does not recall any precipitating activities or events that may have provoked these symptoms and recalls that she was laying in her bed for several hours since waking when the symptoms developed. She admits to an associated sharp, non-radiating pleuritic chest pain, as well as lower extremity swelling, which she states has been "persistent throughout the course of her pregnancy." She denies palpitations, chest pressure, cough, sputum, fever, chills, changes in weight, rashes, diaphoresis, abdominal pain, nausea, or a history of allergies.Her physical exam is noteworthy for tachypnea and tachycardia, but the rest of the vital signs are normal. Her lungs are clear to auscultation bilaterally, without wheezing, rhonchi, or crackles. Her lower extremities are remarkable for 2+ pitting edema up to the level of her knees; there is no calf tenderness, venous cords, or Homan's sign appreciated. Her skin and mucous membranes were without diaphoresis or cyanosis. A bedside EKG reveals sinus tachycardia at 120 bpm with prominent S waves in lead I and Q waves in lead III.

Pulmonary embolism

A 45-year-old man presents with progressive dyspnea and chest discomfort. He is 2 days status post total hip arthroplasty, which was uncomplicated. He denies any trauma to the chest. On exam, his pulse is 110 bpm; respirations are 40/min. The chest radiograph reveals a wedge-shaped opacity. Lab studies reveal a higher D-dimer level.

Pulmonary embolism

A patient recovering from hip surgery begins to ambulate for the first time about 2 hours postoperatively. Suddenly, they experience shortness of breath. The patient becomes tachypneic and tachycardic and experiences pain on inspiration. Prior to getting out of bed, their postoperative course was unremarkable. There is no swelling; there is no palpable thrill at the incision site.

Pulmonary embolism

A 56-year-old Caucasian man presents with a 3 mm papule on the left nostril that has a pearly appearance, is skin-colored with smooth surfaces, and displays well-defined smooth borders. It has been present for 8 months, but it has become more noticeable in the past 3 months. The patient denies any other lesions with the same characteristics and wants it taken care of so it is not as bothersome. He denies weight loss, night sweats, or fevers; there have been no sleeping issues or recent changes in his appetite.

Punch biopsy

A 19-year-old woman presents with a 4-day history of fever accompanied by chills, nausea, vomiting, and back pain. She denies any chest pain, cough, or urinary symptoms. On further questioning, she said she had 2 episodes of diarrhea yesterday with vague abdominal discomfort. She has no other significant past medical history, is on no medications, and has no allergies. Family history is significant for hypertension in father and arthritis in mother. She is single, has no children, does not smoke or drink, and works part time as a waitress. On exam, she has a temperature of 102.4°F, pulse of 110/min, BP 110/60 mm Hg, and SPO2 of 92%. Mucous membranes are dry, and sclera is clear. Lungs are clear, and heart sounds are normal. There is mild left flank tenderness and tenderness in the left costovertebral angle. Labs: Hb 12g/dL, WBC 17,000/uL, bands were 18% and platelets 350,000/uL. Chest X-ray and EKG are normal. Urinalysis shows 35 WBC, 6 RBC, and no casts.

Pyelonephritis

A 28-year-old woman presents because she is concerned about her children, ages 2, 4, 6. She is asymptomatic and there is nothing abnormal in her medical records, but her father was recently diagnosed with medullary thyroid cancer due to the presence of MEN 2A. She is asking if the condition is hereditary; if so, wants to know what can be done to prevent her children from developing the malignancy.

RET mutation test in the patient

A 62-year-old woman presents with excruciating pain, burning, and swelling in her left forearm and wrist. Symptoms began with a fracture 4 months ago, worsening despite strict adherence to instructions. She has continued using a sling and limiting left arm use to prevent exacerbation. Fabric touching her skin when wearing a jacket or long sleeves causes pain. She denies fevers, pain in other areas, new trauma, and urinary symptoms. Past medical history is unremarkable. No tobacco, alcohol, or recreational drug use. Physical exam is remarkable for mild left forearm edema, erythema, and tenderness to light touch. Distribution of findings is elbow to wrist, anterior and posterior surfaces. Left wrist strength and range of motion are decreased compared to right.

Radiograph showing callus formation

A 28-year-old female administrator is referred to your office for further evaluation. She has noted swellings on her neck for the past 3 weeks. She denies any history of cough, fever, or night sweats. She reports she has been getting pruritus after taking alcohol. She is not on any medication and has no prior admissions. On examination, she is not pale and her vital signs are normal. She has a 2 cm rubbery non-tender left anterior cervical node and a 3 cm left posterior cervical node. No other nodes are palpable. The systemic examination is essentially normal. CT scans done of the chest, abdomen, and pelvis are normal. Reed-Sternberg cells are seen on a biopsy of the node. The ESR is 30 mm/hr.

Radiotherapy and chemotherapy

A 34-year-old African American woman presents with recurrent vaginal yeast infections. Over the past 2 years, she has had repeated episodes of similar infections that have been only partially responsive to over-the-counter treatments. She has not seen a physician in the 5 years since her last pregnancy, and she denies a history of any major medical illness. She has been moderately obese for most of her adult life; her maximal weight was 240 lb at a height of 5'1"; she has recently had a 15 lb unintentional weight loss. She also reports nocturia for the past several months. Examination reveals a blood pressure of 155/95 mm Hg, obesity, and findings consistent with vaginal candidiasis.

Random plasma glucose

You are a physician assistant assisting an orthopedic surgeon with a total knee arthroplasty (TKA). You reviewed the knee X-ray prior to the case and confirmed on the consent the correct side. A surgical time out was performed, and all agreed that the patient is having a left TKA. There is no mark on either leg by the surgeon to identify the correct leg. The surgery is completed, and the patient is transferred to the recovery room. Upon waking, the patient reports that they were supposed to have a right TKA. The consent is reviewed and does read as left.

Re-evaluate the consent procedure

A 14-year-old boy presents with bilaterally tender and swollen breasts. He has become increasingly self-conscious about the condition, resulting in his avoiding physical education classes and swim team practices. He has always had good general health with no history of medical illness, hospitalizations, or medications. He does not smoke or drink alcohol, and there is no history of illicit drug use or use of any activity-enhancing products. Family history is positive for a sister and his mother being diagnosed with breast cancer. The remainder of the review of systems is non-contributory. On physical examination, he appears normal in growth and development; there are tender soft masses in the lower quadrants of both breasts, approximately 3 centimeters in diameter. The remainder of the physical examination is unremarkable.

Reassurance that this is normal

A 3-year-old girl presents with a 5-day history of fever, coughing, sneezing, and watery nasal discharge. According to her mother, she passed out and began shaking yesterday. 1 hour before that, her temperature peaked at 40.1°C (104.2°F). The episode lasted for 1.5 minutes, and she remained drowsy for about 10 minutes afterward. She suffered a similar shaking episode during a bout of otitis media 1 year ago. The child reached all developmental milestones at appropriate ages, received all immunizations, and has no other relevant past medical or family history. Her only medication is acetaminophen. Vital signs: BP 110 / 70 mm Hg, HR 86 bpm, RR 20 rpm, and temperature 37.3°C (99.1°F). On physical examination, there is some wheezing in both lung fields. The remainder of the examination, including a full neurologic exam, is normal.

Reassure parents and discharge patient.

A 6-year-old boy is performing poorly in kindergarten. According to his teacher, he can perform some schoolwork and answer test questions, but he has difficulty understanding the instructions. He has to ask for detailed help regarding instructions, and his teacher sometimes has to demonstrate it to him with action so that he can proceed with his lessons. He is the second of three children. Except for language skills, developmental milestones are appropriate for his age. At 15 months, he could not respond to simple instructions like "no" and "give me." At the time, his mother thought, "He's just a little different from the other siblings." He has always had difficulty with school.

Receptive language dysfunction

A 16-year-old girl presents with concerns over her "growth." She feels ashamed and left out because she is the only girl in her class who has not reached menarche. Her mother reached menarche at age 11, and her younger sister at 10. She is sexually active with her boyfriend of 1 year; she has always used contraception. On examination, her vital signs are normal. Physical examination reveals rudimentary breast buds at Tanner stage 2 and an absence of pubic and axillary hair. A pelvic sonogram shows a normal-appearing vagina and uterus. An MRI of the brain shows a normal-appearing pituitary gland and hypothalamus, with agenesis of the olfactory bulb.

Reduced gonadotropin-releasing hormone from hypothalamus

A 70-year-old man with type 2 diabetes mellitus, hyperlipidemia, homocysteinemia, and metabolic syndrome presents with a 5-month history of excessive daytime sleepiness, a lack of refreshing sleep, a depressed mood, and an inability to focus at work and while driving. Additionally, he has been told by his wife that he snores rather loudly while sleeping. He denies fever, chills, headache, cold intolerance, weight loss, hair changes, hoarseness, dysphagia, chest pain, edema, palpitations, or changes in his bowel habits. On physical exam, he is found to be hypertensive. He has elevated BMI with abdominal obesity, and he has an enlarged neck circumference; no other abnormalities are noted.

Reduced inspiratory patency of the airway due to relaxation of the muscles

A 2-year-old boy with his parents presents with colicky pain, a history of irritability, and a 2-day history of lethargy. There is also history of rectal bleeding and passage of "currant jelly" stool for the past 2 days. Vital signs reveal blood pressure of 105/70 mm Hg, heart rate of 90 bpm, respiration of 18/minute, and temperature 99.2°F. Plain abdominal film shows evidence of obstruction, and barium enema detects coiled-spring appearance to the bowel.

Reduction by air enema

A 33-year-old man with no significant past medical history presents with a 2-month history of persistent right knee pain. The knee pain is located in the anterior part of the knee; "behind the kneecap," according to the patient. Pain is worse as he descends stairs, performs squatting maneuvers, and sits for excessive periods of time. He is an avid runner and states that running also increases pain. He denies any trauma, falls, accidents, or prior surgeries. He further denies any fever, chills, insect bites, rashes, effusions, grinding, popping, or clicking sensations in the knee. He denies any hip or ankle pain. The physical exam reveals tenderness to palpation along the medial undersurface of the right patella and a positive patellar apprehension test. The anterior and posterior draw tests, McMurray's test, and Apley's compression and distraction tests are all negative.

Reduction of running exercises

A 21-year-old male presents with a 3-week history of pain in his left shoulder. The pain began when he started spring training and has gradually worsened. In addition, the patient is now having difficulty lifting the arm above his head. He denies injury to the shoulder itself; he states that ibuprofen provides some relief. On physical exam, the patient has tenderness to palpation of the lateral left shoulder just under the acromion, limited abduction of the left shoulder, and a negative drop-arm sign and crossover test.

Refer for physical therapy

A 42-year-old man with a known past medical history of schizophrenia has begun to demonstrate new and unusual behavior over the past 2 weeks. The patient has been compliant with taking risperidone 2 mg for the past year. The patient's son reports that his father has been acting "silly" and exhibiting inappropriate behavior, such as removing his clothes, repeating odd noises and gestures, and speaking incoherently with random loud and violent outbursts. This morning, the patient was observed to have used a knife to cut himself; his son stopped him.

Refer the patient to the hospital for inpatient monitoring.

A 41-year-old woman presents to the local emergency department with a 14-day history of nasal drainage, congestion, fever, and cheek pain. She was started on amoxicillin/clavulanate initially, but she was switched to levofloxacin 7 days ago due to no improvement in symptoms. After 7 days of levofloxacin therapy, she presents again, reporting that she is no better. The fever continues and she now has upper tooth pain. On exam, she is in mild distress, with thick purulent rhinorrhea and halitosis.

Refer to ENT for sinus aspiration

A 52-year-old man presents with a concern of hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only the left side. Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. The patient's past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed; it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Referral for surgery

A physician assistant has just joined an internal medicine practice that has been around for more than 5 years. This practice consists of an internal medicine physician and a nurse practitioner. The patient population consists of >50% with Medicare insurance. While in orientation, the physician assistant overhears that all laboratory exam referrals go to a private laboratory that is owned exclusively by the internal medicine physician.

Referring to self-owned businesses

A physician assistant recently joined a busy family medicine practice. The PA has noticed that their supervising physician is almost always late for work and is often late returning from lunch, at which times the PA has witnessed the supervising physician asleep in their car. The PA has also observed multiple irrational volatile outbursts by the physician while seeing patients in the clinic. He is concerned that the physician may have a substance abuse problem.

Report the physician's behavior.

A physician assistant is working the night shift in an emergency department and she notices that their boss comes in 3 hours late. The boss states that they had an emergency to deal with at home and did not notify the emergency department of their tardiness. The boss proceeds to the nurse's station and has difficulty with ambulation and trouble communicating with nursing staff, slurring some words.

Report them anonymously.

A 30-year-old man presents with recurrent vertigo. He gives a history of attacks when rising from bed in the morning and rolling over in bed that last <1 minute. He does not have headache, earache, hearing loss, tinnitus, nausea, or vomiting. He has no recent history of URI and has no other significant medical history. On examination, external auditory canals are normal. Dix-Hallpike maneuver produces nystagmus. Hearing tests are within normal limits. Pulse is 72/min, and blood pressure is 120/78 mm Hg. Central nervous system examination (including higher functions and mental status) is within normal limits.

Repositioning maneuvers

A 34-year-old pregnant woman presents with what she describes as "tingling in her right arm." She is at 34 weeks of gestation. This is her second pregnancy. It comes on along her palm, and it has been increasing in severity. She also notices it more at night and while attempting to carry her shopping bags. Her pain has been so bad lately that she has been losing sleep. Examination reveals a positive Phalen's test; there is no weakness or atrophy of the thenar muscles. She is not known to have diabetes or hypertension, and she is otherwise healthy. Her thyroid function is normal. Her primary care physician advised treating with NSAIDs and vitamin supplements, neither of which have worked after 3 months of regular use.

Rest and neutral splinting

A 61-year-old man with known cirrhosis presents with a 1-week history of "puffy" ankles and increased shortness of breath. A week before symptom onset, he was on vacation, where he engaged in walking, sightseeing, and eating out. He admits more dyspnea with lying down and with increased exertion. His shoes feel snug, and he notes a definite line from wearing socks. The patient denies chest pain, leg pain, fevers, claudication, nausea, headache, lethargy, and hemoptysis. His past medical history is remarkable for cirrhosis and a history of alcoholism. He is awaiting a liver transplant. He had a liver biopsy, but no other surgeries. He takes no medications, has no allergies, and has abstained from alcohol for 9 months. He lives with his wife, works as an electrician, and smokes a pack of cigarettes per day. Vitals are normal, including oxygen saturation. On physical exam, the patient appears in no acute distress and with normal mental status. His physical exam is remarkable for mild jugular venous distention, 2-3+ edema in lower extremities, and mild dullness to lung percussion. No hepatomegaly or ascites are noted.

Restrict dietary sodium.

A 72-year-old man presents with "being short of breath"; he feels as though his belly is bloated and his legs are swollen. Past medical history includes high blood pressure (for which he is currently taking lisinopril) and high cholesterol controlled with diet modifications. The patient also has a past diagnosis of mediastinal lung cancer around 5 years ago for which he received radiation treatment as part of his prescribed therapeutic regimen. Physical examination reveals an elevated jugular venous pressure and Kussmaul sign. Moderate pitting edema and ascites are also observed. Chest radiograph reveals only mild cardiomegaly. Echocardiogram reveals a normal left ventricle chamber size, normal LVEF, and a thickened atrial septa.

Restricted cardiomyopathy

A 55-year-old man was brought to the emergency department for evaluation of sudden chest pain. He was at a barbecue eating ribs when he developed sudden substernal chest pain with nausea and left arm numbness. An EKG demonstrated 2 mm ST elevations in leads V3, V4, and V5. He was diagnosed with acute myocardial infarction. Cardiology was consulted and angioplasty was recommended. The procedure and potential risks were explained in detail to the patient. The patient declined angioplasty to the cardiologist, opting for medical therapy alone. He is discharged. His family sues the PA and cardiologist for malpractice.

Resulting damages

A 35-year-old woman presents with amenorrhea. She missed her last period and reports fatigue, morning episodes of nausea and vomiting, dry eyes, and difficulty seeing at night. Physical examination reveals dry conjunctiva, corkscrew hair, and hyperkeratotic skin lesions. Laboratory evaluation is remarkable for a significantly elevated serum hCG. Transvaginal ultrasound reveals a molar pregnancy.

Retinol

A 42-year-old man presents with a 4-day history of worsening headache, stuffy nose, and clear-to-green nasal discharge. He admits to facial pain and a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a slight fever of 99.2°F taken orally, pulse 86/min, BP 120/76 mm Hg left arm sitting, and SPO2 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates.

Rhinovirus

A 28-year-old woman presents with severe right ankle pain. Further questioning reveals the patient is unable to move her ankle. She states that it is exquisitely tender and the pain worsens with movement or when attempting to bear weight. She states that she was immediately unable to take any steps because of how substantially painful the right leg is. During the physical examination, the patient continues to be unable to bear weight on the injured leg. You note that the right ankle is painful to even light palpation throughout the malleolar zone. The skin is a healthy color and there are no signs of lacerations or tenting. Pulses are palpable. The entire area of the right ankle is swollen and appears dislocated. The left leg, foot, and ankle are unremarkable.

Right ankle fracture

A 42-year-old man presents with a 3-day history of "not being able to hear in my right ear." He is otherwise healthy and is not taking any medications. There is no history of trauma. On physical exam, the whisper test is decreased on his right, the Weber test lateralizes to the right ear, and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction.

Right ear conductive hearing loss, possibly due to cerumen impaction

A patient presents with a motor deficit on the right side of the body, decreased sensation and pain on the left side of the body, and diminished vibratory and position sense on the right side of the body. What type of spinal cord lesion is present?

Right hemisection of spinal cord

A 10-year-old Latinx boy is brought by paramedics to the emergency department after a motor vehicle accident. He is unconscious and has sustained severe trauma. He has a subdural hematoma, multiple fractures, contusions, and a tension pneumothorax. He is treated with needle thoracentesis and subsequent chest tube placement. A neurosurgeon is consulted regarding the subdural hematoma. The driver of the car, a Latinx woman in her mid-30s, did not survive the accident. Efforts are made to identify the boy and to locate his next-of-kin. The patient's father arrives at the hospital, but he does not speak English.

Right to autonomy

The Tuskegee Syphilis Study conducted by the US Public Health Service followed 600 African American men—399 of whom had syphilis—over 40 years (1932-1972). The men were given free medical exams, free meals, and burial insurance in exchange for participating in the study. The patients were told that they were being treated for "bad blood." They were never explicitly told they had syphilis and were not treated for the disease, even after 1947 when penicillin had been proven effective as treatment. By the time the study was terminated in 1972, 40 of the men's wives had syphilis, and 19 of the children of study participants were born with congenital syphilis. This study is now infamous as an example of unethical research practices.

Right to informed consent

A 13-month-old boy presents with a rash. The mother reports that he has had high fevers over the past 4 days, but he has not had a fever for the past 24 hours. The rash began 6 hours ago, startingt on his chest and back, spreading to his neck, face, and arms. The child does not appear to be itchy, and he has been acting normally since the fever subsided. The mother denies cough, runny nose, vomiting, and diarrhea. The only medication that the child has taken is acetaminophen. On examination, the child is happy and playful. The only physical finding is a blanching macular rash noted on the mentioned areas.

Roseola

An 18-month-old infant presents with a 5-day history of fever of 104°F. On physical examination, you note a mildly irritable infant who has not been feeding well. There are no other clinically significant findings. You prescribe acetaminophen (Children's Tylenol) and tell the mother to monitor the infant's fever for the next few days; if the fever goes down, everything should be fine. The mother calls the next day and says that the fever has stopped, but a rash has developed, and she is concerned. The infant examination reveals a diffuse fine maculopapular rash. Presently, the child does not appear ill.

Roseola

A 49-year-old Caucasian man well known to your practice presents due to his history of hypertriglyceridemia. He seeks evaluation of his recent cholesterol lab values. He has a significant family history of cardiovascular disease; his mother had a heart attack at age 57, and his father had open heart surgery at age 60. The patient has had low HDL levels in several past cholesterol screening tests. At the last office visit, lifestyle modifications were implemented by the patient. He has been extremely conscientious about his diet; for the past year, he has also been participating in physical activity 6 days a week. In addition, he has significantly limited his alcohol intake. Current fasting lab values for the patient are as follows: total cholesterol of 235 mg/dL, triglycerides of 350 mg/dL, HDL of 35, and an LDL of 175 mg/dL. You decide to initiate pharmacologic therapy to treat the patient's cholesterol and triglyceride levels.

Rosuvastatin

A 21-year-old man presents with a 3-month history of pain in his left shoulder. He is a left-handed pitcher for his college baseball team. The pain began when he started spring training a few months ago, and it has gradually worsened since that time. In addition to the pain, the patient is now having difficulty lifting his left arm above his head. He denies any injury to the shoulder itself, and he states that ibuprofen provides some relief. On physical exam, the patient has tenderness to palpation of the lateral left shoulder just under the acromion, limited abduction of the left shoulder, a negative drop-arm sign, and a negative crossover test.

Rotator cuff tendinitis

A 35-year-old man presents with right shoulder pain that is becoming progressively worse. Although he visits the gym 3 times a week, over the past month he has not been able to increase the amount of weight he lifts secondary to the shoulder pain. He has not tried anything to alleviate the pain. He reports that the pain is at its worst at night while he is trying to sleep. He also reports pain while in the shower washing his hair, or when using the shoulder press machine at the gym. He denies any history of recent trauma or sports-related injury. Upon questioning, however, he reports that about 1 month ago he and his wife painted their entire house in one weekend. On exam, there is no notable swelling, atrophy, redness, or bruising of the shoulders. Point tenderness is noted over the right lateral deltoid muscle. Active ROM of the right shoulder at 80° of abduction elicits pain. Patient has a negative drop arm test, negative apprehensive test, and a positive Neer impingement test of the right shoulder.

Rotator cuff tendonitis

In the winter, an 11-month-old male infant presents with a 2-day history of vomiting, diarrhea, and fever. He has not had routine medical care since birth. Mother reports no significant past medical history. His temperature is 102°F. Clinically, he appears dehydrated; his white blood cell count is 5400 cells/mm3 with a normal differential. His stool and urine are negative for white blood cells.

Rotavirus

A 15-year-old boy presents for a routine physical. He reveals a 1-month history of mildly painful swelling of the anterior superior left shin, unaccompanied by fever, erythema, or joint problems. He plays football for his high school and has been assisting his father in in a project that entails considerable kneeling that worsened the pain in the affected area. Examination is unremarkable except for mild slightly tender swelling of the left anterior shin approximately 5 cm below the knee. Radiographs of the left knee showed mild irregularity of the tibial tubercle.

Routine symptomatic treatment

Early one afternoon, a 12-year-old boy presents with his parents to the ER with lower right abdominal pain, anorexia, nausea, and vomiting. He rates his pain at 8/10. Pain started around the umbilical area and has moved to the right lower abdomen worsening since the onset of symptoms of nausea and vomiting this morning. He denies any known history of gastrointestinal disease or recent illnesses. He denies any known ill contacts. Vital signs include temperature of 101°F, heart rate 80 bpm and regular, blood pressure 118/70 mm Hg.

Rovsing's sign

A 28-year-old woman with a 4-year history of end-stage renal disease secondary to diabetes has had intact parathyroid hormone (PTH) levels of 600-800 pg/mL (ref 150-300 pg/mL) for the past 15 months. She does not take prescribed phosphorus binders with meals and she routinely misses her dialysis treatments, during which she receives intravenous paricalcitol.

Rugger jersey spine

A 28-year-old woman presents with abdominal pain and vaginal bleeding. The pain began last night as a dull ache in the right lower quadrant, but this morning it became much more severe. She also complains of dizziness and nausea. She cannot recall when her last menstrual period was, but she says that she began bleeding yesterday and has a light menstrual flow. On examination, the patient is afebrile; pulse is 100/min, BP is 86/60 mm Hg, and RR is 20/min. Physical exam reveals moderate to severe tenderness in the right lower quadrant with rebound tenderness and guarding. Pelvic exam reveals a small amount of blood at the cervical os with cervical motion tenderness. You order a variety of laboratory tests on this patient.

Ruptured ectopic pregnancy

A 73-year-old man presents with worsening shortness of breath on activity over the last few months. Another issue he mentions is not being able to complete as many physical activities during the day as he could perform 3 months ago. He states he has to use at least three pillows to allow him to sleep at night; otherwise, he cannot breathe. Physical examination confirms the suspected diagnosis.

S3 gallop

A 3-year-old African American girl with sickle cell disease presents with a limp; her mother first noticed the limp yesterday morning. The girl has not had any fever, nausea, or vomiting, but she is in pain. The girl's sickle cell disease has been relatively mild; she is fully immunized and takes prophylactic oral penicillin 125 mg 2 times a day. On exam, she is afebrile. There is pain in the left hip on internal and external rotation, but there is no definite point tenderness. Exam of the left knee and right hip are negative. You are concerned about septic arthritis, and you plan further workup.

Salmonella species

A 32-year-old African American woman with no significant past medical history has been referred to a pulmonologist; she presents with a 2-month history of progressive dyspnea. She notes associated low-grade fever, malaise, joint pain, and swollen neck glands. She denies a history of travel, cigarette smoking, drug use, or sexually transmitted diseases (she has not been sexually active in the past year). All other reviews of systems are negative. Her physical exam reveals tender nodular formations on her anterior lower extremities, parotid enlargement, hepatosplenomegaly, and cervical lymphadenopathy. Her vital signs, heart, and lungs are unremarkable. Diagnostic testing reveals leukopenia, increased ESR, hypercalcemia, hypercalciuria, elevations of serum ACE levels, and bilateral hilar adenopathy with diffuse reticular infiltrates. ANCA, ANA, and rheumatoid factor tests are negative. Histological assessment confirms the presence of noncaseating granulomas.

Sarcoidosis

A 62-year-old African American woman presents with a persistent cough and shortness of breath. Bronchoscopy is performed and the report includes the following description: "2 x 2 cm non-necrotizing granuloma in the left upper lung field and a 1 x 1 cm non-necrotizing granuloma in the right middle lung field."

Sarcoidosis

A 16-year-old boy presents with a general itching of his hands and wrists. It started a few weeks after he went to play in a high school soccer tournament. On physical exam, you note several wavy skin-colored ridges on his hands and wrists with excoriations. There are multiple small erythematous papules on flexor surface of wrists. You note that the intertriginous areas of the hands are involved.

Scabies

A 27-year-old woman presents with excruciating back pain. She states that the pain started earlier that morning and caused her to miss work. She has had similar pain like this before, but no doctor has ever found anything wrong. She is currently on fluoxetine for depression and periodic ibuprofen for pain. On physical exam, tissue texture changes are noted at L1 to L3, with no additional findings. The woman seems to be in an immense amount of pain, however, and she continues to insist that something is horribly wrong with her. Diagnostic results are negative, and a pain medication is prescribed. She returns later in the week with the same issue but no new findings. History shows episodes similar to this involving joint pain, abdominal pain, headaches, bloating, diarrhea, a "lump in the throat" feeling, and menstrual cramps.

Schedule frequent visits and involve her in the decision-making process

A 28-year-old man presents for a checkup. Medical records indicate a 3-year history of hospitalizations for mania and depression. The last admission occurred 7 months ago and was due to a suicide attempt after a major depression. The patient has been taking lithium since the last hospitalization; there have been no further mood disturbances, but his mother relates that the patient remains convinced that the "city officers" poisoned the water system over the last 2 months. He refuses to drink tap water. His mother heard him talking alone in his room, and she found several bottles of water under his bed. She reports he has not been very social with his friends over the last 6 months and is showing signs of depression. On examination, the patient appears disheveled; he experiences auditory hallucinations and persecutory delusions throughout the interview. His speech is disorganized.

Schizoaffective disorder

A 70-year-old woman has been refusing to leave her room at the nursing home facility where she resides. She says that people are following her, and she even refuses to go out with her daughter. She has a long history of mental illness; her ex-husband had her committed to a state hospital, where she had resided for over 30 years. On interview, it is difficult to obtain a history; her thinking is disordered and her speech is erratic. When asked why he committed her, she says that she believes her husband was trying to kill her.

Schizophrenia

Police officers found a 27-year-old man walking aimlessly and shouting the names of former presidents. Urine toxicology is negative, and the man appears to be oriented with respect to person, place, and time. He has had 5 similar admissions over the past year. Attempts to interview the patient are fruitless; he is easily derailed from his train of thought. A phone call to a friend listed in the chart provides the additional information that the man is homeless and unable to care for himself.

Schizophrenia

A 26-year-old African American man presents with a rash on his back. He first noticed the rash 3 weeks ago. He describes small whitish upper back lesions that are not painful and do not itch. He has no significant past medical history; he has no known drug or food allergies; he is not taking any medications. On physical examination, there are several small hypopigmented macules that coalesce on the upper third of his back. Fine scaling is produced on scratching. The remainder of the physical examination is unremarkable.

Scrape lesions and KOH stain.

An 8-month-old male infant presents with rashes over the scalp and eyebrows. Physical examination shows a dry scaly crusting lesion over the scalp, eyebrows, and nape area. He is comfortable, so his mother presumed that it was not itchy at all. He has been breastfed up to this point, and he started solid food at about 5 months. There are no other signs or symptoms noted. Bowel movement and urination are normal. Developmental milestones are consistent with age.

Seborrheic dermatitis

A 27-year-old man presents with the "flu." He says that he has felt feverish, tired, and mildly nauseated for the past few weeks. He mentions a headache and non-pruritic rash. He denies any past medical history or medication use. On exam, he is afebrile. Examination reveals diffuse mild lymphadenopathy with mild hepatosplenomegaly; his soft palate has a few scattered shallow ulcerations. The palmar and plantar surfaces have a scattered papular rash that is copper colored, with a few papules on the flexor surfaces of the arms, legs, and trunk. Laboratory evaluation reveals hemoglobin of 12.8 g/dL, hematocrit of 38%, and white blood cell count of 11.1 x 103/ìL.

Secondary syphilis

A 3-year-old boy presents with a 4-hour history of respiratory distress, dysphagia, and fever. On examination, temperature is 104.3°F, pulse 150, and respirations 32 and shallow. Marked inspiratory stridor with an open-mouth appearance and sialorrhea is present.

Securing the airway

A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, red and watery eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She most likely has allergic rhinitis.

Sedation

A 36-year-old G1P0010 woman and her 40-year-old husband present for a family planning visit as they have been trying to conceive for 10 months without results. She has history of one spontaneous abortion five years ago. The spouse has never fathered a child. Neither partner has any other significant past medical or past surgical history. Physical examination of both partners is unremarkable.

Semen analysis

A 15-year-old girl presents with a 1-year history of intermittent abdominal pain with nausea and occasional bloody diarrhea. She denies fever and weight loss; there is no travel history. Past medical history is significant only for migraines. She takes a multivitamin. Her vital signs are within normal limits. She has mild diffuse abdominal tenderness to palpation and guaiac-positive stool. Her exam is otherwise normal. Hemoglobin 9.7, hematocrit 28%, WBC 12,000/uL.

Send stool studies and refer to for colonoscopy.

A 12-year-old girl presents with symptoms of anxiety. Her parents report she has always been anxious, but her anxiety levels have escalated during this school year. She frequently resists going to school in the morning. Once there, her symptoms often escalate enough to involve the school nurse. They are usually alleviated by telephone contact with her mother. Symptoms also occur on weekends when her mother has to work. The patient has a normal group of friends, but she prefers to be with them at her home rather than elsewhere. She has never slept away from home. She spends a considerable amount of time alone in her room, but she will often come out to "check up" on her mother.

Separation anxiety disorder

An 8-year-old girl is brought to your attention because she recently started refusing to go to school. When her mother tries to explain that she must go to school, the girl begins to report headaches and stomachaches. She does not want to sleep alone and is clingy around both of her parents. These symptoms have been present for 6 weeks. The parents are recently separated, and she has been having a hard time adjusting to the divorce. As a result, she has been acting out towards her teachers in the classroom. Her physical and laboratory findings, including drug tests, are normal.

Separation anxiety disorder

A 16-year old girl on her high school's swim team focuses her exercise regimen on endurance rather than building muscle mass. While her menses are regular and moderate in quantity, she is concerned that she may become iron deficient and that this will negatively affect her endurance and athletic performance. She asked if she should begin an iron supplement. Past medical history was unremarkable, and there was no history of tobacco, alcohol, or recreational drug use. Growth and development have been normal, and immunizations are current. Vital signs are normal. Examination is unremarkable, consistent with Tanner stage V. Hematocrit, hemoglobin, and ferritin were normal.

She does not need an iron supplement.

A 20-year-old woman presents to urgent care with diarrhea of 4 days' duration. She describes the stool as greasy and foul-smelling. She has also experienced nausea, mild weight loss, and abdominal cramps. She denies tenesmus, urgency, or bloody diarrhea. She has no relevant past medical history.

She drank stream water from a recent camping trip.

A 5-year-old boy presents with a 4-day history of bloody diarrhea. He has had fever up to 104°F, abdominal pain, and painful defecation. His past medical history is unremarkable, and he has had no surgeries. He is on no medications and has no drug allergies. He attends a local daycare with nine other children. On physical examination, his abdomen is tender with hyperactive bowel sounds. While in the emergency department, he has a 5-minute generalized seizure.

Shigella sonnei

A 32-year-old man reports anorexia, constipation, fatigue, thirst, weakness, drowsiness, nausea, and muscle pain that has developed over the last few days. He has been bedridden for the last 3 months after a traffic accident wherein his 3 cervical vertebrae were fractured. A few weeks ago, a diagnosis of kidney stones and chronic renal insufficiency was established. The rest of his personal and family history is non-contributory. His physical examination today demonstrates quadriplegia, and the rest of examination is within normal limits.

Short Q-T interval

A 16-month-old African American boy presents with a 2-day history of irritability and refusal to bear weight. His mother denies any recent history of fever, vomiting, diarrhea, rash, or trauma. Family history is significant for a maternal uncle who had a stroke and died when he was 35. On exam, vital signs are stable. Patient appears smaller than stated age and is irritable but consolable. He is in no apparent distress, but he refuses to bear weight or play. The only significant findings on exam are swollen hands and feet. CBC reveals WBC 18,000 mm3, with 40% neutrophils, 30% lymphocytes, and 1% monocytes. Hb is 8 g/dL and platelets are 400,000 mm3.

Sickle cell solubility test

A 28-year-old man presents with a rash. The lesions, which are mildly pruritic, are located on his arms and legs. They have been present for about 3 days without change or resolution. He has tried over-the-counter anti-itch creams, but they have been ineffective. The patient reports that he was seen approximately 1 week ago for some blister-like lesions on his penis. He was given an antiviral medicine, and those lesions resolved. He is wondering if he was misdiagnosed and if the two rashes are related. He admits to feeling some malaise over the last 2 weeks, but he is otherwise healthy. He denies fevers, unusual travel, medication use (except for as listed above), and known allergies. He has no known chronic conditions. On physical exam, vitals are normal; the patient is in no apparent distress. A pink-to-red papular rash is observed on the backs of the hands and feet and extensor surfaces of the arms and legs. The individual lesions are quite distinct; they have a red center, and they are surrounded by a pale ring and then another outer ring of red, inflamed tissue. The remainder of his physical exam is normal.

Skin biopsy

A 7-year-old boy presents with a 3-day history of intense pruritus on his wrists, fingers, and antecubital fossae. It began on his fingers and has moved proximally. According to his mother, they are raised red eruptions and some have scabbed over. She states he has never had this before and it is keeping him up at night. He recently started at a new school.

Skin scraping with immersion oil

A 2-year-old boy presents because of his mother's concerns about his sleep. She notes that he is easy to put to sleep, and he has a regular bedtime of 7:30 PM. Most nights for the past 3 weeks, about 90 minutes after being put to sleep, he begins to thrash violently in bed, sometimes letting out bloodcurdling screams. He has his eyes open and seems to be talking, but he does not respond to either parent when spoken to. He sweats a lot. The episodes last about 15 minutes, and he then goes back to sleep; he seems fine in the morning. He naps for about an hour in the morning and an hour in the afternoon, but these episodes do not occur with naps.

Sleep terrors

A 46-year-old woman presents with nausea, vomiting, crampy abdominal pain, and loud bowel sounds for the past several hours. She denies weight loss. She has had one normal bowel movement since the symptoms began, but it did not help her symptoms. She has a past surgical history of an abdominal hysterectomy 7 years prior. On physical exam, she is afebrile, with hyperactive and high-pitched bowel sounds localized to the left upper quadrant. She also has mild diffuse abdominal tenderness.

Small bowel obstruction

A 56-year-old man wakes up in the morning to find that he has a swollen, red, and painful big toe on his left foot. He had been on a cruise to the Bahamas 2 days earlier, and he spent much of the time eating and drinking. He normally has 1 glass of wine with dinner on the weekends, but his alcohol consumption increased substantially while on the cruise. He also did a great deal of walking in an attempt to make up for his excesses. He goes into his physician's office, and tests are run. An X-ray shows no acute fracture, and his vital signs are within normal limits. Blood work shows an increase in uric acid, but it is otherwise normal. He begins treatment and feels better within 24 hours.

Small lower extremity joints

A 65-year-old man presents with flank pain, blood in his urine, and an unexplained weight loss. His past medical history is significant for numerous infections, kidney stones, cigarette use, and alcohol use. On physical exam, there is a palpable abdominal mass, as well as a low-grade fever.

Smoking

A 53-year-old man with a 40 pack-year smoking history presents with a 10-month history of an intermittent cough with productive sputum. He admits to progressive exertional shortness of breath, which recently has limited his activity to climbing 1 flight of stairs or walking 3 city blocks. He denies diaphoresis, fever, chills, chest pain, palpitations, audible wheezing, pleurisy, peripheral edema, hemoptysis, abdominal pain, reflux, regurgitation, diarrhea, melena, or hematochezia. He also denies travel, sick contacts, and drug or alcohol use. His general survey reveals an overweight male with an odor of smoke and nicotine staining of his fingernails. His nails also demonstrate digital clubbing. His pulmonary exam reveals a prolonged expiratory phase, barrel chest, poor diaphragmatic excursion, and wheezing to auscultation. Pulmonary function testing shows airflow obstruction with a reduction in FEV1 and FEV1/FVC ratio; increases in total lung capacity, functional residual capacity, and residual volume were noted.

Smoking cessation

A 52-year-old man has a past medical history of smoking 40 packs of cigarettes per year; he presents for a follow-up. He notes that, over the past week, he has developed increased nonproductive cough and shortness of breath. He has had a chronically-progressive cough and shortness of breath upon exertion over the past year. His occupational history reveals coal mining for 25 years. He denies any alcohol consumption, travel history, or sick contacts. He also denies fever, chills, sore throat, otalgia, chest or abdominal pain, peripheral edema, rashes, and pruritus. A chest radiograph is performed, which reveals diffuse bilateral ground-glass opacities and eggshell calcification of hilar lymph nodes.

Smoking cessation strategies are encouraged.

A 33-year-old woman presents after being found unresponsive in her bedroom. She has a past medical history of depression, and her mother found an empty bottle of amitriptyline by her bedside. Otherwise, the patient has no other medical or surgical history. She is a non-smoker and does not drink alcohol. On physical exam, pulse 138/minute, blood pressure 80/60 mm Hg, temperature 101.2°F (38.4°C), respirations 6/minute. Her heart sounds are normal, and she has thready pulses. Her breath sounds are normal but with shallow effort. The abdomen is soft and non-tender. Neurologically, she moves her limbs from painful stimuli. Her skin is flushed; there are no needle marks. Her chest X-ray is normal, and the electrocardiogram demonstrates a wide complex tachycardia without ectopy. The patient is intubated and hyperventilated.

Sodium bicarbonate

A 35-year-old man presents with intense itching around his anus that has been worsening over the last several weeks. He states that he has noticed an increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10. This intense pain makes him not want to have any bowel movements. He admits to only one episode of a small amount of bright red blood on the toilet paper and on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease.

Spicy foods

A 68-year-old man presents due to lower back pain. The patient reports the pain has been present for the past 3 months and seems to be getting worse. Upon physical exam, the patient appears to get relief of pain when bending forward. Upon standing and extension of the lumbar spine, the patient reports pain. He denies decreased range of motion in the shoulders, neck, and hips. The spine is not in an S or C shape. T2 weighted imaging shows disc degeneration. X-rays show symmetrical joint spaces. C-reactive protein (<1.0 mg/L) and ESR (<40 mm/hr) are in normal range. Gram stain is negative for Staphylococcus aureus.

Spinal stenosis

A 68-year-old Irish farmer presents for his annual physical examination. He smokes 10 cigarettes per day. He has no complaints, but an erythematous scaly non-tender nodule measuring 0.5 cm is noted on his left lower lip. There are no surrounding telangiectasias. The nodule is firm, ill-defined, and fixed to the underlying tissue. It does not blanch with pressure.

Squamous cell carcinoma

A mother brings in her 5-year-old son due to papular and pustular lesions on his face. A serous honey-colored fluid exudes from the lesions. You suspect impetigo. A Gram stain reveals spherical gram-positive arrangements in irregular grape-like clusters.

Staphylococcus aureus

A 58-year-old menopausal woman presents for a wellness exam with no current problems or vasomotor symptoms. She has recently been caring for her mother after a hip fracture. Past medical history is remarkable for stable rheumatoid arthritis since age 28 with weekly etanercept. Her rheumatologist has periodically prescribed a few weeks of prednisone for flares. No other medications, allergies, or surgeries. Her older sister has osteoporosis. She has four grown children, lives with her husband, and is a homemaker. She denies alcohol or drug use but admits to smoking 1 pack of cigarettes per day. Vitals and exam are normal. Some preventive screenings are done. Labs, mammography, and Pap smear return unremarkable. DEXA scan shows a T-score of -3.22.

Start bisphosphonate therapy.

A 3-year-old girl presents with a 2-day history of a sore throat and fever. This morning, she was hoarse and seemed to be having more difficulty breathing. On exam, she appears to be in distress and has an oral temperature of 100.0°F. Tympanic membranes are pink but not bulging. Nares are patent without rhinorrhea. She has a barking cough, stridor at rest, and nasal flaring.

Start humidified oxygen, nebulized racemic epinephrine. and single-dose IM dexamethasone.

A 27-year-old man presents with a burning sensation in his chest, dry cough, hoarseness, and a sensation of a lump in his throat. He also experiences belching followed by a sour liquid taste in the mouth. Symptoms started 2 hours ago, and he thinks that they are worsening. He has had several similar episodes over the past 2-3 years that recently have become more frequent of 3 episodes per week, probably because there is more stress in his life now. Namely, each episode of chest pain is associated with an anticipated or experienced stressful event (exams, job interviews, etc.). Symptoms are severe enough to interfere with his daily living. The rest of his history, family history, and physical are non-contributory. His EKG, chest X-ray, and CBC are normal.

Start omeprazole.

In 1965, in an article published in the Proceedings of the Royal Society of Medicine, Sir Austin Bradford Hill (Professor Emeritus of Medical Statistics, University of London) proposed a series of criteria for evaluating the likelihood of a cause-and-effect relationship between a specific exposure (risk factor) and a disease. If there is an association between the exposure and the disease, he recognized the following criteria: Strength of association Consistency of data Specificity Temporality Biological gradient Plausibility Coherence Experiment Analogy Hill qualified his endorsement of these criteria, however, by stating "None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required sine qua non."As a family practice PA, you routinely recommend HPV vaccine to boys and girls ages 11 and 12. Some parents are initially hesitant, so you have learned to make convincing arguments to the parents in favor of the vaccine based on the evidence that human papillomavirus (HPV) causes cervical cancer.

Strength of association

A 22-year-old woman presents because she developed a fever of 101°F this morning. She has a 2-week history of rhinorrhea, congestion, and headache. She states that her rhinorrhea was initially clear and actually improved after 5 days, but then it returned and developed into a green color. Her headache is felt in the forehead and cheeks, and it worsens when she bends over.

Streptococcus pneumoniae

A 43-year-old man without any significant PMHx presents with acute onset of a productive cough, shortness of breath, pleuritic chest pain, and fever. His sputum is described as "thick, brown-colored, and mucoid" but without blood. He also notes associated fatigue and night sweats. He denies chills, changes in weight, a history of travel, sick or confined contacts, exposure to animals, cigarette smoking, otalgia, sore throat, swollen glands, abdominal pain, diarrhea, rashes, myalgias, and arthralgias. His physical exam is remarkable for fever, tachycardia, and tachypnea. The lung exam is noteworthy for right lower lung field increased tactile fremitus, dullness to percussion, inspiratory crackles, and bronchial breath sounds.

Streptococcus pneumoniae

A 66-year-old man with moderately well-controlled type 2 diabetes mellitus presents to his primary care provider for the management of pneumonia. His influenza test was negative. He is currently being treated with levofloxacin. He is afebrile; pulse is 93, blood pressure is 130/90 mm Hg, respirations are 18/min, and oxygen saturation is 92% on room air.

Streptococcus pneumoniae

A 10-year-old boy is brought to the clinic by his mother. She noted that his face is swollen, and he told her that his urine was cloudy and reddish. He has a history of falling and abrading the skin of his right thigh 2 weeks ago. The next day, the skin became red, hot, and tender; the infection was treated with a topical antibiotic ointment. The cellulitis gradually healed.

Streptococcus pyogenes (group A beta-hemolytic)

A 26-year-old pregnant woman diagnosed with primary tuberculosis and wants to discuss treatment options. Initial labs come back with mild anemia, positive HCG, and elevated cholesterol. All other labs are within normal range.

Streptomycin

A 44-year-old woman G5P5 presents for her annual pelvic examination. Her menses are regular, and she is currently mid-cycle. She notes "leaking urine" when she coughs, sneezes, or strains. There is a bulge into the anterior vaginal wall; it is exacerbated when the patient is asked to "bear down." A urinalysis is unremarkable. There is no cervical motion tenderness or discharge noted on pelvic examination. The patient is afebrile and in no distress. No lesions are noted on the external genitalia and the pelvic examination is unremarkable except for the noted bulge. Vaginal cultures for gonococcus (GC) and chlamydia are pending.

Stress urinary incontinence

A 36-year-old woman gravida 1 para 1 came to the emergency department with severe abdominal pain and two episodes of profuse vaginal bleeding, chills, and light-headedness 10 days after cesarean delivery. Because of her age, she was closely monitored during the pregnancy and several ultrasound examinations were performed. Today, physical examination reveals tender and firm abdomen with bloody vaginal discharge; her pulse is 100/min; blood pressure of 100/60 mm Hg; and temperature 36.0°C. Laboratory reveals a white blood cell count of 10,000/μL and hemoglobin level of 11 g/DL. Coagulation tests and urine beta hCG are within normal limits. Ultrasound reveals low-resistance vessel in the inner third of the myometrium.

Subinvolution of the placental site

A 25-year-old man has a long history of criminal behavior, and he has been in and out of prison for assaultive behavior, theft, armed robbery, and sexual assault. He shows no remorse for his behavior and states that he is the real victim. He also shows little emotion regarding his family history, and he prefers to brag about his sexual exploits. The patient denies a history of mood disorders or schizophrenia.

Substance use disorder

A nurse paged the on-call physician assistant regarding an 87-year-old woman reported to be agitated and experiencing auditory hallucinations. The physician assistant was busy with several new admissions and issued a verbal order to administer risperidone without reviewing the chart. The physician assistant informed the nurse of anticipated follow-up at the bedside 30 minutes later. The nurse administered the medication; the patient developed cardiac arrest and died. A retrospective chart review identified external medical records that had been electronically scanned— but not entered— into the hospital's electronic medical record system. The records included a diagnosis of Alzheimer's dementia and history of a prolonged QTc interval.

Supervising physician

A 6-week-old male infant presents with a 4-day history of cough and nasal congestion. He occasionally has a bluish tint around his lips while sleeping. No history of fever. Older siblings have upper respiratory infections. Appetite has been decreased due to the copious nasal secretions, but he has a normal urine output. He was delivered at 34 weeks. He had mild respiratory distress syndrome—2 days on a ventilator in the NICU. He went home in 10 days and has done well since. No immunizations. Physical exam reveals mild respiratory distress, respirations 52/min, with slight intercostal retractions. Temperature is 100.2°F, HR 130/min. Perioral duskiness is seen. Oxygen saturation at room air is 83%. HEENT exam otherwise normal. Chest exam shows coarse rhonchi, expiratory wheezes. Heart rate and rhythm regular. No murmurs appreciated. Abdomen is soft and non-tender. Neurological is intact. Chest X-ray shows mild hyperexpansion, no consolidation. Nasal swab for respiratory syncytial virus is positive. He is admitted to the hospital.

Supplemental oxygen

A 25-year-old primigravida woman gave birth to a healthy male infant at 40 weeks gestation by normal spontaneous vaginal delivery (NSVD). She breastfeeds on demand and was doing well until day 4 postpartum. At that time, she developed insomnia, fatigue, and feelings of sadness and depression, which have been present for the last 3 weeks. She cries easily and feels guilty that she does not enjoy her baby as much as she had expected. She has not yet resumed any predelivery social activities and is often ready for bed when her spouse returns from work to assume care for the baby. Because she feels so tired, she wishes she had never begun breastfeeding.

Supportive psychotherapy

A 30-year-old woman presents to her primary care office with increasing polyuria of pale colorless urine, urinary frequency, enuresis, and nocturia. She has a past medical history of Sheehan's syndrome and a craniopharyngioma, for which she has followed up with her neurologist. She states that as a busy office worker, she finds it difficult to drink water throughout the day and has developed an "unquenchable thirst." She also finds that her sleep is disturbed and has mild daytime fatigue and somnolence as a result. She denies a family and personal history of diabetes mellitus, thyroid dysfunction, illicit drug use, smoking, and alcohol use. She denies fever, chills, polyphagia, weight changes, vaginal discharge, hematuria, or abnormal urinary odor.

Suprapubic distension

A 52-year-old woman was noted on yearly examination to have a microcytic anemia. She has recently noted a change in bowel habits and rectal bleeding with bowel movement. She reports abdominal pain. She has no prior surgical history. Her only medical issue is an elevated cholesterol level that is controlled by diet. Her pulse is 92 BPM, blood pressure is 140/78 mm Hg, respiration rate is 14/min, and temperature is 98.7°F. Rectal exam is notable for guaiac positive stool without any masses. Neurological examination is normal.

Surgery Colonoscopy

A 40-year-old man presents with fever, weakness, and pain in his right hand. Fever and weakness started this morning. 2 days ago, he noticed painful itching blisters on his hand. He thinks it might have been caused by a spider bite. He has type 2 diabetes mellitus and was treated in the ER for acute alcohol intoxication 2 times over the last month. His records show that he received a tetanus booster dose 5 years ago. On examination, he appears very ill; his blood pressure is 85/55 mm Hg, HR is 120/minute, and respiratory rate is 22/min. His hand is swollen and red; there is a small deep ulcer surrounded by a blue halo with preserved voluntary movements of the hand and fingers. You also notice crepitus and discharge of fluid that resembles "dishwater."

Surgical debridement

A 28-year-old woman presents with a "lump" on her right lateral wrist, first noticed 6 months ago. It was initially 1 inch in diameter and not painful. Over the last 2 months, it has grown to 3.5 inches and is extremely painful when using the right wrist. She has taken ibuprofen 200 mg orally every 8 hours as needed with only mild relief. Physical examination reveals somewhat limited range of motion of the right wrist due to the pain and size of the mass. It has a translucent appearance when shining a penlight through it. It is firm and smooth to palpation.

Surgical excision

A 69-year-old woman with a 2-year history of asymptomatic hyperparathyroidism presents with a 1-week history of generalized anxiety and intermittent confusion. 6 months ago, she had normal results on serum and urine protein electrophoresis, mammography, radiography of the chest, and ultrasonography of the neck. The immunoreactive parathyroid hormone level was 5 times the normal level, and the ionized serum calcium level was also increased. She has no other major medical problems.

Surgical exploration of the neck

A 76-year-old man presents with substernal chest pain; it is associated with progressive exertional dyspnea, easy fatigability, and dizziness. These symptoms are exacerbated by walking short distances, and they are relieved with rest. He denies fever, chills, cough, wheezing, pleurisy, calf pain, abdominal problems, peripheral edema, cigarette, drug use, alcohol use, sick contacts, or travel. His physical exam reveals a normal blood pressure and a rough, harsh, low-pitched crescendo-decrescendo systolic murmur beginning after the first heart sound; it is best heard at the second intercostal space in the right upper sternal border. Its intensity is increased toward midsystole; the murmur radiates to both carotid arteries and is accentuated upon squatting, and it is reduced during Valsalva strain. His lungs are without adventitious sounds.

Surgical intervention provides the only definitive treatment. Metoprolol

A 48-year-old man presents with a 2-day history of left-sided groin and scrotal pain. He has had similar pain episodically for several months, but it has recently become much worse after a weekend of helping his brother move furniture. He admits that he is not in good physical shape, and he thinks he may have pulled a groin muscle. He is in a monogamous relationship with his wife of 17 years. He has never had any testicular or scrotal conditions, and he has a negative surgical history. He denies fever and urinary symptoms. He has no allergies and takes no other medications. On physical exam, the patient has normal sexual development, with no edema, warmth or erythema present in the scrotum. No skin lesions are present. On palpation, there is mild tenderness on the left scrotum. However, with Valsalva, a small bulge is palpable in the left scrotum, and the patient's reported pain level increases. When he lies supine, the bulge is no longer palpable.

Surgical referral

A 2-week-old female neonate has been reported to have an elevated immunoreactive trypsinogen (IRT) level on her newborn screening sample that was sent from the newborn nursery after birth. The state newborn screening lab ran additional tests to screen for the 40 most common mutations known to cause the suspected diagnosis. The result of that mutation screening was negative.

Sweat chloride test

A 3-year-old Caucasian girl presents with her parents for followup after her third episode of pneumonia this year. Her parents report she has been acting more like herself and appears to be feeling better. On exam, she is afebrile and breathing comfortably. She has moderate crackles in the lower right lung base. Past medical history is significant for a few episodes of pneumonia each winter since birth. She has always been small for her age, but her mother says she has a healthy appetite. Her parents and brother are of medium stature. She takes no medication other than the antibiotic that was prescribed 5 days ago.

Sweat chloride test

A 54-year-old man presents with a 6-month history of increasing intolerance to exercise. He describes "breathlessness" with exertion, as well as fatigue and 2-pillow orthopnea. He denies tobacco use but does admit to 4 or 5 whiskey sours daily for the last 20 years. He is a businessman and often entertains clients, which "involves drinking alcohol." Chest X-ray reveals an enlarged cardiac silhouette. EKG reveals normal sinus rhythm. A surface echocardiogram reveals an ejection fraction of 35%, mild mitral regurgitation, and dilated left ventricle.

Symptoms can significantly improve with alcohol cessation.

A 15-year-old girl presents with a 1-hour history of rapid heartbeat, faintness, sweating, and nervousness. She is also experiencing shortness of breath and chest pain. The patient has no significant past medical history. There is no history of similar episodes. The patient is on no medications and she denies illicit drug use. On exam, BP is 70/60 mm Hg, and pulse is 200 bpm. RR is 22/min. She is afebrile, looks pale, and her palms are slightly sweaty. She is not comfortable sitting up, so she prefers lying down. She looks slightly apprehensive. Her heart and lung exam are negative except for the tachycardia; except for cool sweaty hands, a brief abdominal and extremity exam are non-revealing. The physician quickly places the paddles on the patient's chest to record the rhythm; this shows a narrow-complex regular tachycardia at 210 bpm. He requests oxygen, IV line, and continuous monitoring. An EKG is in the process of being completed.

Synchronized cardioversion

A 67-year-old woman is hospitalized because of lung cancer. During her stay in the hospital, she becomes obtunded. During a physical exam, she has a seizure. Soon thereafter, she goes into a coma. Lab results show that her urine is hypertonic. Additional laboratory results are as follows:

Syndrome of inappropriate ADH secretion

A 23-year-old woman presents with a rash and swollen joints. She had been healthy previously, and the only medication she takes is acetaminophen. A review of systems includes recent fevers and a 5 lb weight loss in the past month; she is also experiencing photosensitivity and hematuria. She denies oral ulcers, nasal congestion/discharge, ear pain, pleuritic symptoms, chest pain, neural symptoms, bruising, and bleeding. On physical exam, her temperature is 101°F; her blood pressure is 130/85 mm Hg. She has a malar rash as well as diffusely swollen, warm, and tender joints. Her cardiopulmonary exam is normal. She has no costovertebral angle tenderness. Trace bipedal edema is noted.

Systemic lupus erythematosus

You are covering a weekend shift at a local inner-city free clinic. A 41-year-old woman presents with what she describes as "a cough." The patient states that this cough will not go away and has been present for several months, to the point that the patient is coughing up blood for the last 4 days. She admits to unintentionally losing about 10 pounds in the last 2 months. Progressively worsening fatigue, night sweats, and chills are also present. She is a non-smoker and lives in a rent-controlled apartment with 3 adults and 4 kids.

TB culture

A 75-year-old African American man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. He also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. He denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. His psychosocial history is noteworthy for chronic alcohol use. His physical exam reveals bibasilar rales, JVD of 5 cm, an S3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. A bedside echocardiogram was remarkable for biventricular enlargement.

Tachycardia

A 32-year-old man presents with pain in his right shoulder. He tells you he plays softball every weekend and does a lot of shoveling around his house. The shoulder has been sore for some time, but now it hurts to the point where he tries to avoid using it. The drop arm test is negative, and there is no redness, warmth, or obvious swelling, but the patient is unable to lift his arm up to 90° without pain.

Tendinitis

A 20-year-old female college student presents to the student health center with a 1-week history of daily headaches. She has no significant past medical history. Upon further questioning, she admits to headaches occasionally over the past 2 years, but it is lasting longer this time. She classifies the pain as a 4/10 that is generalized, but is worse in the back of the head. The headaches are not debilitating or throbbing, and she describes it as an annoying pain. Acetaminophen helps somewhat but does not make the headache go away completely. On physical exam, there are no neurologic deficits, vision is 20/20 uncorrected, and vital signs are within normal limits. She does note tenderness upon palpation of the muscles of the head, neck, and shoulders.

Tension headache

A 23-year-old woman presents due to a headache that appears to be bilateral, and she describes it as a "tight" feeling around her head. She started physician assistant school 2 months ago and has been really stressed out. Upon physical exam, no abnormal findings are found. Additionally, all laboratory findings are within normal limits.

Tension headache

A 37-year-old Hispanic man presents with a 4-month history of mild-to-moderate headaches; on average, he gets them 3-4 days per week. He has tried over-the-counter analgesics with minimal relief. He is seeking care now because he had been promoted to store manager several months prior to presentation, and he is worried that his headaches are affecting his concentration. His headaches are generalized in location, described as starting at the base of his head and extending all over, feeling "tight" in nature. He denies memory loss, photophobia, nausea/vomiting, rhinorrhea, lacrimation, and upper respiratory symptoms associated with the headaches. He also denies seizures, syncope, incoordination, vertigo, weakness, and paresthesias. The patient mentions his concerns for his work several times. Although he enjoys his work, he admits to having some anxiety about being able to handle his new duties. His family history is negative for headache.

Tension headache

A 45-year-old woman presents with a 2-week history of daily headaches. She describes feeling as if a rubber band is around her temples, making it extremely hard to concentrate when trying to complete tasks at work or at home. Further questioning reveals that the patient is under a significantly increased amount of stress at work due to a new, extremely rigid boss who started last month. She denies any auras, nausea, vomiting, or specific neurological issues, but she does admit to some sensitivity to excessive noise and glaring lights. She has always treated these with two 500 mg tablets of acetaminophen as needed, but this current episode has had little or no relief with this regimen.

Tension headache

A 56-year-old African American man presents with urinary hesitancy, frequency, and nocturia. He gets up to urinate 3-4 times per night, unsure if he empties his bladder completely. This has been worsening for 2 years. His urinary stream is weaker than it was 1 year ago. He denies hematuria, dysuria, or history of UTIs. He has no significant past medical or surgical history. The remainder of the history and ROS is non-contributory. Vital signs are stable, and the patient is afebrile. General physical exam is unremarkable. Genital exam reveals a circumcised penis with no lesions or discharge. There is no inguinal adenopathy. Testicles are descended bilaterally with no lesions, masses, or hernias. Rectal exam reveals a smooth prostate with no nodules or tenderness. Urinalysis is normal, and prostate-specific antigen (PSA) test is within normal range for age. After emptying 250 mL of urine, the post-void residual urine volume is 50 mL.

Terazosin

A 15-year-old boy presents at 11:30 AM due to left scrotal pain and swelling; it started when he woke up at 7 AM. He recalls no trauma. When questioned, he says that he has never had intercourse. He has been feeling nauseated, and he vomited once. Physical examination demonstrates a well-nourished well-developed boy, appearing moderately uncomfortable. Vital signs are normal except for an oral temperature of 37.9°C. Pain assessment score (Wong-Baker scale) is 6/10. Tanner Stage III puberty. The left testicle is approximately 1.5 times the size of the right testicle and high-riding compared to the right. The skin is diffusely erythematous. It is difficult to palpate the scrotum due to tenderness. Cremasteric reflex is absent. Penis is circumcised and appears normal. Scrotal ultrasonography with Doppler ultrasound demonstrates decreased blood flow to the testis. Remaining physical examination is normal.

Testicular torsion

A 25-year-old Caucasian man presents to the local emergency department due to severe testicular pain. The pain began abruptly about 2 hours ago and has gotten progressively worse. He is numerically currently rating it as a 9/10. This is only affecting the left testicle. He has never had an episode like this before. He also states he has become nauseated during the time you are in with him.

Testicular torsion

A 65-year-old man was diagnosed with mild dementia 2 months ago. The laboratory evaluation, together with a several-year history of symptoms, is consistent with this diagnosis. Although this patient can no longer work as a physicist, he is still able to visit family and friends, play tennis and golf, enjoy church, and travel with his wife. He has lost the ability to keep track of the family finances, and his wife has taken over that responsibility. After obtaining a baseline Mini-Mental State Examination (MMSE) score, you start him on donepezil 5 mg once daily, which you subsequently increase to 10 mg daily after a period of 4 weeks without side effects. You also prescribed vitamin E, 400 IU, twice daily. The family does not note improvement despite 8 weeks of therapy, and they are encouraging the patient to stop taking donepezil, but there is no further deterioration of the patient's condition.

The current dose has shown cognition improvement and attenuation of further decline.

A 7-year-old boy presents with headaches, nausea, and lethargy. According to his parents, the boy has been consuming large amounts of fluids. He also urinates frequently. A previously healthy child, he has no significant past medical history. His symptoms began approximately 3 weeks ago. His parents thought that it was his increased activity level that led to his increased fluid intake. Over the past few days, however, he has been becoming more lethargic and is still consuming large amounts of water and juice. On physical exam, the boy appears thin, ill-appearing, and lethargic. His eyes appear sunken and his skin is dry. His vital signs are: blood pressure 100/54 mm Hg, temperature 99.0°F, pulse 120 beats per minute, respiratory rate of 22 per minute. Laboratory tests show dilute urine with a specific gravity of 1.002 and a urine osmolality of 199 mOsm/kg. His plasma osmolality is 296 mOsm/kg.

The idiopathic form is associated with destruction of cells in the hypothalamus.

A 3-month-old male infant presents for a routine evaluation. His mother states that the child is gaining weight, is feeding appropriately, and has been without fever, chills, dyspnea or other abnormal objective signs. Upon physical examination, the examiner noticed a loud, harsh holosystolic murmur in the left third and fourth interspaces along the sternum that was associated with a systolic thrill. There were no other abnormalities.

The louder associated murmur is a good sign.

A 40-year-old man presents with burning and pain of his oral cavity; the burning and pain have been associated with a pruritic rash of the flexor aspect of his left wrist. He denies a history of smoking, drinking, or recreational drug use. The physical exam is remarkable for violaceous shiny polygonal papules arranged in lines and circles on his wrist. These papules range from 1 mm to 1 cm in diameter, and they have fine white lines on them. In the oral cavity, a reticular white lacy pattern is visualized.

This immune response is associated with hepatitis C.

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. His blood pressure is 180/110 mm Hg, heart rate is 120 BPM, and respiratory rate is 34/min. Physical exam findings include lungs clear to auscultation, heart regular rhythm, normal S1/S2 with an S4 present, and a grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. No evidence of JVD and carotids are negative for bruits. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy.

Thoracic aortic dissection

A 28-year-old primipara woman presents with wide fever swings 6 days after the delivery of a healthy male infant. Her pregnancy was uneventful, but because of the prolonged membrane rupture and prolonged labor, an emergency cesarean section was performed. On the second postpartum day, she started having fever and reporting uterine tenderness. She was treated with IV gentamycin and clindamycin. Today, her physical examination is normal; there is no uterine tenderness, and her WBC count is 11500, but she continues to spike fevers up to 39°C.

Thrombophlebitis

A newborn presents for a 2-week physical exam. On exam, white plaques on the buccal mucosa and palate are noted. Upon trying to remove the plaques, there is an underlying erythematous base and small punctate areas of bleeding. The area appears to be quite tender to touch.

Thrush

A 24-year-old man presents with radial-sided wrist pain following a fall on his outstretched hand 3 days ago. He did not seek immediate medical attention due to a lack of swelling. Despite self-treatment with ice and analgesics, his wrist still hurts, especially with ulnar deviation and while trying to open a jar or grip the steering wheel of his car. On examination, his tenderness seems to be in the anatomic snuffbox of the wrist. Radiographs are normal in all views.

Thumb spica splint and referral to an orthopedic surgeon

A 28-year-old woman at 24 weeks gestation presents with insomnia and fatigue. Her symptoms have worsened as the pregnancy has progressed. She has noticed dyspnea on exertion that is associated with palpitations when grocery shopping or going to the laundromat. Vital signs are blood pressure of 128/88 mm Hg, pulse is 102/minute, respirations are 16/minute, and temperature is afebrile. Weight is 138 lb, which is stable from her last visit 4 weeks ago. On physical exam, the patient is a gravid woman in no acute distress. Clinical findings include mild periorbital edema without ankle edema and brisk ankle reflexes. Examination is otherwise unremarkable.

Thyroid function studies

A 70-year-old woman presents to the ER with a 1-week history of palpitations, dyspnea, and generalized weakness. She also gives history of decreased oral intake and weight loss. The patient has no significant previous medical history. On exam, the patient is afebrile. Pulse is 130/min, BP is 100/68 mm Hg, RR is 14/min, oxygen saturation of 97% on room air. Skin appears warm and smooth without cyanosis or edema. Cardiovascular exam reveals normal S1 and S2, no murmurs, rubs, or gallops. Lung sounds are clear bilaterally. Chest X-ray shows no acute cardiopulmonary disease. Electrocardiogram shows atrial fibrillation with rapid ventricular rate of 135 bpm. Normal QRS and QT intervals.

Thyroid function tests

A 10-year-old boy presents with a 1-week history of a rash on his scalp. His mother states that the boy has been scratching his head often, and she notes that there are areas where his hair appears to have fallen out. She attempted to treat it with over-the-counter preparations, but his condition has not improved. The boy is active and otherwise healthy. The rash appears as erythematous, circular, scaly patches. There are areas where the hairs have become brittle and broken off. A scraping of one of the patches is placed in potassium hydroxide solution and shows hyphae.

Tinea capitis

A 20-year-old Caucasian male college student comes in with a complaint of hypopigmented patches that appeared gradually during the summer. He reports no history of unprotected sex. Scaly patches are present, but no pruritus. On examination, he has hypopigmented patches over the face and chest, but no vesicles or pustules.

Tinea versicolor

A 25-year-old man presents to his primary care provider with a 2-day history of acute pain in his mouth; he has no significant past medical history. He states that the pain is in a localized part of his inner cheek; it is aggravated by eating food, speaking, and smiling. He denies any history of smoking, risky sexual behavior, drug use, transfusions, trauma, fever, chills, otalgia, otorrhea, rhinitis, eye pain/discharge, halitosis, regurgitation, skin changes, swollen glands, sore throat, or headache. His physical exam is noteworthy for painful ulcerations of buccal and labial mucosa with yellowish base and red halos.

Topical corticosteroids

A 62-year-old man who you know well presents due to an itchy rash. His medical history includes Parkinson's disease for the past decade. The patient believed the rash was just a mosquito bite at first because it stayed small and confined to one space. This area has spread and now has characteristics of hives and intense itching. On examination, you note three 1-3 cm tense bullae that appear on an erythematous base. The bullae are located on the right trunk in a region that measures 5 cm in diameter. This patient states he came to you for treatment of this issue around 5 years ago.

Topical corticosteroids

You are evaluating a 16-year old Caucasian male high school junior (his baseball team's starting shortstop) for left hamstring soreness 4 days in duration. He felt a slight pull during infield practice. He was late that day and skipped his normal warmup and stretching routine. Despite rest, the soreness has persisted. He would like some medication for the discomfort but noted that several oral analgesics and anti-inflammatories had caused gastric upset in the past. Past medical history is otherwise unremarkable, growth and development are normal, and immunizations are current. Vital signs are normal. Examination reveals mild tenderness to palpation of the left hamstrings, aggravated by extension at the knee.

Topical diclofenac gel

A 35-year-old man presents for medical care, but he is too embarrassed to tell the nurse his chief symptom. Eventually, he admits to severe, intense itching around his anus; it has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He ranks this pain as a 10/10 on a pain scale. This intense pain makes him try to avoid having bowel movements regularly. He admits to one episode of a small amount of bright red blood on the toilet paper and on the stool itself. Reviewing documentation on this patient reveals that this is the fourth similar episode in the last 14 months. The patient denies fever and diarrhea; according to him, he has never been diagnosed with inflammatory bowel disease.

Topical nitroglycerin 0.2-0.4%

A 19-year-old woman presents with a multi-year history of episodic throbbing headaches. They have intensified, and she now misses classes and work 4-6 times monthly. They last 2-3 days, accompanied by nausea, vomiting, and light sensitivity. She denies residual symptoms after headaches resolve. She denies neurologic symptoms such as vision or taste changes, gait disturbances, and memory loss. She has tried multiple over-the-counter pain medications without relief. Her mother and maternal aunt experienced similar headaches. She reports some increased stressors and less sleep since starting college. Past medical history is unremarkable, with no other known medical conditions, surgeries, chronic medications, or drug allergies. She has never been sexually active and reports regular menses. She denies tobacco, alcohol, and recreational drugs. Physical exam is unremarkable.

Topiramate

A 23-year-old man presents with an unspecified personality disorder; although his group and individual therapy sessions are going well, he wants to gain even more improvement with his diagnosis. He feels that his mood, self-image, and personal relationships have improved overall, but he specifically states he wants to have better anger management. When he becomes angry, for whatever reason, he still becomes extremely irritated, hostile, and even aggressive.

Topiramate

A 49-year-old Caucasian man presents with pain in his left lower extremity. During questioning, the patient states that while doing construction work 3 months ago, he jumped from an elevated height of 6 feet. Ever since this episode, he has noted increased issues with left-sided hip and knee pain. He describes the pain as radiating into the left groin and front middle thigh area. The pain is relieved with sitting and aggravated by walking and climbing up stairs. The patient denies any paresthesias, numbness, bowel or bladder dysfunction, fever, night sweats, or chills. Pertinent medical history includes a 20-year extensive history of alcohol. A radiograph interpretation shows the presence of a crescent sign and marked irregularity of the left femoral head with sclerosis.

Total hip replacement

A 14-year-old boy presents with a 2-week history of 4-5 loose bowel movements a day with blood and mucus accompanied by tenesmus and cramping abdominal pain with a low-grade fever. These episodes have been occurring intermittently for the past 6 months. Physical examination shows mild pallor, temperature 99°F, pulse 88/min, BP 100/70 mm Hg. Oral mucosa and perianal examination are normal. Abdominal tenderness is present. The rest of the examination is normal. Stool examination for ova and parasites and culture for pathogens are negative. Laboratory analysis shows mild anemia and elevated ESR and CRP. Perinuclear anti-neutrophil cytoplasmic auto-antibodies (pANCA) are positive, and anti-Saccharomyces cerevisiae antibodies (ASCA) are negative. Colonoscopy shows hyperemic, edematous, friable, and ulcerated rectal and colonic mucosa; there is no normal mucosa in between. Upper intestinal endoscopy shows normal mucosa.

Toxic megacolon

A 32-year-old woman is brought to the emergency room with sudden onset of fever, headache, sore throat, profuse watery diarrhea, vomiting, and lethargy; symptoms started in the morning. On physical examination, she is slightly confused; her temperature is 39°C (103°F), her blood pressure is 100/50 mm Hg, and she has diffuse sunburn like an erythematous rash. When the emergency doctor is trying to find out if she is pregnant, she mentions that her period started 2 days ago.

Toxic shock syndrome

A 54-year-old man presents after having a generalized seizure. The patient is HIV-positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he has become short-tempered and hypercritical; at times he seems confused. An MRI of the brain is performed, and it reveals several cortical ring-enhancing lesions.

Toxoplasma encephalitis

A 20-year-old primigravida woman at 12 weeks gestation presents with a 2-day history of low-grade fever and swelling in her neck. She does not have any significant medical history and denies previous blood transfusion. On questioning, she states that she is not sexually promiscuous and that she is living with her husband and their pet cat. She is a homemaker and spends her free time gardening. She has received all immunizations, and they are up-to-date. She also states that she has abstained from sex since learning of her pregnancy 2 months ago. On examination, her vitals are temp 99°F, PR 88/min, BP 110/70 mm Hg, RR 20/min. She also has painless prominent cervical lymph nodes. Abdominal examination reveals a just-palpable uterus.

Toxoplasma gondii

You are working as a physician assistant caring for post orthopedic surgery patients. On review of your 36-year-male patient's routine 12-hour post-operative complete blood count, you notice their hemoglobin is 6.5 g/dL; preoperatively this patient's hemoglobin was 13.4 g/dL. The patient's intraoperative report mentions significant blood loss but adequate hemostasis was achieved prior to incision closure. This patient endorses fatigue postoperatively but denies any other acute complaints. Physical exam does not reveal increased erythema, edema, bandage strike through, or significant surgical site tenderness to palpation. Patient is hemodynamically well.

Transfuse one unit packed red blood cells for symptomatic anemia.

You are working as a physician assistant in a neurosurgical practice. You are called to the emergency department to evaluate an 85-year-old man with an acute epidural hematoma found on brain imaging. This patient is obtunded and you determine he will require emergent surgical intervention. His granddaughter—who found the patient unresponsive and is present in the exam room—states that her grandfather would want the surgery if he could consent. Upon review of the patient's medical record, you notice the patient has an advanced directive on file. In this document, you discover the patient previously stated that if he is found unresponsive, he would decline any life-prolonging measures or escalation in care apart from comfort measures. His wife, who is not present, is his power of attorney and cosigned his advanced directive document.

Transition to comfort care measures in accordance with the advanced directive.

A 47-year-old previously healthy Caucasian woman presents due to a 4-week history of dyspnea that started approximately when on vacation in Colorado. She initially attributed these symptoms to the altitude, but she continued to have shortness of breath with mild activity: walking >100 feet, walking up a flight of stairs, housekeeping. Her symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope. Past medical history includes usual childhood illnesses. She has no previous surgeries and no known allergies. Medications include a daily multivitamin and occasional Tylenol for headaches. She is a non-smoker, rarely drinks, and denies recreational drugs. Physical exam reveals an alert white woman in no acute distress: temp 98.2°F, pulse 80 and regular, respirations 16, BP 136/82, O2 sat 96% on room air. There is no obvious jugular venous distention. Respirations are non-labored. Lung fields are clear to auscultation and percussion. No rhonchi, rales, or wheezes are present. Heart shows RV heave present, normal S1 with fixed, split S2 with prominent P2 component. Grade II/VI systolic murmur is present at the left upper sternal border at the second intercostal space. The remainder of a complete physical examination is within normal limits. CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2.

Transthoracic echocardiogram

A 38-year-old woman with a past medical history of rheumatic fever and endocarditis presents with progressive dyspnea on exertion associated with palpitations and intermittent episodes of left-sided chest pain. Both symptoms resolve at rest. Her physical exam reveals resting tachycardia and a widened pulse pressure. The cardiac exam is notable for a decrescendo diastolic high-pitched murmur, loudest at the left sternal border and accentuated with the patient leaning forward in full expiration. Abrupt distention and quick collapse are observed upon palpation of the peripheral arterial pulses. Booming systolic and diastolic sounds are auscultated over the femoral arteries.

Transthoracic echocardiography

A 72-year-old man with a history of poorly controlled HTN and previous myocardial infarction presents with a nocturnal cough, bilateral ankle swelling, and dyspnea on exertion. He denies any fever, chills, URI symptoms, chest pain, headache, N/V, diaphoresis, or syncope. He further denies smoking, alcohol, or drug use. Physical exam reveals bipedal edema and bibasilar crackles. A chest X-ray is remarkable for enlargement of the cardiac silhouette and interstitial infiltrates, while EKG analysis indicates deep S waves in lead V1 and tall R waves in lead V5.

Transthoracic echocardiography

A 72-year-old man presents due to worsening shortness of breath, orthopnea, and chest pain; symptoms have been occurring for the past few weeks. The patient admits to some chronic heart problems, as well as fatigue, dyspnea, and a non-productive cough. He feels like symptoms have worsened recently. He denies fever, chills, and a productive cough. On physical exam, the man has mildly increased respiratory effort, but he does not appear in distress. He is barrel-chested. His breath sounds are diminished bilaterally, with dullness to percussion over the right and left lower lungs. No pleural friction rub is noted. On cardiovascular exam, an S3 gallop and mild tachycardia (110 bpm) are noted. Clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention are also noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on the chest X-ray, and a thoracentesis is performed. The pleural fluid is generally clear in color, testing negative for chylomicrons and triglycerides. It has low levels of red blood cells, white blood cells, protein, and lactate dehydrogenase (LDH).

Transudates from increased hydrostatic pressure or decreased oncotic pressure

A woman presents with her 6-year-old adopted daughter due to excessive scratching of the scalp and ears. The woman states that she washes the girl's hair frequently, but it hasn't been helpful; the woman is very frustrated for her daughter. On examination of the scalp, excessive excoriations are noted on the posterior neck and postauricular regions bilaterally. No cervical lymphadenopathy is noted. Nits are also observed on the shaft of the hair.

Treat with permethrin.

You are a PA in the emergency department (ED) of a community hospital. A 70-year-old woman comes in for evaluation of hematochezia for 1 day associated with dizziness. She is found to have a blood pressure of 100/55 mm Hg, heart rate 110 bpm. Her hemoglobin is 6.0 g/dL, and hematocrit is 20.1%. In the ED, she is observed to have several bloody bowel movements of hematochezia. She presents a durable power of attorney card that states she declines transfusion and identifies her as a Jehovah's Witness. After a lengthy discussion about the diagnosis of gastrointestinal (GI) bleed and the risk of death if she does not receive a transfusion, she still declines blood.

Treat with supportive measures.

A 68-year-old non-smoking man presents to your pulmonology practice for long-standing dyspnea and non-productive cough. The patient has had the cough and progressively worsening dyspnea for about 1.5 years with no current exacerbation. He denies fevers, chills, night sweats, and any other symptoms. He denies unusual travel, hobbies, or occupational exposures. He does, however, endorse relatively frequent reflux symptoms. The rest of his review of systems is negative. He has had a workup through his family practice and was then sent to the cardiologist, who ruled out cardiovascular causes of his dyspnea. He has been given trials of various antibiotics, inhalers, and steroids, all without improvement in symptoms, despite good compliance. He currently takes no medications. Several tests have been performed, and results are shown in the table. Blood count, metabolic panel, HIV, and autoimmune markersNormalHigh-resolution computed tomography (HSCT) scanFew reticular opacitiesPulmonary function test (PFT)Restrictive impairment and reduced perfusion of carbon monoxide Physical exam is significant for fine inspiratory bibasilar crackles and clubbing in the fingers. An occasional dry cough is noted.

Treatment of gastroesophageal reflux disease

A 32-year-old man with a past medical history of allergic rhinitis and asthma that is well-controlled complains of recurrent pruritus associated with an erythematous rash in the flexural areas of his elbows and knees. The lesions seem to become worse when he scratches them and when he is under stress. He denies any recent insect bites, travel, fever, chills, new clothing, or detergent use. Physical examination reveals rough-appearing erythematous plaques in the bilateral antecubital and popliteal fossae, with areas of excoriations within the lesions.

Triamcinolone 0.1% applied to the lesions once or twice daily

A 14-year-old boy presents with a 1-week history of acute watery diarrhea with vague abdominal discomfort and vomiting. He has developed fever, malaise, facial and periorbital edema, and myalgias. He is experiencing pain and swelling of the calf muscles. The patient ate some food prepared from pork and game meat in a restaurant 3-4 weeks ago. Blood examination shows moderate eosinophilia.

Trichinella spiralis

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis. Social history is notable for use of IV drugs. Vital signs show temperature 100.8°F, pulse 108, respirations 24, blood pressure 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen.

Tricuspid valve vegetation

A 28-year-old woman presents with bloody diarrhea for 1 week. After further questioning, she reveals that she had similar attacks in the past that subsided on their own. Her stool specimen is negative for ova and parasites. Stool culture did not grow any pathogens. A sigmoidoscopy is performed. There is friable erythematous mucosa extending from the rectum to the mid-descending colon, with broad-based ulcers in the descending colon. A biopsy taken from the rectum shows diffuse mononuclear inflammatory infiltrates in the lamina propria with crypt abscesses, but no granulomas are seen.

Ulcerative colitis

A 22-year-old man presents with a right groin bulge. During physical assessment, a single sac is found protruding just lateral to the epigastric vessels. Although the clinical scenario is highly suggestive of a hernia, what initial imaging study would be the best choice to support this diagnosis?

Ultrasound

A 29-year-old man is seen in the clinic for groin pain. He works as a cashier at a local supermarket. The pain increases through the day. When asked to point out its location, he localizes it to his left groin fold. Examination of his inguinoscrotal region reveals an ill-defined tortuous swelling that increases with standing and a palpable thrill on coughing.

Ultrasound

A 32-year-old G2P2 woman presents 1 month post-intrauterine contraceptive device placement for follow-up position check. The patient states that she can no longer feel the strings from the device. She was told to check occasionally to make sure it stayed positioned properly. Upon vaginal exam, you confirm that the strings are no longer visible in the cervical os.

Ultrasound

A 48-year-old man presents with a 2-day history of left-sided groin and scrotal pain. He has had similar pain episodically for several months, but it has recently become much worse after a weekend helping his brother move furniture. He admits that he is not in good physical shape, and he thinks he may have pulled a groin muscle. He is in a monogamous relationship with his wife of 17 years. He has never had any testicular or scrotal conditions, and he has a negative surgical history. He denies fever and urinary symptoms. He has no allergies and takes no other medications. On physical exam, the patient has normal sexual development with no edema, warmth, or erythema present in the scrotum. No skin lesions are present. On palpation, there is mild tenderness on the left scrotum. With the Valsalva maneuver, however, a small bulge is palpable in the left scrotum and the patient's reported pain level increases. When he lies supine, the bulge is no longer palpable.

Ultrasound

A 47-year-old Latinx woman presents with a 2-month history of persistent abdominal pains. She becomes uncomfortable after eating, especially after consuming fats, eggs, chocolate, fried foods, fatty foods, and rich desserts. Her pains are primarily located in her right upper abdominal quadrant and often radiate to her right shoulder blade. Physical examination is essentially unremarkable. Blood pressure is 122/82 mm Hg, she has a pulse of 72 per minute, and a temperature of 98.6°F with respirations 16 per minute. Her abdominal examination reveals no tenderness, no guard, no rebound, and normally active bowel sounds. Her liver and spleen are not palpable. She has no readily palpable abdominal masses. She is not jaundiced. She has no scleral icterus.

Ultrasound abdomen

A 30-year-old woman presents with a 2-week history of vaginal discharge. She denies vaginal burning or itching, urinary frequency, hesitancy, and dysuria. The discharge is reported as light yellow in color. She is hesitant to provide much detail, so a physical exam is performed. On physical exam, the patient is in no distress, is afebrile, has normal vitals, and the exam is normal except for the pelvis. On speculum examination, the cervix is inflamed, bright red, and slightly friable with yellow discharge at the os. Vaginal mucosa is pink, moist, and without inflammation. Uterus and ovaries palpate to normal size and are non-tender on bimanual exam. Samples are collected for analysis and the results that are available are listed.

Unprotected vaginal intercourse Prescribe empiric antibiotics

You are a physician assistant (PA) working on an inpatient medical service overnight. In the morning, you give verbal sign out to the PA taking over the day shift. You report to them that there was a 17-year-old patient admitted for appendicitis who received ceftriaxone intravenously and broke out in a rash. You prescribed diphenhydramine and documented the reaction in the progress note.

Update the allergy in the patient's medication reconciliation.

A 10-year-old boy presents with a 2-month history of intermittent burning pain in the epigastrium. Pain is felt more during the night and between meals; it is partly relieved by eating food or by taking antacids. Pain usually lasts 30-60 minutes and is accompanied by nausea and vomiting. He often has a feeling of bloating and burping. He remains asymptomatic for several days between. There is no history of taking analgesics or anti-inflammatory drugs. Physical examination shows epigastric tenderness. The rest of the examination is essentially normal. Stool examination for occult blood is positive.

Upper GI endoscopy

A 52-year-old man presents for a follow-up visit. He saw you about 2 weeks ago due to losing his voice. The diagnosis of acute laryngitis was made at that time, and supportive treatment was described to him. The patient returns a little worried today because he has had no improvement in getting his voice back since his last visit. The patient is a professor at a local university and desperately needs his voice to return in order to lecture properly. Social history reveals a 32 pack-year smoking history. Further questioning of the patient during your review of systems reveals unintentional weight loss of 5 lb since his last visit.

Urgent referral to an otolaryngologist

A 12-year-old boy presents with a 3-month history of intermittent moderate right knee pain and mild right hip pain increasing in frequency and severity over the past week. There is no history of trauma or associated symptoms. He has begun to experience stiffness in the right hip and has developed a limp. Examination reveals normal vital signs, height 64", weight 182 lb (>95th percentile). He walks with an antalgic gait with the right foot externally rotated. There is pain on passive range of motion of the right hip, but not the right knee. Internal rotation of the right hip is limited. External rotation of the right hip with the knee flexed produces external rotation of the right lower leg. Radiographs of the right knee are normal, but radiographs of the right hip reveal a moderate increase of the angle of the femoral head to shaft.

Urgent referral to orthopedic surgery

A 32-year-old woman presents for her annual health maintenance exam. She is concerned regarding weight gain. She states she has been watching her dietary intake closely but reports being hungry frequently. She has also had skin changes with frequent breakouts of acne and purple striae. Past medical history is noncontributory. She is not currently on any medications.

Urinary free cortisol level

A 20-year-old woman presents with a rapid onset of nausea, headaches, fast breathing, and dilated pupils. Her sister thinks that the patient is exhausted from staying up several nights to study for final exams. The patient refused food several times, arguing that she did not have time to spend on anything but her studying; she even became aggressive when her roommates insisted on her going out to dinner with them. Upon physical examination, the patient seems tired and has a dry mouth; her body temperature is 99.8°F and her blood pressure is 135/85. The patient states that she took 2 acetaminophen pills the night before and in the morning to get rid of her headaches.

Urine drug test

A previously healthy 8-year-old African American boy presented with a 3-day history of worsening fatigue and generalized edema. You saw him about a week ago when he had symptoms of a cold, for which you advised only supportive therapy. He appears alert and cooperative. His vitals are normal (temperature 37°C, pulse 90/min, respiratory rate 20/min, and blood pressure 100/70 mm Hg). Physical examination reveals the presence of generalized edema, and the rest of the examination is within normal limits. His laboratory values are below:

Urine protein

A 33-year-old Caucasian man presents with redness, itching, and burning on the back of his hands. He gives a history of clearing "weeds" on his farm yesterday. You ask him to describe the weeds, and he states that they had a cluster of three leaves. There are several tiny blisters with a linear distribution on both of his hands.

Urushiol

A 58-year-old man is admitted with an episode of acute diverticulitis. He will be started on ciprofloxacin, metronidazole, and morphine. He supplies a list of medications, including metoprolol, atorvastatin, aspirin, and tamsulosin. He reports he is on another medication but cannot recall the name. He describes it as a small white pill he thinks he takes for overactive bladder.

Use barcode-scanned medications only.

A 53-year-old man presents with increased difficulty swallowing and occasional regurgitation of his meals. His symptoms have been occurring with greater frequency and severity over the last 4 months. He also has some shortness of breath but attributes that to his weight and lack of physical activity. His past medical history is remarkable for chronic heartburn, which he treats intermittently with over the counter antacids. He takes no regular medications has no allergies. He has not had any surgeries. He is not a smoker and he denies use of alcohol and drugs. He works as a building inspector, and he lives with his wife and children. The patient is obese, but the rest of his physical exam is normal. Blood tests, electrocardiogram, and chest X-ray are done in the clinic; they are normal. He is referred for endoscopy, and esophageal biopsy shows specialized intestinal metaplastic cells (of columnar epithelium).

Use of proton pump inhibitors

A 32-year-old woman is 2 hours status post cesarean delivery of a singleton gestation at 38 weeks. The course of her pregnancy was uncomplicated. She presented in early labor, which became prolonged despite oxytocin infusion. A cesarean section was performed when she failed to progress in labor and there were signs of fetal distress. While in the recovery area, she begins to complain of nausea and lightheadedness. On exam, her heart rate is 133 beats per minute and blood pressure is 76/42 mm Hg. Significant vaginal bleeding is noted, and abdominal palpation reveals a soft "boggy" uterus.

Uterine atony

A 24-year-old man presents due to increasing pain in his right groin and buttock and difficulty walking. The pain has been present and worsening for about 1 month. He further reports that he had quite significantly injured himself also near his right hip in a fall while snowboarding about 3 months ago. He did not seek care immediately and had difficulty ambulating for a week, then saw a chiropractor to "put his lower back back in." The pain and gait problems eventually improved. Now he is concerned because the pain has returned with no new history of trauma. He is otherwise healthy and takes no regular medicines. He denies any chronic health conditions and has an unremarkable family history for musculoskeletal and rheumatologic conditions. On physical exam, the patient was noted to walk into the exam room with a slight limp. Examination of the hip, buttock, and groin region reveals no edema, erythema, or ecchymosis. The exam does not produce one particular point of tenderness with palpation, but pain is elicited with right hip motions, particularly internal rotation. Diagnostic testing revealed a "crescent sign" and confirmed the suspected condition. The patient will be scheduled for definitive treatment within a week.

Utilize crutches for any ambulation.

A 32-year-old woman with no significant past medical history presents with a 4-day history of vaginal discharge. She describes the vaginal discharge as thin, fairly uniform in its consistency, and of a light grayish color. Her last sexual intercourse encounter was 1 week ago; she admits that it was unprotected. She is not in a monogamous relationship. She denies any fever, chills, swollen glands, dysuria, hematuria, urinary frequency, dyspareunia, or back pain. She further denies any vulvar or vaginal pruritus. Physical exam is significant for a pungent ammonia-like scent with an associated thin gray-white vaginal exudate, but it is otherwise unremarkable. Microscopic evaluation of the vaginal exudates is remarkable for the presence of clue cells.

Vaginal pH of 5.2

A 64-year-old woman presents with urine leakage that has been progressively worsening for the past 6-12 months. She also admits to having vaginal dryness, poor lubrication with intercourse, and subsequent dyspareunia. Urinary leakage primarily seems to occur with coughing, sneezing, or high-impact exercise. She denies dysuria, hematuria, urgency, and vasomotor symptoms. She tries to empty her bladder every 2-3 hours and has cut out all alcoholic and caffeinated beverages, but symptoms persist. The patient is a G6P6. She has no chronic medical conditions and no past surgeries. She wants to do everything she can to avoid surgery. She is in a monogamous relationship. She was last seen 1 year ago with a normal well-woman exam and normal Pap smear. On physical exam, vitals are normal. The pelvic exam reveals dry pale vaginal mucosa with a bulge on the anterior vaginal wall that increases in size with a Valsalva maneuver. Urinalysis is normal.

Vaginal pessary

A 62-year-old woman with diabetes and hypertension is evaluated for incontinence. She is found to have a cystocele and grade 3 uterine prolapse. Her diabetes and hypertension are both poorly controlled. On examination, the uterus can be repositioned with firm digital pressure. In addition to being declared unfit for surgery, she is not keen on undergoing any procedure. She has no history of any urinary infections or pelvic inflammatory disease.

Vaginal pessary placement

A 25-year-old man develops clinical signs of bacteremia in the hospital. Examination reveals erythema, tenderness, and a slight purulent discharge around the insertion site of a central venous catheter. Gram stain of discharge shows gram-positive cocci in grape-like clusters. Culture sensitivity of the fluid showed methicillin-resistant Staphylococcus epidermidis.

Vancomycin

A 16-year-old boy is currently an inpatient 7 days after a motor vehicle accident that resulted in multiple lower extremity fractures. The fractures were surgically corrected recently. He is currently immobilized below the waist, but casts will not be placed until the majority of his edema has resolved. He is stable, the edema is resolving, and he is recovering well, with the exception of new onset of increased edema and erythema over his left thigh. X-rays show evidence of acute osteomyelitis. The patient does not have any allergies. A culture from the infected bone has revealed methicillin-resistant Staphylococcus aureus.

Vancomycin (Vancocin) 1 g IV q 12 hours for 6 weeks

An 18-month-old child presents with a 2-day history of fever that is currently 101°F rectally. You symptomatically treat the patient and ask the mother to return if the condition worsens. The mother returns 2 days later because the child has developed small red spots that became bumps and are now blisters. The mother also noted the child was scratching the lesions. Physical exam reveals macules, papules, and vesicles are on the face and thorax bilaterally. Each vesicle resides on its own erythematous base.

Varicella

A 64-year-old man presents with a 3-day history of insidious chest pain. He has a past medical history of hypertension, coronary artery disease, and poorly controlled left ventricular congestive heart failure due to medication noncompliance. Pain is made worse when he takes a deep breath and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and peripheral edema. He denies any relation of pain to position, activity, or food intake and is able to perform his normal daily activities. His physical exam reveals no respiratory distress, cyanosis, or accessory muscle usage. There are bibasilar thoracic friction rubs upon inspiration, an absence of lung fremitus, dullness to percussion, and reduced lung sounds. A chest X-ray is performed. Refer to the image.

Counseling regarding compliance with heart failure medications

A 22-year-old man presents with a 3-month history of worsening diarrhea that comes and goes. While performing a comprehensive oral exam, you note two lesions on the buccal mucosa on the right side of the oral cavity. You document these lesions as two round lesions approximately 2 mm in diameter with a white-yellow center surrounded by a red halo. Pertinent positives also include a reduced appetite, abdominal pain, and cramping.

Crohn's disease

A 2-year-old boy presents with failure to gain weight. He is the same weight he was at his 18-month well check. His mother says that she offers him three meals per day and three snacks, but he usually just picks at them. He does not seem hungry. He does enjoy chicken nuggets, Goldfish crackers, and cookies. She gives him a cup of juice each day and around 40 oz of whole milk. He was a full-term delivery and has no significant past medical history. He was fed breast milk exclusively until age 1. He was then switched to whole milk and solids were introduced. Other than his failure to gain weight, his physical exam is normal. He is gaining adequately in height and head circumference. He is reaching age-appropriate milestones and appears well, without any sign of systemic disease.

Decrease milk consumption

A 36-year-old man with a history of diabetes and obesity presents with weakness and flu-like symptoms. His girlfriend reports that he had taken several caffeine pills the day before, but he denies a suicide attempt. During evaluation at the hospital, he experiences vomiting and seizures. A laboratory workup is within normal limits. He is admitted to the hospital and improves over the course of his 3-day admission. He is subsequently released with no lingering effects.

Decrease or stop caffeine intake

A 58-year-old man presents with worsening shortness of breath (SOB); it has been especially problematic over the last 4 months. He states that the SOB has been noticeably severe with exertion, and this has drastically decreased his ability to do any physical activities. He is now experiencing SOB at rest. Physical examination reveals mild abdominal distension secondary to ascites and 4+ bilateral peripheral lower extremity edema. Past medical history includes that the patient underwent radiation and chemotherapy for lung cancer about 7 years ago.

Decrease pulmonary congestion

A 28-year-old woman presents for a routine follow-up. She has type 1 diabetes and is on a combination of glargine 40 units before bed and insulin lispro with meals. At her last visit, she mentioned having difficulties with her morning glucose levels. She has been tracking her glucose levels daily and brought along her log. Her pre-breakfast glucose averages 285 mg/dL. At dinnertime, it averages 95 mg/dL, and 68 mg/dL at 3 AM.

Decrease the evening dose of long-acting insulin.

A 25-year-old woman presents because she feels weak and tired all the time. She also reports that she has been amenorrheic for the past 3 months. Her past history is significant for transsphenoidal surgery followed by salvage radiation therapy for a pituitary macroadenoma 5 years earlier. On examination, she is not pale, but she appears fatigued. Her BP is 100/50 mm Hg, and a pregnancy test is negative.

Decreased axillary hair

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and tremor in her hands. Past medical history is non-contributory. She takes a multivitamin and drinks 1-2 cups of coffee daily. She denies any recreational drug use. Blood pressure is 110/70 mm Hg. Heart rate 105 bpm, regular. Respirations 16/minute. She appears anxious, and you note the presence of bulging eyes. Thyroid is diffusely enlarged. Cardiovascular exam reveals normal S1 and S2 without murmurs, rubs, or gallops. Normal breath sounds bilaterally.

Decreased thyroid-stimulating hormone

A 40-year-old man presents with stage 4 liver cancer. The patient, despite the diagnosis, continues to make business transactions over the hospital telephone and tells everyone he is fine. He gets angry with the nurses for thinking he is sick and giving him medicine.

Denial

A 35-year-old woman notices a change in the appearance of a mole on her neck. Physical examination reveals that the lesion is an irregular nodular superficial mass with a variegated appearance. Biopsy demonstrates a primary malignant tumor.

Depth

An 8-year-old boy is evaluated for persistent bedwetting. He has never been continent, averaging 2-3 episodes of bedwetting per week. His urological evaluation revealed a normal bladder and urethra and no neurological problems. Lately, his problem has been a source of much embarrassment; he is unable to attend camp or sleepovers due to fear of wetting his bed. He has tried multiple interventions, including lifestyle changes, alarm systems, and reward systems. His physical exam shows no abnormalities. His parents are keen on a rapid resolution to his problems, and they insist treatment be initiated.

Desmopressin

A 43-year-old woman presents with reddish-pink eruptions on her neck, upper back, shoulders, and arms. The skin lesions appear annular and do not hurt or itch. The patient is concerned about having a contagious disease, but she does not feel sick. Her body temperature is 38.4°C, her pulse is 65, and her blood pressure is 150/70. She has a history of hypertension and gastritis, which she has been treating for several years. She exercises regularly, mostly outdoors, and uses sunscreen whenever she feels it is needed.

Determine the medication history of the patient.

A 60-year-old man presents with difficulty climbing stairs, dyspnea, and fatigue. He has gained 30 lb over the past year. On examination, he is found to have edema, pigmentation of the skin, palmar creases, and proximal muscle weakness. Chest X-ray shows an irregular mass in the right upper lobe. Lab values show an increase in evening cortisol levels and an increase in ACTH.

Dexamethasone suppression test

A 6-year-old boy's parents are concerned about their son's behavior. There have been complaints from his teachers that he is frequently fidgeting and disruptive in class. His parents state that he is extremely active at home and requires frequent discipline. After a complete history and physical exam, your suspected diagnosis is attention-deficit/hyperactivity disorder (ADHD).

Dextroamphetamine

A 13-year-old girl is drowsy and unable to answer questions. Her mother says that she has been extremely thirsty lately and urinates frequently. Her father notes that the patient has also been fatigued. There is a fruity odor to the patient's breath. Blood gases are drawn and reveal the following:

Diabetes mellitus

A 54-year-old man presents with chest pain. He has a past medical history of hypertension and diabetes mellitus. The pain is located in the middle of his chest and radiates to his jaw. The pain began about 20 minutes ago, and he rates the pain as a 10 on a 0-10 point scale, with 10 being the worst pain he has ever felt. He has had 3 similar episodes, but they have always resolved after 5 minutes or so of rest. He has smoked 1 pack of cigarettes a day for the past 36 years. He drinks 2 or 3 beers on Friday nights. Review of systems (ROS) is positive for diaphoresis, acute dyspnea, and impending doom. ROS negative for fever, chills, and malaise. Physical exam shows an obese, middle-aged man in moderate distress. BP is 126/80 mm Hg, pulse is 100, and respirations are 26. Heart and lung exams are normal, except for tachycardia and tachypnea. He has no pedal edema.

Diabetes mellitus

A 26-year-old woman is in the 24th week of her first pregnancy. She is in fairly good shape, and the pregnancy is progressing well, but a fasting blood glucose done in the office shows it to be 146 mg/dL. It is repeated the next day, and the value is 142 mg/dL. An oral glucose tolerance test is ordered, which comes back as abnormal. She is diagnosed with gestational diabetes and advised to meet with her obstetrician.

Diet and insulin if blood glucose remains high despite diet control

A family friend calls you for medical advice. She just gave birth to her third child 1 week ago. She is worried after a nurse from the hospital called her. The nurse said the baby tested high on a newborn screening for phenylalanine and that she would set up an appointment at a specialty center for the family. Your friend could not remember the name of the disorder, but she was told that it could prevent the infant from normal neurological development if left untreated. The friend reports that her pregnancy was uncomplicated and that the infant appears healthy so far. No one in the infant's immediate family has any health problems.

Dietary control

A 55-year-old man presents with a 5-day history of sharp chest pain. He has a history of rheumatic fever that occurred when he was 15. Further questioning reveals that the patient has had a high fever along with this chest pain. The pain itself seems to vary with positioning and movement, but it extends into the shoulder; he gains mild relief sitting up, but when he is laying down, the pain becomes intense. Physical examination reveals a pericardial friction rub. You order an ECG to be performed.

Diffuse ST-segment elevation

An 11-year-old girl with no significant past medical history presents with an increase in the frequency of her nosebleeds. She has experienced 3 episodes in the last week. Her mother was able to control and stop the bleeding by applying direct pressure to her external nasal area. Past medical history shows no significant issues with bleeding discrepancies or coagulopathies; she had a tonsillectomy when she was 8 years old; there were not any postoperative complications. Physical examination reveals a raw and irritated anterior right nare; the presence of dried crusted blood is noted.

Digital trauma

A 57-year-old man presents to the ED with syncopal spell 1 hour ago. 7 days ago, he experienced significant diarrhea for 4 days, with progressively worsening nausea and vomiting since. PMH is significant for congestive heart failure secondary to non-ischemic cardiomyopathy, atrial fibrillation, hypertension, chronic renal insufficiency (with baseline creatinine 2.0), and BPH. He denies drug allergies but reports blood pressure was low with diltiazem. Medications: furosemide, digoxin, enalapril, carvedilol, tamsulosin. Decreased appetite for 3 days with fatigue and malaise. Yellow/green halos around lights for 3 days. Vitals: temp 98.8°F, pulse 40 bpm slightly irregular, respirations 16/min, blood pressure 108/60 mm Hg. Normal S1 and S2 without obvious rub, murmur, or gallop. Lungs fields clear without rales, rhonchi, or wheezes. Laboratory workup: potassium 5.8 mEq/L, BUN 40 mg/dL, creatinine 4.2 mg/dL, digoxin level 4.8 ng/mL (reference range: 0.5-2.0 ng/mL). EKG: complete AV dissociation present.

Digoxin toxicity secondary to renal failure

A 52-year-old Caucasian man who frequently visits the emergency department presents due to "being short of breath." He is currently homeless, in and out of shelters. Past presenting problems that have brought him to the emergency department indicate that he has a chronic issue with alcohol overuse. Today, the patient is experiencing severe shortness of breath at rest. Physical examination findings reveal rales auscultated in bilateral lung fields, an S3 gallop, and elevated JVP.

Dilated cardiomyopathy

A 43-year-old patient presents with a 3-hour history of acute onset of palpitations and dyspnea. There is no other significant medical history. Chest X-ray and echocardiography are normal. EKG reveals absence of P wave, with variable R-R interval with atrial rate of 300/min and ventricular rate of 120/min. Patient is afebrile, radial pulse is 90/min, BP is 110/70 mm Hg, and RR is 18/min. A diagnosis of newly detected atrial fibrillation is made.

Diltiazem

A 62-year-old man who is well known to you presents with a severely itchy rash. The patient's medical history includes Parkinson's disease for the past decade. The patient felt the rash was just eczema at first, but the areas have progressed to significant hives; the itching has become far worse. On examination, you note multiple bullae that are 1 to 3 cm in size; they are tense and appear on an erythematous base. The bullae are noted to be located on the patient's trunk as well as the bilateral axillary and inguinal folds.

Direct immunofluorescence

A 30-year-old man presents to the ER with fever, malaise, and decreased urine output while taking ibuprofen for back pain. His temperature is 101°F, his blood pressure is 135/85 mm Hg without orthostatic change, and the remainder of his examination is normal. A post-void residual is normal, as is his renal ultrasound. His urine output is estimated at 1.5 L/day.

Discontinue ibuprofen.

A 5-year-old girl presents with a rash. The girl's mother states that she took the child to an urgent care center over the previous weekend; the patient was diagnosed with a urinary tract infection. The child was started on a 7-day course of sulfamethoxazole/trimethoprim and currently only has one more dose to take. The mother states the child has never taken this type of medication before. The rash in question was first noticeable 2 days ago; it has spread, worsened, and intensified, prompting the mother to bring the child in today. She denies any recent fevers, irritability, itching, or other significant symptoms. Her previous UTI symptoms have resolved. On physical examination, you note scattered lesions on the child. Each lesion appears to have three concentric circles of color change.

Discontinue sulfamethoxazole/trimethoprim; monitor symptoms.

A 15-year-old male Jehovah's witness presents to the clinic for a follow-up appointment after he was notified about abnormal lab work. Labs demonstrated the following: Hemoglobin: Low Hematocrit: Low Bleeding time: Normal PT: Normal APTT: Prolonged He is advised to undergo subcutaneous injections to replace missing clotting factors. The patient does not give verbal consent due to his religious beliefs.

Discuss the risks and benefits of the procedure with the patient and his parents.

An 86-year-old man was recently admitted to the hospital for diastolic congestive heart failure exacerbation. His code status was not addressed before his admission. He was later intubated due to cardiogenic shock and his family was notified of his admission. A meeting was convened with the patient's hospitalist team, his close friend, and his family to discuss the patient's medical wishes. His recently divorced wife brought in his will expressing his wishes not to be intubated. His close friend brought a document expressing that the patient wants all lifesaving measures. His son expressed that the patient does not want to be intubated in past conversations. His daughter believes that the patient wants to be intubated to "live as long as he can."

Discuss with hospital ethics committee.

You are working at the Centers for Disease Control and Prevention, assigned to the National Center for Chronic Disease Prevention and Health Promotion. You are asked to prepare a report describing the impact of cardiovascular disease in the US. You learn that: Cardiovascular disease—including stroke and hypertension—caused 840,768 deaths in the US in 2016. 635,260 of these deaths were due to cardiac disease. The US population in 2016, according to the official government census, was approximately 323.4 million. In order to prepare the report, you make the following calculation: 635,260 deaths323,400,000 person-years=x100,000 person-years635,260 deaths323,400,000 person-years=x100,000 person-years x=635,260 deaths×100,000 person-years323,400,400 person-years=196 deathsx=635,260 deaths×100,000 person-years323,400,400 person-years=196 deaths Substituting the result in the original equation yields: 635,260 deaths323,400,000 person-years=196 deaths100,000 person-years635,260 deaths323,400,000 person-years=196 deaths100,000 person-years

Disease-specific mortality rate

A 46-year-old woman underwent elective cholecystectomy. The attending nurse noted mild bleeding at the site of IV line and the incision site during dressing. The patient also reported bleeding from the gums and nose. Coagulation profiles revealed prolongation of aPTT, PT, and TT; decreased fibrinogen level; and increased levels of fibrinogen degradation product (FDP). Platelet count was also decreased. The patient was not experiencing any bleeding disorder before her hospitalization.

Disseminated intravascular coagulation

A 48-year-old previously healthy African American woman was involved in a severe motor vehicle accident, sustaining multiple injuries. She was stabilized in the emergency department but is now bleeding extensively from her laceration sites, her IV catheter site, and from mucous membranes. Laboratory results show thrombocytopenia, fragmented red blood cells, and low fibrinogen levels.

Disseminated intravascular coagulation

A 22-year-old woman presents for psychiatric follow-up. During the visit, she begins to reveal what appear to be distinct personalities. Identities appear to repeatedly take control of the patient's behavior and affect. You know she is an incest survivor. She denies any drug or alcohol use.

Dissociative identity disorder

A 70-year-old woman presents to be evaluated for bizarre behavior. Her daughter arrives with her and speaks with you alone; she describes her mother's behavior as consisting of mood swings, lavish trips, spending foolishly, staying up at night, and being hyper. According to her daughter, her mother has been diagnosed with bipolar disorder in the past. Past medical history is significant for chronic kidney disease stage III, obesity, diabetes mellitus, and hypertension.

Divalproex (Depakote)

A 19-year-old man with a family history of schizophrenia is receiving medical attention for his first presentation of psychosis. After ruling out organic causes and substance abuse as etiologies of his symptomatology, antipsychotic therapy with haloperidol is initiated. Within 48 hours, the patient begins to experience involuntary spasmodic contractions of the muscles in his face and neck.

Dopamine (D2)

A 34-year-old woman presents with worsening headaches. She says that the headaches are present throughout the day and that she has been feeling nauseous. She has also noticed difficulty in seeing vehicles on the freeway lately. She has had several close calls while driving due to this impairment. Her previously regular periods are now irregular, with heavy bleeding every 3-4 months. She has also noticed a milky discharge from both nipples. Her pregnancy test is negative. An MRI of the brain confirms the diagnosis.

Dopamine agonists

A 22-year-old man presents to his physician with swollen lymph nodes in the right axilla. He notes that he develops pain in the area after drinking alcohol. He has been feeling fatigued for the last few weeks and has lost weight without trying. Examination confirms lymphadenopathy in the right axilla. Biopsy of the region shows the presence of Reed Sternberg cells.

Doxorubicin, bleomycin, vinblastine, and dacarbazine

A 15-year-old girl presents due to a rash. She does not take any over-the-counter or prescription medications and she does not have any pertinent medical history or drug allergies. She denies known exposure to any sick contacts in the last several days, but she admits to traveling to Tennessee and hiking in the Smoky Mountains last week. Further questioning reveals that the patient admits to feeling feverish (although the patient has not formally taken her temperature), headache, lack of appetite, and muscle pain. Physical examination reveals a rash on her bilateral wrists, forearms, and bilateral ankles; it consists of numerous small flat pink macules that are non-pruritic and non-scaly.

Doxycycline

An 80-year-old man has a past medical history of chronic obstructive pulmonary disease, persistent asthma, and hypertension. He presents due to acute chest pain, dyspnea, and pleurisy that began suddenly 30 minutes ago. He denies fever, chills, hemoptysis, wheezing, diaphoresis, cough, or abdominal pain. His vital signs are notable for tachycardia and tachypnea. His thorax demonstrates unilateral decreased tactile fremitus, hyperresonance to percussion, and decreased to absent breath sounds. There is no jugular venous distension, cyanosis or accessory muscle usage. He is identified as a poor surgical candidate, and he has had previous episodes of similar manifestations in the past.

Doxycycline

A 33-year-old woman presents to the office with multiple vesicles with associated intense itching on her hands and feet. Her past medical history is negative. The patient is a waitress who takes no medication and does not work with chemicals. The vesicles are tense with some scales. There is no erythema or initial incidence of itching. The vesicles have responded well to a limited treatment with a high steroid cream.

Dyshidrotic eczema

A 65-year-old man with a 10-year history of hypertension controlled with lisinopril comes for preoperative evaluation before his arthroscopic knee surgery. He has never smoked and has never had a heart attack, congestive failure, arrhythmia, valvular problems, or abnormal lipids. His activity level is limited by knee pain; he does light to moderate housework and occasional swimming without dyspnea or chest pain. He is sexually active. His medications include ibuprofen for knee pain. His BMI is 26.5, blood pressure is 120/80 mm Hg, and the remainder of his exam is normal. His last electrocardiogram (EKG), taken 5 years ago shortly after a panic attack, showed normal sinus rhythm. His most recent (fasting) serum creatinine was 2.1 mg/dL with a blood urea nitrogen of 20 mg/dL. Past serum creatinines were in the 1.8-2.1 mg/dL range. He has no proteinuria.

EKG

A 12-year-old boy who presented to the emergency department 3 days ago with a right ankle injury. He "rolled over" his ankle playing football. Radiographs were negative. He has been treating with rest, icing, compression, and elevation (RICE). Past medical history is unremarkable, without prior ankle injuries. Today, he has mild pain and swelling of the outer aspect of the right ankle near the lateral malleolus with mild tenderness on motion, especially inversion, with a mild limitation of motion due to pain. He can almost fully bear weight on the ankle. There is no joint instability.

Early mobilization

Your patient is a 1-day-old "floppy baby"; he was born full term by normal vaginal delivery in the hospital. Birth weight was 2.4 kg; Apgar scores were 6 (1 min), 8 (5 min), and 8 (10 min). His mother had a normal pregnancy, except for an episode of a mononucleosis-like illness, but her heterophile antibodies were negative. On examination today, the patient is febrile, with a heart rate of 130/min, shallow breathing, and bilateral fine crepitations. You notice petechial purpura. He has hepatosplenomegaly and generalized lymphadenopathy (cervical, axillary, and inguinal). Neurological examination reveals hypotonia and bulging anterior fontanelles; there are no meningeal signs. Ophthalmological examination reveals multiple foci of chorioretinitis on both eyes. He is polypneic and hypoxic; nasal oxygen therapy and wide-spectrum antibiotic therapy is introduced (ampicillin, gentamycin, and cefotaxime). Labs are listed below.

Eating undercooked meat during the pregnancy

A 3-month-old male infant is brought into the pediatric clinic for assessment. The mother states that her child is not gaining adequate weight despite a regular breastfeeding schedule. She notes that the child appears to get "very tired and inactive" during and after feedings and that she can feel copious amounts of sweat on the child's skin following feedings. She denies any known illness in her child and recalls a normal birth. The general survey reveals a weight and length in the 40th percentile, tachycardia, and tachypnea. The cardiac exam is remarkable for a bounding and hyperdynamic precordium, a holosystolic harsh murmur audible over the lower sternal border (LSB), and a loud second component of the second heart sound.

Echocardiogram

A 35-year-old woman presents with fatigue and yellowish coloration of her eyes and skin that started several weeks after non-eventful implantation of a prosthetic mechanical heart valve 6 weeks ago. She denies any history of similar episodes. She has a history of severe aortic stenosis. Other past medical history is non-contributory. Physical examination reveals the presence of regurgitant murmur and subicterus. Laboratory results: hemoglobin 7.0 g/dL, reticulocytes 21%, WBCs 11,500/µL, platelets 80,000/µL, undetected levels of haptoglobin. Lactate dehydrogenase (3100 U/L), direct bilirubin (2.1 mg/dL), and indirect bilirubin (1.2 mg/dL) levels are all elevated. Peripheral blood smear shows burr and helmet cells (schistocytes) and polychromasia. Direct and indirect Coombs tests are negative. You suspect microangiopathic hemolytic anemia.

Echocardiography

A 5-day-old female newborn was born 5 weeks prematurely and presents to her first pediatrician's appointment. She did not have any feeding or breathing issues, so mother and child had only a 2-day stay at the hospital. During the cardiovascular examination, the pediatrician notes that the newborn has a distinct murmur with a rough machine-like quality that is maximal at the second intercostal space at the left sternal border. The murmur starts after S1 and passes through S2 into diastole.

Echocardiography

An 82-year-old man with a past medical history of hypertension, dyslipidemia, type 2 diabetes, and chronic kidney disease is being evaluated for progressive exercise-induced fatigue and shortness of breath over the last year. He also admits to more recent chest pain and lightheadedness, both of which occur with ambulation. He denies cough, fever, chills, lower extremity edema, or abdominal complaints. The physical exam revealed a narrow pulse pressure following blood pressure assessment. His cardiac exam noted a laterally displaced point of maximal impulse, as well as a mid-systolic ejection murmur that is low-pitched, rough, rasping in character, and loudest in the second right intercostal space. This murmur radiates to the bilateral carotid arteries. His peripheral vascular exam demonstrated a delayed peak of his radial pulsations.

Echocardiography

A 14-year-old boy is seen for a sports physical for the freshman basketball team. Past history is significant for a high degree of myopia bilaterally (first diagnosed at age 4) and a dislocated shoulder at age 10 that was easily reduced. Family history is significant for several unidentified ancestors having died in their 40s of an unidentified cardiovascular disorder. Physical examination revealed normal vital signs. Height is 6'1" and weight 145 lb. The upper to lower segment ratio is 0.65 (decreased). Arm span was 76". The palate is highly arched and mild pectus excavatum is present. A 2/6 early diastolic murmur is present and best heard at the second intercostal space at the right sternal border. Arachnodactyly of the fingers and toes and generalized loose jointedness and pes planus are also present.

Echocardiography needs to be performed with follow-up.

A 25-year-old man presents after experiencing pronounced shortness of breath at the gym. You cannot obtain satisfying information from him during the interview, and you think that he may have an intellectual disability disorder. On examination, he appears short for his age and you notice webbed neck, dental malocclusion, antimongoloid slanting of the eyes, and hypogonadism. Auscultation reveals high-pitched systolic ejection murmur maximal in the second left interspace with radiation to the left shoulder and ejection click that decreases with inspiration. His second heart sound (P2) is delayed and soft. The impulse of the right ventricle is increased, and you palpate a thrill at second left intercostal space.

Echocardiography/Doppler

A 40-year-old Asian American man presents with a 3-day history of nausea and vomiting. He also reports mild fatigue and loss of appetite. He reports he is in good health besides having a positive PPD test 2 months ago. He was started on medication after the positive test. Surgical history includes an appendectomy. He is a non-smoker, drinks 7 alcohol beverages a week, and exercises 4 times a week.

Elevated AST and ALT

A 62-year-old man presents with vision problems and difficulty swallowing. Over the last week, he has had a constellation of symptoms; they began with numbness and tingling in his feet and progressed to weakness that now affects both lower and upper extremities. He has started to notice difficulty swallowing and double vision since yesterday. It feels difficult for him to take a big breath. His past medical history is non-contributory, and he takes no medications. Exam reveals bilateral absence of patellar and ulnar reflexes. A lumbar puncture is performed to confirm the diagnosis.

Elevated CSF protein content

A 16-year-old girl presents due to concerns of significant acne and hirsutism. She states she is extremely embarrassed regarding this. Review of systems is positive for irregular periods. On exam, she is 5'2" tall and weighs 300 lb. You note a dark velvety discoloration of her neck fold.

Elevated LH: FSH ratio

An 11-year-old boy presents with increasing cognitive trouble in school. His parents state that he has had more trouble with grades and schoolwork since starting middle school. He also seems slightly more defiant. His history is significant for a metabolic disorder; it was diagnosed at birth, but it has been controlled with diet. He is interviewed while his parents are out of the room; mild cognitive impairment is noted. He tells you that, since he started middle school, he has been "cheating" on his diet.

Elevated serum phenylalanine

A 74-year-old man with a history of diabetes mellitus, hypertension, and hyperlipidemia presents with severe chest pain and dyspnea. On exam, he is confused, agitated, pale, apprehensive, and diaphoretic. His pulse is weak and tachycardic; systolic blood pressure is 80 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, significant jugular venous distention, and pulmonary crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads, while a portable chest X-ray notes diffuse pulmonary congestion.

Emergent percutaneous coronary intervention

A 53-year-old woman is seen by her gynecologist. She has had three children and had her tubes tied through tubal ligation. She reached menopause at 48. Over the last few weeks, she has noted some vaginal bleeding that occurs unpredictably. She has had regular pap smears that have always been normal. The last one was 11 months ago. Speculum examination and bimanual palpation of the genitalia reveal no abnormalities.

Endometrial biopsy

A 36-year-old woman presents with lower pelvic pain. She noticed that pain worsens during intercourse. She also reports heavy menstruation for the past 4 months. She has lost weight over the past few months. Upon physical exam, her gynecologist did a pelvic exam and felt a mass, but cervical motion tenderness and suprapubic tenderness was negative. A transvaginal ultrasound showed an increase of >4 mm of endometrial thickness. A D&C was then conducted and positive for dysplasia cells. Upon laboratory findings, the patient was negative for STDs and Escherichia coli.

Endometrial cancer

A 27-year-old G1P1 woman has recently given birth by cesarean section to a 36-week male newborn. She did well throughout her pregnancy until 34 weeks gestation; she presented with fever, abdominal pain, and wetness. She was diagnosed with preterm premature rupture of membranes (PPROM) and chorioamnionitis. She was treated with steroids and antibiotics, stabilized, and then delivered by C-section with no complications. On postpartum day 7, she presents with sore breasts from breastfeeding and a sore abdomen. She admits to an odorous vaginal discharge, but she denies any associated vaginal bleeding. On physical examination, she has moderate lochia alba, and her temperature is 101.2°F.

Endometritis

A 7-year-old boy presents to the pediatrician's office with a 3-week history of clear nasal discharge, itchy eyes, and excessive sneezing. The family recently took in a stray cat, which sleeps with the boy. On examination of the nasal passage, you note swelling of the turbinates with clear drainage from the nares bilaterally. On examination of the oral cavity, you note slight pharyngeal erythema, post-nasal drip, and no tonsillar edema. He denies fevers, chills, nausea, and vomiting.

Eosinophils

A 37-year-old man fell from a ladder as he finished working on the roof of his house. The right side of his head hit the alley cement, and he lost consciousness for about 1 minute; he woke up with a headache, but he had no other complaints. A few hours later, the patient is brought to the emergency room by his neighbor because of an intense headache, confusion, and left hand hemiparesis. On examination, the patient has a bruise located over the right temporal region, mydriasis, and right deviation of the right eye, papilledema, and left extensor plantar response. An emergency CT scan of the head without contrast reveals a lens-shaped hyper-density under the right temporal bone with mass effect and edema.

Epidural hematoma

A 3-year-old child presents with sudden onset of high-grade fever, sore throat, pain during swallowing, and drooling of saliva. There is no history of a cough. The child appears toxic and is dyspneic with inspiratory stridor. The child is sitting upright and leaning forward with chin up and mouth open. Suprasternal and intercostal retractions are present. Chest is clinically clear. Blood count shows polymorphonuclear leukocytosis. Lateral radiograph of upper airway shows "thumb sign."

Epiglottitis

A 10-year-old boy presents with swelling on his face that has been progressively increasing in size. He is an immigrant from East Africa. On examination, he has mild pallor and large swelling involving his right maxilla. A biopsy taken reveals a starry sky pattern of lymphocytes.

Epstein Barr virus (EBV)

A full-term Caucasian infant is a product of an uncomplicated pregnancy, labor, and delivery. Birth weight is 8 lb, length is 21 in, head circumference is 14 in. As you examine the newborn's mouth, you identify 6 raised yellowish-white raised lesions, each approximately 1 mm in size; these lesions are located along the mid-palatine raphe. The remainder of the physical examination is normal.

Epstein pearls

A 19-year-old woman presents with a 2-week history of rash. Other than a sore throat that she had last week, she reports being in good health; her sore throat was treated with penicillin. She does not believe that she has come in contact with any type of irritants or any individuals who are sick. On physical examination, you note several target-like lesions on the palms of her hands that are bilateral and symmetric. She indicates that she is on birth control medication.

Erythema multiforme

A 12-year-old girl is diagnosed using a quick antigen test as having a pharyngeal infection due to Streptococcus pyogenes. She also presents with a rash on the upper part of the chest and trunk.

Erythrogenic toxin

A 22-year-old woman at 24 weeks gestation presents with a 3-day history of a nonproductive cough and fever. She states she has been battling an upper respiratory infection that does not seem to go away. Initially, she thought that she had a cold, but the symptoms persisted. She was told by her obstetrician that she has the flu and to drink plenty of fluids and get some rest. Vital signs reveal temperature 101.2°F, blood pressure 120/80 mm Hg, heart rate 110/bpm, and respiratory rate 22 breaths/min. On physical examination, she appears ill; lungs exhibit wheezing.

Erythromycin

A 9-year-old girl presents with a sore throat. The parents state that she began a fever a few days ago, reporting that her throat hurt. On physical exam, you note a red throat, a red and beefy tongue, tonsillar exudates, and swollen anterior cervical lymph nodes. The parents report a history of a severe anaphylactic reaction to penicillin.

Erythromycin

A 35-year-old woman presents with a 24-hour history of purulent drainage and erythema of her right eye. Cultures of the drainage are taken, and she is started on a medication to cover the most common bacterial causes of conjunctivitis.

Erythromycin ointment

A 15-year-old boy was prescribed an antibiotic for acne. While being treated, he developed nausea, vomiting, fever, and jaundice. Liver enzymes are elevated, including AST, ALT, and alkaline phosphatase.

Erythromycin-induced hepatic injury

A 26-year-old African American woman presents 2 weeks after an uncomplicated vaginal delivery complaining of signs and symptoms of a urinary tract infection (UTI).

Escherichia coli

A 26-year-old G1P0 pregnant woman with type 1 diabetes presents to her obstetrician for her 20-week appointment. Over the past day, she has had to urinate more frequently; she has also developed a burning sensation with urination. Urinalysis reveals the following:

Escherichia coli

A 53-year-old man presents with increased difficulty swallowing and occasional regurgitation of meals; symptoms have been more frequent and severe over 4 months. Past medical history is remarkable for chronic heartburn, which he treats intermittently with over-the-counter antacids. He takes no regular medications, has no allergies, and has not had any surgeries. He is a smoker, but he denies use of alcohol and recreational drugs. He lives with his wife and children. The patient is obese, but the rest of his physical exam is normal. Laboratory evaluation, electrocardiogram, and chest X-ray are normal. Esophageal biopsy shows specialized intestinal metaplastic cells (of columnar epithelium).

Esomeprazole

A 58-year-old man with a history of COPD, hyperlipidemia, a 40 pack-year smoking history, and obesity is being evaluated at his primary care office for complaints of post-prandial regurgitation that is associated with an acidic sensation in his mouth and a chronic, nonproductive cough, all of which have been occurring over the past year. He has taken over the counter famotidine (Pepcid) without any relief. He denies any fever, chills, changes in weight, diaphoresis, chest pain, shortness of breath, sputum, palpitations, abdominal pain, or changes in bowel habits. His physical exam reveals an obese BMI, but it is otherwise unremarkable. His stool hemoccult is negative. Bloodwork reveals an iron-deficiency anemia; a chest radiogram was without pulmonary disease. An upper barium esophagram noted an outpouching of barium at the lower end of the esophagus and a wide hiatus through which gastric folds are visible above the diaphragm. H. pylori antibody testing and urea breath tests were negative.

Esomeprazole (Nexium)

A 62-year-old woman presents to her physician with persistent reflux symptoms despite medical management. An upper endoscopy is performed, revealing the attached image. Biopsy findings reveal replacement of the esophageal squamous epithelium with columnar epithelium. Refer to the image.

Esophageal adenocarcinoma

A 45-year-old chronic alcoholic man presents with history of massive hematemesis. This hematemesis followed a bout of prolonged vomiting. Patient has been a known alcoholic for 20 years. On examination, he has a pulse rate of 100/min and a BP of 90/70 mm Hg with cold extremities.

Esophageal laceration

A 60-year-old African American man presents due to dysphagia. The dysphagia started 3-4 months ago and has progressively gotten worse. He has also lost weight; current weight and height are 170 lb and 72". He appears older than his stated age. He wants something to help him in swallowing. He does not report heartburn. You note he does not eat on a regular basis, and when he does eat, it is usually fast food. He has smoked for the last 40 years, 2 packs a day. He drinks 12 cans of beer on weekdays and approximately 48 cans of beer during the weekend. He uses recreational drugs occasionally.

Esophagus neoplasm

During newborn nursery rounds, a young new mother tells you that there is a family history of eye problems that run on her dad's side. She is not sure what the problem is exactly, but many relatives have had to wear glasses. On exam, the infant's eyes seem to be deviated toward the nose. Corneal light reflex testing confirms your suspected diagnosis.

Esotropia

A 63-year-old woman presents with a blood pressure of 171/93 and returns for a follow-up appointment with a blood pressure of 181/94. The patient states she has a past medical history of alcohol abuse and high sodium intake. Additionally, the patient reports never using any antihypertensive medications. Upon physical exam, S2 heart sound is increased. The patient overall feels well besides her specific issue, and no other abnormal findings are found. Blood is not found in the urine, she presents with no flank pain, and she has a normal CT scan. Additionally, her T3 of 120 nanograms per deciliter and T4 levels of 5.0 micrograms per deciliter are in normal range.

Essential hypertension

A 32-year-old woman with a history of a tremor presents seeking help. She has experienced emotional stress from work over the past 6 months. Upon physical exam, a tremor is observed in her right hand when hands are outstretched. Tremor is also present in her head. Laboratory findings showed no abnormal findings, but her family history reveals that her father was also diagnosed with a tremor around the same age.

Essential tremor

A 48-year-old Caucasian woman presents due to feeling like she is losing her mind. She wants some tests done. Upon further questioning, she reports she is having multiple episodes daily in which she suddenly becomes very hot, flushed, and diaphoretic. These episodes last about 1 minute, then resolve. She has not measured a fever. The patient reports that these episodes occur during the day and at night, the latter causing her to awaken drenched in sweat. As a result, her sleep has been poor, and she feels fatigued and irritable both at work and at home. She has noticed these symptoms for about the last 2 months, and they seem to be increasing in severity. The patient has not had a period for 3 months; she recently did a home pregnancy test, which was negative. Prior to that, she had regular menses. This patient denies weight changes, palpitations, cold intolerance, bowel changes, as well as changes in her nails, skin, and hair. Although she admits irritability, she denies anxiety, depressed mood, and suicidal ideation. Her past medical history is significant for seasonal allergies, which are relieved with over-the-counter antihistamines and taken as needed. Her surgical history includes a tonsillectomy and bilateral tubal ligation. Her family history is remarkable for diabetes in her maternal grandfather and hypertension in her father. She is a G4P3Ab1. Social history reveals the patient is an office manager for a dental clinic; she is a married nonsmoker with 3 children living at home. She denies any major psychosocial stressors recently. She drinks alcohol rarely, and she denies use of other drugs. Vitals and a urine specimen for hCG were obtained prior to the physical exam.

Estradiol/norethindrone acetate (Activella) 1 mg/0.5 mg by mouth daily

A 51-year-old woman presents due to menstrual irregularity, hot flashes, and mood changes. Physical examination reveals an atrophic vagina and breasts that have decreased in size. She is diagnosed with menopause, and she decides not to start hormone replacement therapy (HRT). 8 years later, a dual-energy X-ray absorptiometry (DEXA) reveals a T score of -3.

Estrogen

A 30-year-old man presents with a 2-month history of coughing and a 2-day history of coughing blood. He has been losing weight and sweating at night. On physical examination, the patient appears wasted and tachypneic with bronchial breath sounds in the right upper lobe and crepitations in the left upper lobe and right mid-zone. His direct sputum result comes back positive for acid-fast bacilli with Ziehl-Neelsen stain. His sputum is sent for culture and treatment is started for his condition. After starting the medication, he notices he is unable to distinguish between red and green colors.

Ethambutol

A 45-year-old man presents with a 24-hour history of severe anal pain and swelling. The pain started after straining at defecation and has worsened over the course of the day. There is no history of fever. Examination of the anal area reveals a swollen ecchymotic mass in the perianal skin, very close to the anal verge. What is the treatment of choice for this condition?

Excision of thrombosed external hemorrhoid

A 53-year-old Caucasian man presents due to a bleeding mole on his left cheek that has been present for the past several years. In the last 3 months, it has started to spontaneously bleed. The patient denies any other moles with the same characteristics, and he just wants it taken care of so it is not as bothersome. The patient denies weight loss, night sweats, or fevers; he has no recent changes in his appetite or sleeping issues. He is a farmer, and he owns over 100 acres that he plants and harvests yearly; he has done so for the last 25 years. Physical examination reveals a 4 cm macule with irregular borders, at least 3 different shades of color, and small ulcer in the middle.

Excisional biopsy

A routine EKG 5 weeks ago determined that a 59-year-old Caucasian man developed new-onset atrial fibrillation. It was asymptomatic, not associated with dizziness, palpitations, chest pain, or shortness of breath. He was started on warfarin 5 mg daily for anticoagulation. Cardioversion was scheduled as a subsequent elective outpatient procedure. PMH includes hypertension. Allergies: None. Usual medications: Hydrochlorothiazide 25 mg daily, metoprolol tartrate 50 mg b.i.d., warfarin 5 mg daily. He presents to the outpatient cath lab for planned cardioversion procedure, reporting no new medical problems or symptoms. He claims compliance to his medications. Review of lab work 3 days ago showed protime 16.2, INR 1.7. CBC and basic chemistry profile were normal. Today's lab work shows protime 19.2 seconds, INR 2.1. EKG shows atrial fibrillation with ventricular rate 87 bpm. Your supervising physician intends to proceed with the cardioversion procedure. You (PA) believe the cardioversion procedure is contraindicated based on lab work.

Express your concerns to your supervising physician privately.

A 12-month-old girl presents with her parents after a 3-day history of intermittent episodes of strange behavior. A neurologist is consulted because the parents are concerned she is having some form of seizure activity. Her health history includes 2 episodes of otitis media, but she is otherwise healthy. Her initial vital signs and physical exam by the emergency room staff are all normal.

Eye deviation with facial twitching that lasts 1-2 minutes

You are performing a physical examination on a 14-year-old girl. She reports no issues, has no problems at school, participates in school sports activities, and is not sexually active. Her past medical history is non-contributory. Her mother is worried because she still looks prepubertal and still has not gotten her period (her mother had menarche at age 12). Her height is 5 ft; weight is 79 lb (BMI 15.46; 3rd percentile); her Tanner stage is 1 for both breast and pubic hair development; the rest of physical examination is normal. Laboratory results are all within normal limits (CBC, ESR, LFT, and basic metabolic panel).

FSH levels

A 20-year-old Lebanese woman wants to start birth control. She has never been sexually active, and her wedding is in 2 months. She feels well and reports no issues. She thinks she wants "the pill." Her fiancé is also a virgin, and they are not interested in condoms or other barrier contraception. She wants to delay childbearing for at least 2 years. Past medical history includes occasional OTC ibuprofen for menstrual cramps and headaches, penicillin allergy, previous tonsillectomy, menarche age 12, and regular menses with mild-moderate dysmenorrhea. Her older sister had a blood clot in her lung after giving birth. Her paternal grandfather has diabetes and hypertension, maternal grandmother had a stroke, mother had a DVT in a leg, and maternal grandfather had prostate cancer. She denies tobacco, alcohol, and recreational drug use. Vitals: 123 lb, 5'4", BMI 21.1, pulse 88, BP 134/86, temperature 97.9°F.

Factor V Leiden

You are employed as a PA in a large fast-paced high-volume hospitalist practice that employs several PAs. The practice's patients include a mix of 60% covered by commercial insurance, 30% by Medicare, 5% by Medicaid, and 5% uninsured. One of your primary responsibilities is performing initial assessments of new patients admitted to the hospital in collaboration with a physician whose documentation is sufficient to permit shared billing. Although you dictate or record the patient's admission history and physical exam, the collaborating/supervising physician submits and determines the billing charges for the hospital admission. The practice administrators have instructed all of the PAs to always perform a complete review of systems so that the physician is free to bill the H&P at the highest level of medical complexity, if merited. One of your colleagues admits that they seldom perform a complete review of systems, instead only asking the patient, "Do you have any other symptoms?" If the answer is "No", your PA colleague indicates in their written note/dictation that "Twelve systems were reviewed and found to be negative, except as detailed in the history of present illness and past medical history."

False or fraudulent claims

A 34-year-old man was the driver in a single-car motor vehicle accident. Preliminary radiologic studies show a comminuted fracture of the right tibia. The patient is describing a substantially increasing amount of pain felt in the injured extremity. He describes the pain as being a 10/10; it seems as if it is becoming worse every minute. He describes it as a deep achy burning pain. You quickly examine the right leg; you note pallor, a tense wood-like feeling of the extremity, diminished sensation, and muscle weakness.

Fasciotomy

A 50-year-old African American man with no chronic medical conditions is overdue for an annual wellness visit. You call the patient to ask why he has not scheduled an appointment. He informs you that he no longer has health insurance and is concerned about how to pay for routine healthcare examinations. He is particularly concerned about how he will afford a screening colonoscopy that is due. His neighbor died from colon cancer as a result of failing to undergo screenings. You inform the patient that there are alternative screening tests for colorectal cancer, and there is a program at your clinic that covers the cost of annual wellness visits for uninsured patients, but it does not cover additional screening or diagnostic tests. He returns for an office visit, and you establish that he remains in an optimal state of health. You proceed to further discuss screening options.

Fecal occult blood testing

A 21-year-old Caucasian man reports symptoms of sneezing, runny nose, itchy nose and eyes, and occasional cough occurring intermittently. He describes his symptoms as mild and intermittent; they do not negatively impair his quality of life. He fractured his collarbone in childhood. No other significant past medical history. He does not use alcoholic beverages or recreational drugs. His only brother has asthma and eczema. The patient has occasional headaches and has dark circles under both eyes. Vitals: temperature 98.4°F, pulse 72 and regular, respirations 12, blood pressure 124/76. HEENT: Normocephalic. EOMs intact. PERRLA. Erythematous injection of the conjunctiva is noted. Pale boggy nasal mucosa is present. Oral mucosa is pink with a small amount of post-nasal drainage present. The remainder of the physical examination is unremarkable. Treatment options are discussed with the patient. He requests medication to treat his symptoms without affecting his daily activities.

Fexofenadine

A 16-year-old girl presents with a mass palpated over the left breast. There are no associated signs or symptoms noted. Menarche was at age 12; it is described as regular with moderate flow, lasting 3-5 days with occasional dysmenorrhea. She is in high school with good school performance. Vital signs are within normal limits. Weight and height are appropriate for age. Physical examination reveals a non-tender mass on the upper outer part of the left breast measuring about 2 x 3 cm. Aspiration is done, but no fluid is aspirated. An excisional biopsy is contemplated.

Fibroadenoma

A 35-year-old woman presents with a single firm, well-delineated, round, non-tender nodule in her left upper breast. It is very mobile with respect to its surrounding tissue.

Fibroadenoma

A 30-year-old woman presents with recurrent bilateral breast lumps and pain. She states that it seems to be worse during the last few days of her menstrual cycle; the lumps appear to get smaller after her cycle. She has felt different sized lumps in her breast that occur at the same time as the pain. On examination, several small, nodular lesions are noted in both breasts; they are freely movable. The axillary lymph nodes are unremarkable bilaterally.

Fibrocystic condition

A 42-year-old woman presents with a history of chronic fatigue and pain around her neck, shoulders, and lower back. She is also experiencing chronic headaches and irritable bowel symptoms. Upon physical exam, no abnormal findings were found except for trigger points that produced pain around the trapezius, lateral epicondyle of her elbow, and the medial fat pad of her knee. Laboratory findings showed a normal ESR, negative RF factor, and a negative ANA.

Fibromyalgia

A 24-year-old Muslim woman with no past medical history presents to establish care. She is dressed in a burka. She is given paperwork but does not fill it out. She enters the room and waits for the provider. A physician assistant enters the room several minutes later and introduces themselves. In presence of a nurse, the PA instructs the patient to change into a gown. The physician assistant returns several minutes later with the nurse and sees that the patient is still in her burka. She asks the patient why she did not change into the gown, but the patient does not respond.

Find an interpreter for the patient.

A 55-year-old woman presents with constant fatigue. She has experienced multiple episodes of falling asleep at work and dozing off while waiting at red lights. Her husband consistently complains about her snoring and snorting while asleep; it wakes him at night. On physical exam, she is 5'2" and 205 lb. Her blood pressure is 150/90 mm Hg, her pulse is 82 BPM, her respirations are 16/min, and she is afebrile. The rest of her physical exam is unremarkable. Laboratory studies, including thyroid function tests, are within normal limits. After advising her on diet and weight loss, you schedule her for an overnight sleep study.

Five or more episodes of apnea or hypopnea per hour

A recently married 22-year-old woman presents with a 7-day history of severe vulval and vaginal pruritus and purulent vaginal discharge. She was having dysuria and dyspareunia. Examination showed frothy yellowish mucopurulent vaginal discharge with an offensive odor. Vaginal mucosa appeared inflamed, and cervical erosion was also observed. Vaginal secretion was collected, and a microscopy of wet film done immediately. Oval pear-shaped organisms about the size of white blood cells with wobbling rotatory motility were observed among inflammatory cells. Gram stain was negative for Candida and clue cells. Based on the diagnosis, the patient and her husband were treated with metronidazole.

Flagellated protozoan

A 73-year-old man with no significant past medical history presents with a 1-month history of light-headedness, dizziness, and near syncope; it has been occurring in response to sitting up and standing from a supine position. He denies chest pain, palpitations, shortness of breath, cough, loss of consciousness, vision or speech changes, nausea or vomiting, numbness, tingling, paresthesias, and focal weakness. His physical exam is noteworthy for a drop in systolic blood pressure of 24 mm Hg from a supine to standing position.

Fludrocortisone and compression stockings

A 22-year-old woman presents due to feeling depressed, withdrawn, and irritable from 3 days prior to her menses until the day after her flow begins. She frequently misses her college classes, and she is concerned about her symptoms' potential impact on her academic performance. She is otherwise in a good state of health, and she has no history of chronic medical or psychiatric disorders. She is not taking any medication. She does not use tobacco, drink alcohol, or use illicit drugs. Menarche was at age 13, and her menses are currently regular each month. She denies cramping, bloating, and other associated physical symptoms. She is sexually active with one partner, and she uses condoms for contraception.

Fluoxetine

A 66-year-old man presents with a 2-month history of fatigue. He reports that he has recently joined Alcoholics Anonymous. On examination, he is malnourished and pale, but his neurological examination is essentially normal. A peripheral blood smear reveals macrocytic red cells.

Folic acid deficiency

A 14-year-old girl presents to her family practice physician assistant with her mother. She reports no issues, has no problems at school, participates in school sports activities, and is not sexually active. Her past medical history is non-contributory. Her mother is worried because she still looks prepubertal and has not gotten her period (the mother had menarche at age 12). Height is 5 ft, weight is 79 lb (BMI 15.46; 3rd percentile), Tanner stage is 1 for breast and pubic hair development. The rest of physical examination is normal, including pelvic exam. Laboratory results are all within reference ranges (CBC, ESR, LFT, basic metabolic panel, and urine HCG).

Follicle-stimulating hormone (FSH)

A 6-month-old girl is brought in to the pediatrics clinic by her 15-year-old mother, and they are accompanied by the infant's grandmother. The pregnancy was uncomplicated, and the infant was born full-term by spontaneous vaginal delivery. The mother had prenatal care and has brought the infant to all scheduled appointments. The infant has received all age-appropriate vaccinations so far. She has been gaining weight appropriately and breastfeeding exclusively. She is meeting age-appropriate milestones, and the mother and grandmother have no concerns at this appointment. Your physical exam reveals no abnormalities. You discuss the risks and benefits of the vaccines due at this visit. The mother is able to restate these risks and benefits to demonstrate understanding, but she refuses to consent. She has been reading about vaccines online and is concerned about their safety. She requests that her infant is vaccinated on a delayed schedule. The infant's grandmother disagrees and would like the infant to receive the vaccinations per CDC guidelines. Despite a thorough conversation with the family, you are unable to reach an agreement.

Follow the 15-year-old mother's request.

A 4-year-old boy presents with a 4-day history of frequent sneezing, noticeable congestion, nasal discharge, and irritability; his mother has a history of airborne seasonal allergies and believes her son may have a problem with his sinuses. The mother denies noticing any shortness of breath, problems breathing, or fever; the boy has not been in close contact with sick individuals in the last few weeks. Physical examination reveals unilateral purulent nasal drainage from the left nare and a foul odor.

Foreign body

A 4-year-old girl presents to the emergency department with her mother due to pain and itching in her right ear. The patient denies hearing loss and dizziness. She came back from her grandmother's house yesterday and told her mom that her ear "really itched inside." There is some drainage noted on exam from the affected ear. There is no pain when manipulating the tragus or erythema on the pinna. The mother mentions the patient and her sister were playing dress up with earrings yesterday. The mother reports the patient was inside most of the weekend and did not go swimming.

Foreign body

A 14-year-old boy is brought to your medical office by his mother for a physical examination. According to the mother, the child was diagnosed with intellectual disability (intellectual developmental disorder) 2 years ago. They have just relocated from another state, and he requires a physician's clearance to start at a new special education school. She states that he has been in good physical health since birth. His past medical history includes a few mild headaches and upper respiratory tract infections, but no chronic conditions, hospitalizations, operations, or medications. The mother has brought his vaccination records with her, and they show all immunizations are current. Family history is positive for a maternal grandmother that developed dementia at age 55 and a maternal uncle with autism. Pertinent findings on the physical examination include an unusually narrow face, a prominent forehead, large protruding ears, a prominent jaw, and unusually large testes.

Fragile X syndrome

A 77-year-old right-handed woman presents with a history of right-side hemiparesis and global aphasia. She has long-standing diabetes, for which she takes metformin; she also has a history of well-controlled hypertension. CT shows large left hemispheric infarction. On examination, she is alert, and you notice that she appears queasy. She has been incontinent of urine since admission. Serum analysis shows elevated glucose. Glomerular filtration rate shows mild renal insufficiency; dipstick urinalysis is glucose positive, and post-void residual volume is 80 mL.

Functional incontinence

A 41-year-old woman presents due to increasing dyspnea and fatigue. She was diagnosed with idiopathic pulmonary hypertension 2 years ago and is on home oxygen therapy. She reports swelling in her ankles, right-sided abdominal pain, and inability to breathe well when lying down. She has gained 10 lb in the last month. EKG reveals peaked P waves, right axis deviation, and tall R wave in V1.

Furosemide

A 68-year-old African American woman with past medical history of obstructive sleep apnea, hypertension, and COPD presents with chronic progressive dyspnea. The dyspnea initially occurred upon exertion, now noted at rest for the past 8 months. She is maintained on home oxygen for COPD. There is associated fatigue, substernal exertional chest pain, and 2 episodes of exertional syncope. She denies other symptoms. Physical exam reveals oxygen saturation of 90%, left parasternal lift, narrow splitting of the second heart sound, accentuation of the pulmonary component of the second heart sound, an early systolic ejection click, and an S4 gallop. No murmurs are identifiable. +1 pitting edema bilaterally to the lower extremities to the mid-calf level. EKG shows right axis deviation and incomplete right bundle branch block. Chest x-ray shows right ventricular enlargement with prominent right pulmonary artery.

Furosemide

A 29-year-old African American man develops dysuria and increased frequency of micturition. In the emergency room, he is found to have a urinary tract infection and is treated with nitrofurantoin and recommended to follow up with his primary care physician in the office. Over the next few days, the patient experiences fatigue, fever, jaundice, abdominal and back pain, and dark urine. Blood tests show Hb 4 g/dL, reticulocyte count 6%, and MCV 93. Coombs test is negative. Bilirubin levels are elevated. Peripheral smear reveals cell fragments, microspherocytes, and blister or bite cells. Heinz bodies are present.

G6PD deficiency

A 44-year-old man comes in with reports of heartburn, substernal pain, regurgitation, and difficulty swallowing. He likes to eat foods that have "substance," like hamburgers, steaks, fries, rich desserts, etc. He says his wife is a great cook and prepares all his favorite dishes with extra butter. He has had heartburn for years. To relieve the heartburn, he has taken antacids. This time, the pain is worse. He has eaten a large fatty meal within the last hour. He denies other medical problems. He does not smoke and only occasionally uses alcohol. On physical exam, he weighs 280 lb and is 5'10".

Gastroesophageal reflux disease

A 27-year-old woman followed by your practice for several years tells you that her 24-year-old brother has been recently diagnosed with von Hippel-Lindau disease. She has been told it is a hereditary disease. She asks if she should undergo genetic testing for von Hippel-Lindau disease. You cannot immediately recall any details regarding the genetics, pathophysiology, or clinical manifestations of von Hippel-Lindau disease. Following your physical examination of the patient, you briefly step out of the exam room, intending to return in 5 minutes to conclude your office visit with her. During this break, you try to conduct online research for accurate information regarding this rare disease.

Genetic Testing Registry Online medical database

A 32-year-old woman presents with increasing irritability. She reports involuntary movements of her arms and increasing incoordination. Her husband is worried because she is having trouble remembering things. She was adopted, and her family history is unknown. Physical examination is remarkable for rapid involuntary movements of fingers bilaterally, impaired ability to concentrate, slurred and disorganized speech, and difficulty responding with appropriate words or phrases when prompted.

Genetic testing

A 34-year-old man presents for his first doctor's appointment. He had always neglected his health, but he finally sought medical attention at his wife's insistence. He explains that he was from an "unhealthy family" and that he was tired of being around doctors while growing up, so he avoided medical attention. His father died at the age of 30 of "very high blood pressure" and "heart failure." His older brother was recently operated on for the removal of a cancer from his neck. Prior to that, his brother had had surgery to remove a mass from his adrenal gland. He wants to know what he can do to be healthy. His blood pressure and BMI are within normal limits. He does not smoke or use alcohol, and he exercises regularly.

Genetic testing for possible familial cancer syndrome

A 16-year-old girl presents with shortness of breath, wheezing in her chest, and swelling of the lips that started several minutes after she had a snack. She had similar symptoms several months ago at a Chinese buffet. She appears restless. Her face is erythematous and her lips and tongue are swollen. She is able to repeat her name when asked. Her blood pressure is 89/60 mm Hg, and heart rate is 110/min rhythm regular, with respirations 26/min and shallow. On auscultation, diffuse wheezing is heard.

Give epinephrine.

An African American male neonate born 12 hours ago presents with yellowish coloration of the whites of his eyes. His skin also appears darker and yellowish compared to his twin sister's skin. Pregnancy was normal, and the 23-year-old mother had no infections or complications and took no drugs during the pregnancy. Delivery was uneventful; the neonates were born on term with APGAR score 9 and 10, respectively. Family history of anemia, splenectomy, bile stones, and liver disease is negative, but the father has a "beans allergy" that presents with abdominal pain and jaundice. Peripheral smear does not reveal spherocytosis, echinocytosis, or eliptocytosis, but some keratocytes are present. Bilirubin levels in the patient are high (13 mg/dL) with direct bilirubin 1 mg/dL. Coombs test is negative and hemoglobin is low.

Glucose-6-phosphate dehydrogenase deficiency

You are performing an annual physical examination on a 14-year-old girl. In the last couple of years, she started having constipation "every other day or so," followed by loose stools. She still feels depressed because of her parents' recent divorce. She has no problems at school, her grades are good, and she participates in sports. Her mother is worried because she is so slim despite excellent appetite: that she has not grown enough. She still has not gotten her period. Her mother had her first period when she was 13. The rest of personal and family history is non-contributory. The patient's height is 5 ft, weight 79 lb (BMI 15.46; 3rd percentile); she is in Tanner stage 2 (the same as last year, according to her records); and her bone age is 12.5 years. The rest of physical examination is normal. Laboratory shows Hct of 31% and MCV of 73, low insulin-like growth factor (IGF), low FSH, positive anti-tissue transglutaminase antibodies. The rest of laboratory results are within normal limits, including TSH and prolactin.

Gluten-free diet

A 43-year-old woman was diagnosed with type 2 diabetes mellitus 6 months ago. She presents for follow-up. She states she is feeling well and has no current symptoms. She currently receives oral hypoglycemics. The patient has no other significant medical history. Her glucose, acetone, lactate, and glycated hemoglobin are performed, and they are reported as follows:

Good glycemic control

A 60-year-old man with a history of recurrent sinus infections presents with hemoptysis and hematuria. Physical examination shows a temperature of 101°F, a blood pressure of 145/85 mm Hg, decreased breath sounds on his right lower lobe, and palpable purpura on his bilateral lower legs. No warm or swollen joints were noted.

Granulomatosis with polyangitis (GPA, Wegener's granulomatosis)

A 35-year-old woman presents because of weight loss and palpitations. She lost 10 kg over 5 months despite having a good appetite. Her heart pounds and her hands tremble "all the time." She feels hot, is sweating profusely, and has difficulties going to sleep and maintaining sleep; the slightest stimulus wakes her. Her job is suffering because of her nervousness, and her supervisor became concerned because she uses the bathroom 3-4 times a day in a need to move her bowels. She thinks that poor sleep quality and frequent bowel movements make her weak; she cannot climb stairs anymore and has to take a rest every 10 steps or so. Physical examination reveals a slim anxious woman with pronounced stare, fine postural hand tremor at rest, and slight proximal weakness. Her thyroid is diffusely enlarged and non-tender; her pulse is 100/min; the rest of examination is within normal limits.

Grave's disease

A 12-year-old girl presents with a 3-day history of progressive weakness and paresthesias in lower legs. Yesterday, she developed weakness in both upper extremities. She is unable to walk without assistance, so her mother brought her in. She had a sore throat 2 weeks ago. PMH is significant for measles and mumps. Because of religious beliefs, she has not had any immunizations. Physical examination reveals a well-developed well-nourished girl. She is awake, alert, and in no acute distress. Oral temperature 98.7°F, blood pressure 140/80 mm Hg, heart rate 84/min and regular, respirations 22/min and unlabored. Speech is moderately dysarthric. She can smile weakly but cannot raise her eyebrows against resistance. Pupillary responses are normal. There is mild upper extremity and severe lower extremity weakness, greater distally than proximally. Reflexes are hypoactive-to-absent. Sensation is intact, except for mildly impaired position and vibratory sensation in both feet.

Guillain-Barré syndrome

A 55-year-old man with no significant past medical history presents for a routine evaluation and fasting bloodwork. He does not note any symptoms at this time. His physical examination reveals an obese body mass index with a waist circumference of 120 cm and a blood pressure of 140/90 mm Hg. Physical exam is otherwise unremarkable. His fasting bloodwork is drawn.

HDL value of 35 mg/dL

A 5-year-old girl presents with a rash of clear and grayish vesicles on a reddened base. Her hands and feet are affected, including her palms and soles. She reports sores in her mouth. There is no desquamation to the rash. Her heart and lungs are clear. She is febrile, and there is an accompanying tachycardia. Her blood pressure is normal. Her oral cavity shows ulcerations.

Hand-foot-mouth disease

A 35-year-old man presents with a 2-week history of recurrent swollen painful lips and a rash primarily affecting the arms and hands. His first episode occurred while in jail 6 months ago. He has had two additional episodes since then. He was treated with oral steroids each time, which improved his symptoms, but symptoms always returned. On examination, you notice several targetoid lesions on the dorsal hands and forearms, with darkening, swelling, and peeling of the lips.

Have you ever had fever blisters, cold sores, or genital herpes?

A 10-year-old boy is referred to you for being fidgety at school, even though he gets good grades. Prior history is unremarkable, and there has been no recent illness. The boy's father had a similar history as a child. While speaking with the patient, you notice that he clears his throat several times per minute. Examination is otherwise normal, except for rapid non-rhythmic jerking movements of the face, neck, and shoulders while at rest.

He has a condition that clusters in families.

An 8-year-old boy in third grade is referred to you by his school doctor to be evaluated for poor speaking and reading ability, failure to follow directions in class, and classroom disruptiveness. Despite these problems, he appears to be alert and interactive with other children and there is no demonstration of aggressive behavior or rage. He does not appear to be preoccupied with internal stimuli, and IQ testing results are within normal range.

Hearing impairment

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child's mother is concerned about the risk of hearing loss and its effects on development.

Hearing loss during OM may adversely affect cognition and language.

A 71-year-old woman, previously in excellent health and taking no medications, presents with new shortness of breath when she lies down at night. She denies any difficulty breathing during the day and states she is able to maintain her usual level of light activity. She denies any chest pain or palpitations. She noticed some mild ankle edema around the time the respiratory symptoms started. Office spirometry is normal, but her EKG reveals a widened QRS complex and her laboratory results reveal an elevated BNP (brain naturietic peptide).

Heart failure

A 13-year-old African American boy presents with a 4-month history of increasing fatigue, pallor, exertional dyspnea, and depression. Past medical history is significant for an ischemic stroke due to sickle cell disease 6 years ago. Since his stroke, the boy has been receiving chronic red cell transfusion therapy, and subcutaneous iron chelation therapy started 3 years ago. On physical exam, pulse is 150 bpm, respirations are 20/min, blood pressure is 105/75 mm Hg, and O2 saturation by pulse oximetry is 92% on room air. In general, he appears ill; he is dyspneic and refuses to lie flat on the bed during his examination. Otherwise, he is cooperative with his exam. He is diaphoretic, with no rashes or skin abnormalities noted. His cardiovascular exam is significant for a 4/6 systolic ejection murmur and a gallop. His pulmonary exam demonstrates scattered expiratory wheezes throughout all lung fields. His liver is 4 cm below the right costal margin; no spleen is palpable. The remainder of his exam is unremarkable.

Hemoglobin, ferritin, liver function tests, chest X-ray, echocardiogram

A 31-year-old multigravida known to have blood group A and Rh-negative red blood cells is pregnant with her third child. Her husband is also type A, but he is Rh-positive. She has an indirect Coombs titer at 1:16 dilution of her serum at 28 weeks gestation. Her past medical history includes two pregnancies; her first child (a boy) was healthy, while the second child (a girl) was born at 36 weeks gestation after the mother was noted to have an indirect Coombs titer at 1:16. Amniotic fluid obtained at 26, 28, 30, 32, and 34 weeks of gestation was analyzed by determining the optical density (OD) for bilirubin and indicated a progressive increase in the bilirubin level.

Hemolysis of red blood cells in the fetus

A 24-year-old African American G2P1 presents to her obstetrician at 34 weeks gestation with weight gain, fatigue, diffuse "swelling," and headache. On physical examination, you note periorbital edema and 3+ pitting edema in the lower extremities peripherally. Physical examination also demonstrates tenderness to palpation in the right upper quadrant. The patient has increased reflexes bilaterally. Vital signs are as follows: Temperature is 99.2°F. Pulse is 89 beats/minute. Respirations are 18. Blood pressure is 174/99 mm Hg. Urinalysis reveals no erythrocytes per high power field and no casts, but there is a large amount of protein in the urine.

Hemolysis, elevated liver tests, and low platelets syndrome (HELLP)

A mother presents with her 5-year-old Caucasian son; he has a significantly swollen right knee. She states that her son has a blood coagulation disorder and frequently bleeds into his joints when he sustains any injury. His past medical history includes the use of the blood product cryoprecipitate or factor VIII concentrates for treatment for his disorder.

Hemophilia A

While covering the ED, you attend to a 12-year-old boy who cut his hand while trying to slice a bagel. His mother wrapped his hand with a dishrag and drove him to the ED. On exam, his vitals are stable. He has remained alert and cooperative, but the rag has soaked through and his fingers feel numb. On removal of the rag, there is a fairly deep-looking straight-edged transverse laceration running the length of his palm, with overlying clotted blood that begins to actively bleed.

Hemostasis

A 5-year-old boy presents with history of low-grade fever, headache, and intermittent colicky abdominal pain localized mainly around the umbilicus since yesterday. He has vomited once. His symptoms are also accompanied by a purplish-red maculopapular rash more confluent over the lower extremities and the buttocks. There is no itching. Both knees and ankles are swollen and tender, and there is edema of the hands and feet mainly in the dependent areas. Examination of cardiovascular, respiratory, and abdominal are essentially normal.

Henoch-Schönlein purpura

A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, breast cancer, hip fractures, and coronary artery disease is being evaluated for acute-onset severe left-sided pleuritic chest pain over the course of the last 2 hours. The pain is associated with feelings of anxiety, hemoptysis, shortness of breath, and nausea. She "feels warm" but denies chills, palpitations, wheezing, edema, vomiting, abdominal pain, abnormal bowel habits, or dietary intolerances. She admits to a 30 pack-year smoking history but denies drug or alcohol use. Upon physical exam, she is found to be febrile, hypotensive, tachycardic, tachypneic, diaphoretic, and in acute painful distress. There are perioral cyanosis and a pleural friction rub to the left lung fields; the remainder of the exam is normal.

Heparin

A 50-year-old obese woman undergoes a cholecystectomy and T-tube drainage of the common bile duct. On postoperative day 7, she develops sudden epigastric and left-sided chest pain. She is short of breath and is sweating profusely. Her temperature has been between 99-100°F for the past 2 days. The patient's vitals are: pulse 90/min, BP 110/60 mm Hg, and RR 24/min. The ECG reading shows tachycardia, and the ventilation-perfusion lung scan shows a VQ mismatch.

Heparinization

A 32-year-old man presents with a 2-day history of high fever and progressive severe headaches that are associated with blurred vision and increasing confusion. The patient is normally healthy, and he does not have a remarkable past medical history. He is married. He does not drink alcohol, smoke, or use recreational drugs. He has not had any blood transfusions and takes no medications. On physical examination, he appears ill and disorientated to time, place, and person. His pulse is 110 bpm, temperature 39°C (102°F), respirations 22/minute, and blood pressure 115/70 mm Hg. He is well-hydrated. He has no scleral icterus, pupils are equal and reactive, and fundi are normal. His cranial nerve examination is intact. He does not respond to pain stimuli appropriately. He can move all of his limbs. Deep tendon reflexes are normal; plantar reflexes are equivocal. His neck is supple and there is no palpable adenopathy. Skin exam is normal without rashes. His lab work includeswhite blood cell count (WBC) = 18x109/L with 70% polymorphonuclear neutrophils and 30% lymphocyteserythrocyte sedimentation rate = 90 mm/hour

Herpes simplex virus encephalitis

A 20-month-old boy presents with a 1-week history of fever up to 101°F and irritability. His mother noted sores in his mouth 4 days ago; she states that she has noticed him drooling and that his appetite is quite diminished. His past medical history is unremarkable. He has no medical allergies and his only current medication is acetaminophen. He is current on his immunizations. His physical exam reveals normal vital signs except for a temperature of 100.5°F. On examination of his oral cavity, you note swollen erythematous gingiva with ulcerations present mostly on the left of his mouth. The ulcerations appear yellowish-white and friable. White-gray lesions approximately 3 mm in diameter are seen on the anterior tongue. The tonsils appear erythematous without exudates. His lips are slightly cracked, and his mucous membranes are slightly tacky. Neck examination reveals bilateral anterior cervical adenopathy. He has no skin lesions. The remainder of his exam is normal. His strep test is negative.

Herpetic gingivostomatitis

A 21-year-old woman presents with recurrent painful nodules that form in her armpits. On physical examination, you note red inflammatory nodules that are very tender to palpation. Also noted are open comedones that seem to be paired. The patient indicates that these areas ultimately break down and drain a foul-smelling purulent material.

Hidradenitis suppurativa

A 72-year-old man is evaluated at his bedside following hospital admission for a 1-year history of progressive dyspnea, nonproductive cough, weight loss, low-grade fevers, fatigue, and myalgias. Past medical history is remarkable for atrial fibrillation (for which he takes amiodarone), hypercholesterolemia, and recurrent urinary tract infections. He is currently on nitrofurantoin on a chronic prophylactic basis. He denies cigarette use. He denies chills, fatigue, rhinitis, otalgia, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, arthralgias, vomiting, and urinary complaints. A bedside echocardiogram and electrocardiograms are unremarkable for abnormalities. A chest x-ray reveals peripheral reticular opacities at the lung bases and a generalized honeycombing pattern.

High-resolution computed tomography (HRCT)

A 52-year-old woman presents because her menopausal symptoms have been extremely distressing. Over the past 4 months, she has experienced severe mood swings, hot flashes, night sweats, breast tenderness, and changes in her appetite. She has never smoked; she has an occasional drink. She had an IUD that was removed at age 35. She had irregular periods in her 40s and menses stopped at 50. There is no family history of cancer. After a prolonged discussion, a decision to start hormone replacement therapy is made.

Higher risk of endometrial cancer

A 15-year-old girl presents with loss of consciousness. She is accompanied by her mother, who states that the patient initially fell ill several days ago with a headache, muscle aches, and fever. The patient developed a severe headache today, accompanied by double vision, difficulty speaking, confusion, and eventual loss of consciousness. She has not taken any medications aside from acetaminophen (Tylenol) for her fever. Her mother states that her daughter is usually active and had been playing soccer regularly until she became ill; the patient has been fairly healthy aside from occasional cold sores. Past medical history is significant for frequent ear infections as a toddler that were treated with tympanostomy tube placement at age 2. Brain imaging reveals edema of the temporal lobe.

History of cold sores

A 24-year-old woman presents with a 3-month history of excreting fluid from her left breast. When her symptoms first started, she had noted clear fluid staining her bra, which recurred infrequently. If she compressed the left breast tissue around her nipple area, she could easily express clear fluid. Occasionally, with difficulty, she was also able to express the same fluid from her right breast. Medical and surgical history is positive for depressive disorder; it has treated with tricyclic antidepressants for the past 4 months; she had an appendectomy 2 years ago. Her menstrual history is regular, with dysmenorrhea present. She drinks alcohol occasionally. Family history is positive for diabetes.

History of tricyclic antidepressant use

A 68-year-old man with a 50 pack-year smoking history presents to his primary care provider due to a 4-month-history of progressive dysphagia. His review of symptoms is notable for intermittent ear pain (especially upon swallowing), an involuntary weight loss of 12 lb over the past 4 weeks, and occasional hemoptysis. He denies chills, abdominal pain, shortness of breath, chest pain, vomiting, or skin changes. His physical exam is remarkable for non-tender immobile lymphadenopathy of the cervical nodes and stridor upon auscultation of the trachea. A nasopharyngoscope revealed complete replacement of the right true cord with a mass lesion.

Hoarseness

A 24-year-old man presents with a large painless mass above his right clavicle. He reports no change in its current size over the last 6 months. He denies excessive fatigue/malaise, weight loss, fevers, or chills. Physical exam reveals no hepatosplenomegaly or palpable cervical, axillary, or inguinal lymphadenopathy. Excisional biopsy of the mass is performed and the pathologist reports the presence of Reed-Sternberg cells.

Hodgkin's lymphoma

You have just taken over the management of a 55-year-old man with COPD who was admitted 3 days earlier for community-acquired pneumonia. He currently feels somewhat better, and he has been afebrile for the last 24 hours. Leukocytes count5,600/μLSerum glucose106 mg/dLSegmented neutrophils75%Sodium138 mmol/LHemoglobin19g/dLChloride102 mmol/LPlatelets245,000/μLPotassium4.2 mmol/LArterial blood gas PH 7.25Bicarbonate29 mmol/LPCO2 55BUN18 mmol/LPO2 57Creatinine1.0 mmol/LHCO3 29 O2 sat 88%

Home oxygen

The mother of a 3-year-old boy asks to have a blood test done on her son for lead poisoning. He has not been tested before. They have moved into an older home, built before 1960. She has noticed some peeling paint on windowsills and doors and has seen small paint chips on the floors. They are now having the house repainted and are staying with relatives. A careful environmental history is obtained, and risk reduction and nutrition education are provided. His fingerstick blood lead level comes back at 13 mcg/dL.

Home visit to identify potential lead sources

A 17-year-old boy comes into the urgent care clinic due to dysuria, frequency, urgency, and urethral discharge. His mother is present in the exam room during your interview. When asked, the patient says his mother can remain in the room for the interview but not for the exam. You conduct the interview, then ask the mother to step out. When she leaves, you ask the patient about his sexual history and discover he had consensual unprotected sex with a new partner just before the onset of these symptoms. He asks you to not discuss this information with his mother.

Honor the patient's wishes and do not disclose any information to the mother.

A 33-year-old man presents with a 1-day history of a painful left upper eyelid. He denies any change in vision, discharge, trauma, or foreign body. The pain started after the patient was cleaning out the garage. On physical exam, the visual acuity is OD/OS/OU = 20/20. The lateral aspect of the left upper eyelid is swollen, erythematous, and tender to palpation. The rest of the eye exam is normal.

Hordeolum

A 35-year-old woman presents with a painful swelling of her left eyelid. On physical exam, there is tenderness to palpation and erythematous swelling present on the lid margin involving the eyelashes.

Hordeolum

An 8-year-old child is brought to your office because of swelling of the left upper eyelid; the swelling is associated with redness and tolerable pain. No fever is noted. Physical examination shows a localized swelling and redness on the upper middle lid of the left eye; there is slight tenderness on palpation. Vital signs are within normal limits.

Hordeolum

A 50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has a 60 pack-year history of cigarette smoking. Past medical and surgical history are otherwise unremarkable; he does not take any medications. On examination of his right eye, both ptosis and miosis are noted. A chest X-ray shows a rounded opacity in the right lung field.

Horner syndrome

A 50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years (60 pack-years). On physical examination, the right eye demonstrates ptosis and miosis, and the right side of the face is unusually dry compared to the left. No weakness is noted on the musculoskeletal exam. A chest radiograph reveals a rounded opacity in the right lung field.

Horner syndrome

A 45-year-old man presents with concerns of uncontrollable movements that he has noticed for the past 2 months. He feels he cannot control these involuntary movements of his upper body. His wife reports that he appears irritable and impulsive. She feels that his personality has changed, but she is more concerned about the sudden jerking in his body. She shared that the patient's father passed away in his 50s with similar symptoms. Upon physical exam, the patient appears to have tics that are sudden and appear depressed. Additionally, Hoffmann's sign and Babinski's sign are normal. A CT scan shows cerebral atrophy and genetic testing from the lab is pending.

Huntington's disease

A 4-month-old female infant is presented for a well-child checkup. She was a spontaneous vaginal delivery at 39.5 weeks without complications. The mother notes she has been irritable and has not been eating well. No cough or fever. No one smokes at home. On exam, you note impaired extraocular movements, especially in the upward gaze, and a bulging anterior fontanel. There is increased tone of the legs. Skin exam is normal. Like her last visit, the length and weight are 50th percentile. Head circumference was formerly at the 75th percentile and is now above the 99th percentile.

Hydrocephalus

A 55-year-old woman presents with bumps around her eyes. She states they have been worsening over the past 3-4 months. They are not painful, but she is worried they may be something serious, especially since they seem to be increasing in size. The patient is currently taking a regular dose aspirin, which was suggested by her gynecologist, but she is not on any other daily medications. Family history is pertinent for her father dying at age 82 due to a heart attack and her mother still living at the age of 79 with a known medical history of hypertension and high cholesterol. On physical examination, slightly raised yellowish well-circumscribed plaques along the nasal portion of both eyelids are noted.

Hypercholesterolemia

A 22-year-old woman presents with an 8-month history of amenorrhea. Further questions elicit additional pertinent positives of backaches, headaches, and acne. Physical examination reveals a female patient with a moon-shaped face, multiple purple striae, and significant central obesity (body mass index of 36).

Hypercortisolism

A 72-year-old woman presents with a 2-week history of fever, cough, and excessive diuresis. The woman has diabetes mellitus that is being treated with glimepiride (Amaryl). Her fluid and food intake have been poor during this time, as well. On physical examination, blood pressure is 98/58 mm Hg, pulse is 112/min, temperature is 100.6°F, and respirations are shallow and regular at 20/minute. On physical assessment, the patient is stuporous, skin and mucous membranes are dry, heart has a regular rate and rhythm without murmurs, and auscultation reveals rales in the left lung base. Her serum BG level is 602 and blood pH 7.35. She is diagnosed with pneumonia.

Hyperglycemic hyperosmolar state

A 73-year-old frail-appearing woman is brought in by her daughter who is concerned about her mother's increasingly poor memory. The mother reports fatigue and weakness so profound that "her bones hurt," as well as polyuria and chronic constipation. She is being treated for depression and osteoporosis, but she is otherwise in good health.

Hyperparathyroidism

A 33-year-old man presents for an initial visit to a new primary care office. He has not seen a healthcare provider in the past 5 years. His past medical history reveals a coarctation of the aorta repair at age 13, after which he saw a cardiologist yearly until age 18. Since then, he has not had insurance and has only sought care for urgent problems in acute care clinics.

Hypertension

A 40-year-old obese Caucasian man says that his father recently passed away after having a heart attack. He is worried and wants to know whether he is at risk for cardiovascular disease. He is hypertensive; however, he does not take any medications. His BP in the office today is 140/96 mm Hg, and his BMI is 31. You explain to him that the risk factors for cardiovascular disease may be non-modifiable or modifiable.

Hypertension

A 26-year-old woman presents after a syncopal episode. She has lost of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and a III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage.

Hypertrophic cardiomyopathy

A 42-year-old man has had systolic blood pressure in the 140s and diastolic blood pressure in the 80s on several occasions despite changing his diet and exercise regimen. His physician decides to start him on hydrochlorothiazide.

Hypokalemia

A 5-month-old girl presents with a 3-day history of vomiting. She is exclusively breastfed, and her mother states that today she has vomited within 15 minutes of each feeding. Her last wet diaper was 10 hours ago. On physical examination, she is afebrile, tachycardic, and irritable, and she does not express tears when crying. She was a full-term vaginal delivery. She has no significant past medical history. Her 3-year-old sister has had gastroenteritis for the past few days.

Hypokalemia

A 16-year-old girl has just been diagnosed with severe allergic rhinitis caused by ragweed and dust mite. She is a candidate for allergy immunotherapy, which will involve weekly subcutaneous delivery of the offending allergens in increasing concentrations.

Hyposensitization

A 22-year-old female college student presents because she does not eat properly and has missed several menstrual cycles. Her sorority sisters are certain she is not pregnant because she rarely, if ever, leaves their sorority house except to attend classes; she has not dated in more than 6 months. On examination, she is underweight. She walks unaided and her speech is clear and distinct. She has adequate vision, normal-appearing facial expressions, and adequate hearing. On her college entrance physical examination, her height was 5'7" and her weight was 130 lb. Her weight 1 year later is now 103 lb.

Hypothalamus

A 58-year-old Caucasian man presents to his primary care physician's office reporting lethargy. His heart rate is 44 bpm. The patient is sent to the emergency department where he is treated with atropine 0.5 mg x 1 dose. Heart rate then increases to 57 bpm, and the patient is admitted to the hospital for further evaluation. Cardiology consultation is requested. The patient reports no history of cardiac disease. He denies symptoms of chest pain or pressure but admits to intermittent lightheadedness and mild dyspnea on exertion with moderate activity in the last 2-3 months. He denies paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema, palpitations, and frank syncope. He admits fatigue and lethargy for 3 months. He had an exercise tolerance test 10 years ago that was reportedly normal. His last physician's office visit was 2 years ago. His past medical history is notable only for high cholesterol and history of tonsillectomy. He has no known drug allergies. His only daily medication is Lipitor 20 mg once daily. He does not smoke and does not use alcoholic beverages or recreational drugs. Review of systems reveals cold intolerance and episodes of constipation. Physical examination reveals an alert white man who is somewhat slow to speak and respond. His voice is moderately hoarse. He has coarse facial features and dry skin. Mild periorbital puffiness is noted. Deep tendon reflexes are delayed. 12-lead EKG reveals sinus bradycardia, rate 52, without evidence of prior myocardial infarction, ischemia, left ventricular hypertrophy, or bundle branch block. The EKG is otherwise within normal limits.

Hypothyroidism

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis. Vital signs show: Temperature 100.8°F, pulse 108, respirations 24, and blood pressure 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. Oral exam shows overall poor dentition. Skin exam shows non healed puncture wound in left antecubital region surrounded by old granulomas and scarring. A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen.

IV drug abuse

A 34-year-old man is brought to the emergency department after a single-car motor vehicle collision. Preliminary radiologic studies show a comminuted fracture of the left tibia. The patient is describing a markedly increasing amount of pain felt in the injured extremity. He describes the pain as being a 10/10 that is becoming worse with each passing minute. With anguish on his face, he describes it as a deep achy burning pain. You quickly examine the left leg and note pallor, a tense "wood-like" feeling of the extremity, diminished sensation, and muscle weakness.

IV opioids

A 4-year-old boy presents with a 3-day history of fever with chills, cough, and fast breathing. His parents report decreased oral intake and increased difficulty breathing with retractions over the last 24 hours. His initial vital signs are heart rate 144 bpm; respiratory rate 32/min; temperature 101.3°F (38.5°C); oxyhemoglobin saturation 89% on room air. He is immediately started on supplemental oxygen, and his oxyhemoglobin saturation improves to 95%. Subsequent evaluation, including a chest X-ray, is suggestive of right middle and lower lobe pneumonia.

Ventilation-perfusion mismatch

A 44-year-old man with a history of coronary heart disease presents to the emergency department with crushing chest pain and heart palpitations. He smokes 3 packs of unfiltered cigarettes daily. He has periods of wide-complex rapid regular tachyarrhythmia at 160 beats per minute that last for 20-30 seconds. When you reach his examination room, you note his monitor also reveals evidence of a QRS width of 0.16 seconds.

Ventricular tachycardia

A 70-year-old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have become "dull." Over the past month, she has started having urinary urgency and involuntary leaking of urine. Besides multivitamins and local application of Timolol for glaucoma, she takes no other medications; there are no other symptoms.

Ventriculoperitoneal shunt

A 42-year-old man presents to the emergency department with a severe headache. He has been getting several of these headaches recently and has tried all over-the-counter pain relievers and headache medicines with no relief. His current headache started 15 minutes ago. He describes the pain as located next to and behind his left eye and "stabbing/excruciating" in nature. He feels like his left eye tears up profusely with these headaches. He reports he has been healthy otherwise, with no chronic medical conditions, no history of surgery, no medications, and no drug allergies. He denies recent stressors that may have caused his headaches. On physical exam, the patient appears slightly agitated and appears uncomfortable. His left eye's conjunctiva is mildly injected, and lacrimation is noted. His right eye is normal. Cranial nerves II-VII are intact, although the patient expresses discomfort when the light is shown in his left eye. Speech, gait, coordination, and reflexes are all normal. The remainder of his exam is normal. Head MRI is performed and reported as normal.

Verapamil

A 28-year-old woman presents to the emergency department due to a 3-hour history of nausea, abdominal cramping, vomiting, and watery diarrhea. She recounts her lunch approximately 8 hours ago, which consisted of a shrimp salad and a diet soda. She denies any neurological or other symptoms. She also denies any similar problems prior to this episode and was feeling well just before this incident. She denies fever or recent travel.

Vibrio parahaemolyticus

A 22-year-old man presents with a temp of 101°F, a headache, stiff neck, and some limitation of flexion of his neck for the past 2 days. The patient also has generalized myalgia for the past 3 days. The patient was advised rest, adequate hydration, and treatment with antipyretics. The recommended treatment caused the resolution of symptoms.

Viral syndrome

A 26-year-old woman presents for her second obstetric visit in the first trimester. Routine screening tests (blood typing, testing for syphilis, hepatitis, rubella immunity, and HIV) are performed; the test returns positive for HIV. She is counseled to start antiretroviral therapy and to have a cesarean delivery.

Virus replication

A 16-year-old girl presents for continuing concerns about her weight. She has a family history of diabetes and has tried to lose weight before without success. Her BMI (body mass index) is at the 99th percentile for age, and she is given a trial of orlistat. Within 2 weeks, she returns to her pediatrician with bowel movement changes, flatulence, oily discharge, and mild abdominal pain. She lost 5 lb and would like to continue the treatment if the side effects could be eliminated.

Vitamin D

A 4-month-old girl has been gaining weight well and achieving normal milestones. She was a full-term infant born via vaginal delivery without complication. Her past medical history is significant only for a mild URI the previous month, and she is current with her vaccines. She has been exclusively breastfed since birth. Her mother eats a well-rounded diet that includes meat and dairy.

Vitamin D

A 20-year-old woman presents with intermittent nose bleeds for the past 2 weeks. She also reports that her menstrual periods have increased in number in the past 2 months. She recently underwent surgery for small bowel resection and eats only one meal a day. Laboratory investigations reveal prolonged prothrombin time, prolonged activated partial thromboplastin time, and a normal platelet count.

Vitamin K deficiency

A 50-year-old woman presents with a 4-month history of white patches on her skin. The patches of discoloration easily burn when exposed to sun but are not painful. Physical exam reveals well demarcated white macules on her face, neck and hands. There is no erythema, crusting, or drainage.

Vitiligo

An 18-year-old woman presents with chronic fatigue and menorrhagia. Menorrhagia has been present since her first menstrual cycle, but it has recently become worse; she sometimes uses 20 tampons per day. About a year ago, she started using contraceptive pills but is now considering stopping using them because of migraine-like headaches. Her headaches are sometimes so severe that she has to take aspirin or other painkillers several times a day. The rest of her past medical history is unremarkable. Physical examination reveals pale skin and mucosa, pulse rate of 100 beats per minute, and a systolic ejection murmur 1/3 intensity over the precordium. Laboratory findings include white blood count 9 K, hemoglobin 10, platelet count 250 K, normal prothrombin time, slightly prolonged partial thromboplastin time, and normal fibrinogen. Her bleeding time is prolonged. Blood smear shows microcytic hypochromic anemia.

Von Willebrand disease

A 40-year-old woman undergoing chemotherapy develops fevers and respiratory symptoms. A chest radiograph is ordered; it reveals bilateral fluffy pulmonary infiltrates. A bronchoscopy with biopsy is performed; the specimen is found to contain septate hyphae with acute-single branching.

Voriconazole

A 31-year-old Caucasian woman presents for genital itching that she has been experiencing for a while. She has treated herself with OTC medication for a yeast infection, which has not helped. Now she notices a lump, which appears to be raised and nodular on exam. Her menstrual cycles have remained unchanged since puberty. She is G0P0 and has been taking oral contraceptives for the past 11 years. Her family and social history are insignificant.

Vulva

A 56-year-old Asian woman presents to establish care for a wellness exam. She recently relocated from out of state; she brings a copy of her medical notes and labs from her previous medical provider. The patient tells you that sexual intercourse is very uncomfortable for her. She admits insertional dyspareunia and poor lubrication, but she denies deep dyspareunia. Outside of intercourse, she denies pelvic issues. She denies vaginal bleeding, pruritus, or discharge. She also denies urinary issues, such as dysuria, frequency, and incontinence. She has occasional hot flashes, but she feels they are tolerable. Her relationship is otherwise healthy, and she does not feel pressured into intercourse against her will. She is a G2P1. Surgical history includes open fracture reduction of the left ankle at age 22 and a dilatation and curettage (D&C) at age 24 for a spontaneous abortion (SAB). She is divorced, and she has been in her current monogamous relationship for 1.5 years. She is a non-drinker and non-smoker; she denies recreational drug use. Family history is unremarkable.

Vulvar and vaginal atrophy

An 18-year-old man presents to the emergency department due to right lower quadrant abdominal pain for 12 hours associated with nausea and vomiting. His temperature is 101°F, and he is hemodynamically stable. The patient has abdominal guarding, a positive Rovsing's sign and tenderness at McBurney's point. A computed tomography (CT) scan demonstrates a perforated appendix. General surgery is called and they request the patient be added on the OR schedule for emergency appendectomy.

Wait for the surgeon to obtain consent from the patient.

A 40-year-old man presents with irregular heartbeats over several days. His past medical history is significant for the presence of mitral valve stenosis and atrial fibrillation (AF). He takes beta blockers regularly. His ECG shows atrial fibrillation with an irregular heart rhythm around 80 bpm.

Warfarin

A 6-year-old girl is brought in by her mother and presents with sudden localized swelling of her left upper eyelid at the lid margin. Mom states this has never happened to the girl before. She denies discharge, fever, or trauma. There is mild pain on to palpation. The remainder of the eye exam is within normal limits.

Warm compresses

A 58-year-old man presents for further evaluation after being brought in by the local police because of an unstable gait and disheveled appearance; his breathalyzer test is 0.08 g/dL. On exam, the man is gaunt and clearly malnourished; he is disoriented and confused and unable to respond to questioning. His right elbow and knee are bruised, but he appears to have no other significant injuries; however, his eye movements are uncoordinated and bounce from side to side. He is unable to fixate his gaze. Vital signs are as follows:

Wernicke's encephalopathy

A 3-year-old girl presents with progressive abdominal enlargement associated with abdominal pain. The mother denies any past medical history. Physical examination shows a palpable mass over the right upper quadrant extending to the right flank. Patient looks pale and the BP is slightly elevated. Urinalysis shows microscopic hematuria.

Wilms tumor

A 12-year-old boy presents with fatigue and jaundice. His past medical history is not significant for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On further eye examination using a slit lamp, brown-yellow rings encircling the iris in the rim of the cornea are noted bilaterally. AST and ALT are elevated, and a serum ceruloplasmin level is reported as low and confirms the diagnosis.

Wilson disease

A 17-year-old boy develops progressively abnormal muscle fatigability. He is diagnosedwith myasthenia gravis and is admitted to a hospital. In the course of his treatment with pyridostigmine, he develops increased weakness, nausea, vomiting, sweating, and bradycardia.

Withdraw pyridostigmine.

A 66-year-old woman presents for a health maintenance visit. She reports no issues and has no history of chronic illness except postmenopausal osteoporosis, with a bone mineral density >3 standard deviations below the mean. She takes supplemental calcium and is being treated with denosumab IM every 6 months. Her only recent fracture was a compression fracture at T-6, diagnosed 5 months ago. Although she had previously enjoyed tennis, dancing, and gardening, she has drastically reduced her activity for fear of suffering further fractures. She asks if she should resume any sort of regular physical activity. Past medical history is otherwise unremarkable except for anemia, which is now resolved. Vital signs are normal, as is the remainder of the examination.

Work toward resuming former exercise program.

A 52-year-old man presents with concerns over hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only the left side. He also hears a ringing sound all the time. He denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. Past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and recreational drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Yearly head imaging

You are evaluating a 14-year boy for a pre-participation sports physical. He has been conditionally accepted as a wide receiver on his high school's football team. He was diagnosed with generalized tonic-clonic seizures at age 6. He is well-controlled on valproic acid, having had only 2 seizures in the past 3 years, associated with an intercurrent illness. There is no history of status epilepticus, head trauma, or other neurologic abnormalities, and he maintains a B+ average in school. Past medical history is otherwise unremarkable. Growth and development have been normal and immunizations are current. Vital signs are normal. Examination is unremarkable.

Yes; his seizure disorder is well-controlled.

A 43-year-old woman presents for possible seizures. She was having an argument with her supervisor at work when she slumped back in her chair, became pale, and had a 5- to 10-second spell of generalized tonic-clonic jerking. She was placed on the floor and began to rouse 15-30 seconds later. She has a history of generalized tonic-clonic seizures, and she has been on divalproex sodium (Depakote). At age 8, a repeat electroencephalogram was normal, and divalproex was discontinued. Seizures did not reoccur. Exam reveals a well-developed well-nourished woman; awake, alert, fully-oriented, and in no acute distress. Temperature is 98.8°F orally. Blood pressure is 129/85 mm Hg. Heart rate is 76/min and regular. Respirations are 14/min and unlabored. General neurological and medical exams are normal. Lab studies include a normal complete blood count and differential, blood chemistry panel, urinalysis, chest X-ray, and EKG. Portable electroencephalogram is normal.

Young (20-30) women with a history of sexual abuse

A 24-year-old woman notices that she has a bruising tendency. She frequently has numerous small bruises and purple blotches on her skin. She hates having dental work because of the associated bleeding. On physical exam, you note that she has numerous petechiae. Her lab results are shown in the chart.

Antiplatelet IgG

A 42-year-old man presents with a firm painless bump on his left upper eyelid. On examination, you note a 5 mm mass within the tarsus of the left eye. The skin is freely movable over the mass. The remainder of the eye exam is unremarkable.

Chalazion

A 27-year-old woman presents in active labor. She is G3P2 and at 39 weeks of gestation. She has been receiving prenatal care since 6 weeks gestation, and her pregnancy has been uncomplicated. Both of her prior births were normal spontaneous vaginal deliveries. Her cervix is 6 cm, 90% effaced, mid-position, and soft. The fetus is not engaged and is thought to be vertex. Initial fetal monitoring shows a heart rate in the 140s with good accelerations, and it is reassuring. Contractions are 4 minutes apart, and she is comfortable. 20 minutes later, she experiences a large gush of clear fluid, and severe variable decelerations appear on the fetal heart rate monitor.

Cord prolapse

A 50-year-old man presents for a follow-up exam. He has a history of hypertension and morbid obesity. His routine labs reveal a hemoglobin A1c was 6.8%.

Diet modification only

A 43-year-old man presents for a general physical exam. He states that he has no significant past medical history. On physical examination, you note that the patient has a 3/6 diastolic murmur; it is heard best in the right upper chest. Blood pressure is 152/62 mm Hg. No other abnormalities are noted.

Echocardiogram with color Doppler

A 29-year-old African American woman and a 31-year-old African American man present for preconception counseling for sickle cell disease.

Evaluation of both patients by hemoglobin electrophoresis

A newborn child is routinely evaluated in the pediatrician's office 1 month after delivery. The mother reports that the patient is behaving normally and is feeding well. The physical exam is remarkable for a murmur, which is located at the second left intercostal space. The murmur is continuous throughout cardiac systole and diastole, non-radiating, and of a "machinery" quality. There is additionally a widened pulse pressure. The skin and mucosa are without cyanosis, and there is no evidence of fluid retention.

Patent ductus arteriosus

A 70-year-old woman with long-standing type 2 diabetes mellitus presents due to pain in the left ear along with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal.

Pseudomonas aeruginosa

You are an emergency department (ED) physician assistant working in a Level 1 trauma center. You are notified by emergency medical services (EMS) that there was a mass casualty shooting at a night club and to anticipate a large number of patients arriving quickly for care. You activate the hospital policy for a trauma alert, including calling in additional staff and notifying the operating room to anticipate emergency cases.

Response

A 73-year-old man has had a history of pain in that shoulder for over 6 months that kept him from sleeping on the left side; the pain would wake him often. He presents with an inability to actively raise his left non-dominant arm, which began a month ago after his shoulder pain improved. There was no specific injury he can recall, but he felt a pop a month ago while taking out the trash. On inspection, you notice the back of the shoulder appears sunken compared to the other shoulder.

Rotator cuff tear

A 47-year-old man presents for his annual physical exam. His past medical history is not significant, and he is not currently on any medications. He consumes 2 beers weekly and does not smoke. His blood pressure is normal during this visit. His primary care physician orders a fasting lipid panel with the following results:

Simvastatin

A 21-year-old man presents with a 3-month history of pain in his left shoulder. He is a left-handed pitcher for his college baseball team and states that the pain began at spring training and has gradually worsened since that time. In addition to the pain, the patient is now having difficulty lifting his left arm above his head. He denies any injury to the shoulder itself and states that ibuprofen provides some relief. You suspect rotator-cuff tendinitis.

Tenderness to palpation just under the acromion

A 35-year-old woman presents with intensely pruritic red papules over the anterior wrists. On close examination, the papules are shiny; they have a flat surface and there is occasional central umbilication. A red plaque is seen along the scratch line at the anterior forearm.

Topical corticosteroid

A 41-year-old woman has been hospitalized for over a week. Her laboratory results reflect an electrolyte abnormality and her EKG demonstrates peaked T waves and a widening of the QRS complex.

Hyperkalemia

What is the most accurate statement concerning the treatment of migraine headache with sumatriptan?

If it is effective in the initial therapy, it is often effective in aborting a recurrence of symptoms.

Routine physical examination of a 55-year-old man demonstrates marked finger clubbing. Radiography of the hand shows new bone formation beneath the periosteum.

Intrathoracic cancer

A healthy couple presents for an evaluation before traveling to the Dominican Republic; they leave in 1 month and will stay for 4 weeks. The CDC lists the Dominican Republic as a malaria-endemic area, but it is not considered to have a resistant strain of Plasmodium falciparum.

"You should both take chloroquine weekly starting 1 week before travel."

A 15-year-old girl presents with short stature and primary amenorrhea; her neck is short and broad, her palate is high-arched, and her genitalia are infantile. Her parents recall several episodes of otitis media during childhood. Her serum FSH is elevated and estradiol is low.

45,XO

A 32-year-old woman is brought in via ambulance due to a fast heart rate. Her blood pressure is 114/76 mm Hg, and her heart rate is 156 bpm. She reports mild chest pain and shortness of breath. Her 12-lead EKG reveals retrograde P-waves that occur simultaneously with the QRS complexes but appear "hidden."

Adenosine 6 mg IV

An otherwise asymptomatic, thin 18-year-old woman presents with a history of scoliosis and the presence of a mid-systolic click that is auscultated during physical examination. The patient most likely has what valvular disease?

Mitral valve prolapse

A 50-year-old man presents with the acute onset of chest pain. He describes the pain as sharp, worse with deep breaths, and improved with leaning forward. Physical exam is remarkable for a pericardial friction rub on cardiac auscultation.

Diffuse ST elevation

You are following up on laboratory results for your supervising physician while they are out of town. A bone marrow biopsy result for a 62-year-old man is noted.

Lymphadenopathy Chemoimmunotherapy

A 38-year-old male patient with HIV develops diabetes; he takes stavudine. What diabetes medication is most likely to exacerbate potential acid-base disorders of his antiviral therapy?

Metformin

A 73-year-old male presents reporting that his toenails are thick, hard to cut, discolored, and dystrophic. A KOH culture confirmed a fungal infection. What is the most likely diagnosis?

Onychomycosis

A 5-year-old girl has paroxysms of cough that increase in severity and duration. Some coughing episodes are followed by a high-pitched inspiratory noise, and vomiting has also occurred after paroxysms.

PCR assay and antigen detection

A 49-year-old right-hand dominant woman presents with a 2-week history of progressive pain in her right thumb and wrist area. She says that her thumb seems to "stick" in place upon movement. She states that she has never experienced this before. You ask her if she has been using her hands more often than normal, and she tells you she recently began to crochet a sweater for a family member. On physical examination, her pain is markedly exacerbated when she places her thumb into the palm of her hand, and when you passively move her hand in an ulnar direction.

de Quervain's tenosynovitis

A newborn boy is evaluated in the delivery room at 1 minute of life after an emergency cesarean section due to late decelerations. He is limp, pale, and unresponsive; he has a heart rate of 78 and a slow irregular respiratory rate.

2

A 63-year-old woman presents with a 1-hour history of left shoulder pain and nausea. She has a past medical history of coronary artery disease and had a stent placed 5 years ago. Troponin is elevated. An ECG shows large R waves and ST segment depression in leads V1, V2, and V3.

Acute posterior myocardial infarction

A 23-year-old woman presents with dysuria and left flank pain. She is 27 weeks pregnant. Physical examination reveals a temperature of 38°C (100.4°F); there is tenderness with percussion over the left costovertebral angle. Urinalysis shows 15-20 WBC/hpf and 15-20 bacteria/hpf.

Admit for intravenous antibiotics.

A 30-year-old male presents for routine follow-up. He has a history of intermittent headaches, low back pain, knee pain, and dysuria over the last year. Additionally, he notes nausea, diarrhea, poor libido, and extremity numbness. He states he feels worthless. He admits to daily alcohol use in an attempt to feel better. Lab studies, urine testing, plain radiographs, CT scans, and MRIs are all unremarkable and show no explanation for his symptoms, but he is consumed by worry about his illness.

Associated personality disorders and depression are common.

A 23-year-old woman presents to the emergency department after a baseball hit her in the right eye. She has double vision, pain upon moving the right eye, and numbness of the cheek, nose, and right side of the eye. Upon physical exam, swelling, tenderness, numbness of the nose, and epistaxis are present.

Blowout fracture

A 25-year-old woman who is 36 weeks pregnant presents for her regular obstetrics care examination. She was diagnosed with hepatitis C a couple years ago. No viral RNA was detected during her pregnancy, which progressed smoothly and without major discomfort. She has no history of intravenous drug use or blood transfusions. She is HIV negative. She plans on breastfeeding, but she is concerned about transmitting the hepatitis C virus to the newborn.

Breastfeed, but temporarily stop if nipples crack or bleed.

A 10-day-old male newborn presents with bilateral conjunctivitis with moderate white discharge. He is acting normally, has no fever, and is feeding well. He was born full-term without any complications. His mother had minimal prenatal care. He has been gaining weight well. On exam, he is alert and active. Culture with immunofluorescence reveals inclusion bodies.

Chlamydia trachomatis

A 15-year-old boy presents with bloody diarrhea and abdominal cramping. A double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. A biopsy finds an extensive inflammatory process in the mucosa and submucosa. The glands are filled with eosinophilic secretions; there is also mild involvement of the terminal ileum. Sulfasalazine treatment is attempted without improvement.

Corticosteroids

A 36-year-old African American woman presents with a nonproductive cough, malaise, mild fever, and mild dyspnea. She also indicates that she has some lesions around her nose. Upon physical exam, you note red-brown dermal papules around her nares. A chest X-ray demonstrates a right hilar mass. A pulmonologist is consulted and performs a biopsy during bronchoscopy. The report reveals that the mass is a non-caseating granuloma.

Corticosteroids

A 15-year-old girl presents with a 2-day history of excessive vaginal discharge. She had unprotected sex with a boyfriend 4 days ago, and he later informed her that he has gonorrhea. On speculum exam, the girl is found to have a moderate amount of off-white and frothy vaginal secretions. The appearance of the cervix is normal. A cervical swab reveals copious gram-negative intracellular diplococci.

Counsel the patient about safer sex and treat.

A 38-year-old woman presents with a new tremor. She also reports weight loss and heat intolerance along with increased anxiety and palpitations. She has noticed swelling of her neck.

Exophthalmos

A 60-year-old Caucasian man comes to your office to establish care. He has no known medical problems and his only medication is daily ibuprofen for 5 years for musculoskeletal aches associated with his work as a handyman.

Gastrointestinal bleed

A 55-year-old woman presents with a slight cough she has had for about a week. She is a nonsmoker, and she does not remember having a fever or feeling sick. The patient currently works as a third-grade teacher and has done this for 30 years. She has no past medical history of significant pulmonary diagnoses. Auscultation of the chest reveals clear lung fields. A chest X-ray shows a subpleural "coin lesion" in the right upper lobe.

Granuloma

A 24-year-old man undergoes a routine medical check-up to become a volunteer in the ER. PPD skin test shows an induration diameter of 9 mm. Sputum and chest X-ray are done; they are negative for tuberculosis. He is otherwise healthy and has no fever, cough, or other symptoms of Mycobacterium tuberculosis infection.

He was given BCG vaccination earlier in life.

A 63-year-old man with long-standing right shoulder pain from impingement syndrome presents because he cannot lift his arm after pulling the starter cord on his lawn mower 1 month ago. An AP view of his right shoulder is ordered.

High-riding humeral head

You are performing an annual physical examination of a 14-year-old girl. Over the last 3 years, she has been treated for the depression related to her parents' divorce process. She complains of frequent constipation followed by loose stools and is treated for dermatitis herpetiformis. She participates in swimming competitions and spends about 18-20 hours per week training. However, her mother is worried because she has not grown enough and still has not gotten her period (her mother had her period when she was 12 years old). The rest of her personal and family history is not contributing. Your patient's BMI is 15 (percentile 3%); she is in Tanner stage 2 (the same as last year); and her bone age is 12.5 years. The rest of the physical examination is normal, and complete blood count results are within normal limits.

Hypogonadotropic hypogonadism

A 45-year-old woman presents with vision loss. The patient states that she was watching TV the other day and experienced vision loss in her right eye for a few minutes. She describes the loss as a curtain being brought down over the right eye; it stayed there for a few minutes and then lifted back up.

Internal carotid artery

A 47-year-old obese woman presents with left non-dominant shoulder pain and limited motion. The pain began about a month ago but has reduced over time. Her shoulder has progressively lost motion during that time; she cannot reach overhead with that arm. There is no history of trauma, it does not wake her at night, and she can sleep on the left side. Her past medical history is significant for type 1 diabetes and hypothyroidism. She is on regular insulin, NPH insulin, and levothyroxine.

MRI Decreased active and passive range of motion ≥50%

A 70-year-old man with hypertension, diabetes, obesity, and coronary artery disease presents with a 3-day history of fever, headache, nausea, vomiting, lethargy, and myalgias. His wife states that the symptoms began the day after a summer evening walk around a lake. Today, his condition has worsened; he has developed a diminished level of consciousness, behavioral changes, and abnormal movements. His physical exam reveals a lethargic man with photophobia, cranial nerve deficiencies, neck stiffness, and abnormal extremity movements.

MRI of the brain

A 3-year-old girl presents to her pediatrician with perianal itching that wakes her up at night. Her pediatrician performs an anal swab, and microscopic examination reveals eggs.

Mebendazole

A 33-year-old woman presents with tingling and numbness in the palms, thumbs, and index fingers bilaterally. Her symptoms are worse during the night. Recently, she noticed that she has difficulty grasping small objects. She works at a poultry farm and is involved in assembly packing. On examination, Tinel's sign and Phalen's test are positive.

Median nerve

A 22-year-old woman presents for her annual well-woman examination. She was seen last year and she had her first pap smear done, which showed no evidence of intraepithelial neoplasia. She is sexually active with one partner currently and a history of two partners total. She reports using condoms intermittently.

No cervical cancer screening recommended

A 45-year-old Caucasian woman presents with a 2-month history of a lump in her right breast. She has had no children. Her menstrual periods began at age 15 and are still regular. She is a successful businessperson who does not smoke cigarettes and drinks 6 cups of coffee per day. She gets 30 minutes of physical activity at least 5 times weekly. On examination, she has a nontender lump in the upper outer quadrant of her right breast. Several matted right axillary lymph nodes are also palpable.

Nulliparity

A 66-year-old man with a history of obesity and hyperlipidemia presents with an 8-month history of progressing "burning in his chest." This sensation is noted in the midline of his chest, and it is provoked when he bends over, when he wears tight clothing, after he eats a large meal, and when lying supine. He denies any chest pressure, cough, shortness of breath, palpitations, dizziness, lightheadedness, and diaphoresis. His physical examination is unremarkable. An upper endoscopy is performed. An upper endoscopy is performed and inflammation in the esophagus is noted.

Omeprazole

A 20-year-old male student presents with a "weird" heart sound. He indicates that while in the anatomy lab, they were practicing with stethoscopes and listening to each other's heart sounds as a part of the course curriculum. One student said that his heart had a rumbling sound. On further history of the patient, he indicated that he had acute rheumatic fever twice as a teen.

Patient lying on the left side, at the apex of the heart

A 3-day-old male neonate is seen in the nursery due to failure to pass meconium and two episodes of vomiting. Prenatal and perinatal histories are unremarkable. Family history reveals a brother and sister with severe asthma. Examination reveals a moderately distended abdomen without signs of tenderness. A barium enema reveals meconium ileus with distal narrowing and proximal dilatation of the colon. Meconium is passed during the procedure, relieving the distention.

Rectal manometry, rectal biopsy, sweat chloride

A 27-year-old man is admitted to the hospital following a motor vehicle accident. He sustained lacerations to his arms bilaterally and has fractures of the right tibia and fibula. A cast is placed and the patient is scheduled for surgery the following day. A few hours after the cast is placed, he develops severe pain; the pain is unresponsive to several doses of intravenous morphine. His pain increases when he extends his right leg. Peripheral pulses are weak but present.

Remove cast and check compartment pressure.

A newborn infant is delivered at 30 weeks since the last menstrual period. At birth, the infant weighs 1500 gm but otherwise appears normal. Soon after birth, the infant becomes cyanotic and breathes with a grunting noise. Chest X-rays reveal dense lungs with significant atelectasis but no cardiovascular abnormalities.

Respiratory distress syndrome

A 45-year-old woman presents with insidious onset of increasing dyspnea. A chest X-ray revealed nodular infiltrates and marked hilar lymphadenopathy. The transbronchial biopsy demonstrated non-necrotizing granulomas.

Sarcoidosis

In order to maintain certification from the National Commission on the Certification of Physician Assistants (NCCPA), each PA is required to earn 100 hours of continuing medical education (CME) over their 2-year recertification cycle. The NCCPA awards additional CME credit hours (beyond the face value of earned CME credit hours) for certain types of CME activities.

Self-Assessment Category 1 CME

A 36-year-old non-smoking man is diagnosed with emphysema. Upon further questioning, he tells you his father was also diagnosed with emphysema when he was in his 30s and never smoked. He states that his father passed away at age 50 of hepatocellular carcinoma.

Serum alpha-antitrypsin (AAt)

A 38-year-old woman gave birth to a healthy female neonate 3 months ago. Her pregnancy and vaginal delivery were unremarkable. Over the past 3 months, she developed increased oral bleeding with hemorrhagic bullae.

Splenomegaly

A 1-year-old boy appears to be physically underdeveloped. His vital signs are not remarkable. His parents are concerned about his health because he seems to be weak and lethargic. The parents are recent immigrants from southern Italy. A brief history check reveals that both parents have a history of mild anemia. The child is afebrile. A complete blood count (CBC) is ordered: red blood cell (RBC) count of 3.0x 1012/L; Hb of 8.0 gm/dL; Hct of 24%; peripheral smear showed 1+ basophilic stippling; hypochromia; and the presence of codocytes.

Thalassemia

A 27-year-old woman who is 18 weeks pregnant states that her 3-year-old daughter was just diagnosed with erythema infectiosum (Fifth disease). An antibody test is ordered, and the woman is found to be seronegative. She is healthy and has no signs or symptoms of parvoviral infection. 2 weeks later, the test is repeated and the patient is IgM-positive.

The patient should undergo serial fetal ultrasounds to monitor for signs of hydrops fetalis.

A 16-year-old Caucasian girl presents with a 6-month history of blackheads and whiteheads on her face. On examination, there are a few papules and pustules on her cheeks; there are no nodules. Her mother reports having similar spots on her face at this age.

Tretinoin

A 16-year-old sexually active girl is seen for a 2-month history of amenorrhea. She denies unprotected sex but relies on her partner to use a condom. She has vomited in the early morning twice this week and had vaginal spotting for 3 days accompanied by cramping lower abdominal pain that became sharp. Onset of menses was at age 12, with normal regular periods since then. No history of sexually transmitted disease. Normal vital signs. Slight right and left lower quadrant abdominal tenderness without guarding and rebound is present. Cervix is closed. No blood is seen in the vaginal vault. The uterus is not palpable. Serum β-HCG: 5200 mIU/mL. Vaginal spotting has increased, and abdominal pain has become more frequent. Repeat examination 3 days later is unchanged. The uterus is still not palpable. Repeat serum β-HCG is 6800 mIU/mL. Transvaginal ultrasound fails to reveal an intrauterine pregnancy or gestational sac.

Tubal ectopic pregnancy

A 6-year-old boy presents due to lethargy, polyuria, nocturnal enuresis, and polydipsia. His mother tells you that he reports being tired and thirsty all the time. You note that he has lost 5 lb since his last visit 6 months ago.

Type 1 diabetes mellitus

A 13-year-old boy diagnosed with autism spectrum disorder repeats phrases in a parrot-like fashion; he repeats whatever he hears, but comprehension is absent.

Echolalia

Daily cleaning with a damp cotton applicator and baby shampoo

Hyposensitization

A 38-year-old man had a total thyroidectomy for stage II papillary carcinoma yesterday.

Hypocalcemia

A 15-year-old boy presents with abdominal pain and rectal bleeding. His family history is significant for the premature deaths of his mother and maternal grandmother from metastatic colon cancer. Both died before age 35; in both, autopsy findings included hundreds of colon polyps along with multiple primary colon cancers. Endoscopy of the boy also demonstrates extensive colonic polyp disease.

APC

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never had this as bad as she does currently. The patient denies any other significant past medical history and is currently taking only a multivitamin daily. She admits to recently having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days. She hopes that after finals are over her headaches will subside. She also states she was given a 10-day course of amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stools, use of tobacco/alcohol, or coughing up blood. Physical examination is unremarkable for any abnormalities.

Acetaminophen

A 15-year-old boy is being treated at the dermatologist for lesions on his cheeks, forehead, chin, upper chest, and upper back with a history that has been progressively getting worse. Upon physical exam, open and closed comedones are present on the patient. Additionally, inflamed papules and some scarring are present. All labs are within normal limits.

Acne vulgaris

A 16-year-old boy presents to his primary care physician with skin lesions. The lesions are scattered over his forehead, nose, and chin. He denies facial flushing and pruritus. The following presentation is seen on examination.

Acne vulgaris

A 40-year-old man presents with severe pain in his left eye, decreased vision, nausea, and abdominal pain. He denies recent trauma. He wears glasses for myopia. On examination, the patient's left pupil is moderately dilated and nonreactive. The cornea is "steamy" in appearance and the eye is red in general.

Acute angle-closure glaucoma

A 3-day-old female newborn presents at your outpatient clinic with rapidly progressing bilateral conjunctivitis with white discharge. She was born full-term via precipitous vaginal delivery; her mother had no prenatal care. On exam, she is alert and active. The eye discharge is purulent and she has bilateral eyelid edema.

Admit to the hospital for IV antibiotics and evaluation.

An obese 45-year-old woman is requesting medical weight loss therapy. She reports excessive weight gain of (37 kg) over the past 3 years. A detailed history also reveals easy bruising, oligomenorrhea, and increased hair growth on various parts of her body. A thorough examination shows hypertension (BP 180/110), truncal obesity with a buffalo hump, and moon face, along with hirsutism and pigmentation, with purple abdominal and lower leg striae. Lab reports confirm the most likely diagnosis.

Adrenocorticotropic hormone

A 62-year-old woman is being treated for chronic congestive heart failure. She has been put on hydrochlorothiazide therapy. Her serum electrolyte levels are being monitored and show a persistent hypokalemia.

Amiloride

A 3-year old boy is brought to the pediatrician with a 2-week history of symptoms of an itchy, red "wound" on the right knee. The mother ignored the wound initially, assuming that the boy got injured while playing on the street, but it did not heal and seems to have worsened. On examination, there are a few intact vesicles and a few ruptured vesicles covered with honey-colored crusts. You suspect non-bullous impetigo.

Antibiotic ointment

A 5-year-old boy presents because of concerns about his behavior. His mother notes he gets extremely distracted and can only focus for 1-2 minutes at a time. He cannot seem to sit still, and he displays extremely impulsive behavior at inappropriate times. She describes impulsive behavior recently at a funeral and at an older sibling's music recital. Because the mother works full time, the patient attends daycare after kindergarten. His kindergarten teacher and the daycare staff have expressed similar concerns.

Attention deficit hyperactivity disorder

A 35-year-old woman presents with 5-hour history of progressive shortness of breath, cough, and wheezing. This morning she felt that she was "catching a cold" because of sore throat and thin purulent rhinorrhea, for which she took aspirin. Her past medical history is significant for persistent rhinitis resistant to therapy.

Avoid aspirin

An 11-year-old boy presents with a chronic history of mild hemolytic anemia, intermittent jaundice, and right upper quadrant pain. He denies any shortness of breath, muscle aches, or joint pain.

Folic acid

A 67-year-old woman presents with shortness of breath and chest pain. She admits to getting home yesterday from a 2-day car ride after visiting her grandchildren. Heart rate is 110 beats/minute. Respirations are 22 breaths/minute. Blood pressure is 125/85 mm Hg. Oxygen saturation is 89% on room air. Temperature is 98.9°F.

CT chest with contrast

A 1-year-old boy presents with a history of vomiting, lethargy, and respiratory distress of sudden onset; there is no prior illness or injury. The parents state that the boy is "always irritable" and he keeps them up all night. The parents have missed several well-baby visits; they both work and are unable to keep the appointments. Physical examination reveals red bruises on the boy's arms that appear in the shape of fingers, along with a full fontanel. Ophthalmologic exam demonstrates the presence of retinal hemorrhage.

CT scan of the brain and a skeletal survey

A 47-year-old Native American man presents to the Indian Health Service primary care clinic for evaluation of headache. His blood pressure is 165/75 mm Hg, weight 225 lb, heart rate 98 beats per minute, respiratory rate 18 respirations per minute, and temperature 98.7°F. He smokes 1 pack of cigarettes per day and drinks approximately 12 beers per week.

Chronic liver disease

A 45-year-old woman presents as a new patient. She was recently seen in the emergency department for right flank pain, and a CT scan revealed a right-sided ureteral stone. The stone was 4 mm, a passable size, and she was sent home with analgesics and advised to hydrate well and strain her urine. She was straining her urine and noticed a small dark fleck. She brought the sediment to the urologist's office to undergo a stone analysis, as this is her first episode of a renal or ureteral stone.

Calcium

A 24-year-old woman presents with lower abdominal pain, nausea, and vomiting that has persisted for about 12 hours. She rates the pain at a 4 last night when it began, but she currently puts it at a 9; she states the pain seems to be worsening with each passing hour. She states she had her menses 1 week ago and noted an irregular flow and excessive vaginal discharge since it ceased. She is single. She admits to not being monogamous, and she only occasionally uses barrier contraception during sexual encounters. She takes a daily oral contraceptive pill.

Ceftriaxone 250 mg IM and doxycycline 100 mg BID for 14 days

A 30-year-old woman presents because she recently had a PPD skin test; the transverse diameter of the induration was 14 mm. The patient denies ever having tuberculosis and she is asymptomatic now, but she expresses some anxiety about the result of the skin test. For the last 6 months, she has worked as a nurse for a long-term care facility. Her patient is a vent-dependent tetraplegic. On clinical examination, there are no abnormalities.

Chest X-ray

A 9-year-old boy presents with burning during urination and a creamy white penile discharge. The grandmother is concerned about sexual abuse by a female caregiver.

Chlamydia urethritis

A 40-year-old woman is seen in the emergency department because of right upper quadrant pain and fever. She has been experiencing episodic epigastric pain over the past few months, but this is the worst her symptoms have been. She also reports anorexia and vomiting. She is in obvious distress. On physical examination, her doctor notes the presence of jaundice. Her lab results are as follows:

Cholangitis

A 55-year-old Caucasian man presents for yearly physical. On review of systems, he admits intermittent allergies that are worse with dust, weight loss, excessive hunger, intermittent back pain only with lifting, and new excessive frequent urination. His vitals are blood pressure 138/88, respirations 16, pulse 70, weight 258 lb, height 5'9", SpO2 96%, temperature 97.8°F. Labs show normal electrolytes, ALT of 10 U/L, AST of 18 U/L, and random glucose of 207 mg/dL. You check some additional labs, then explain his new diagnosis based on his lab work, telling him you are going to start him on a chronic medication for his condition. You want to make sure there are no contraindications.

Chronic kidney disease stage 3A

A 58-year-old man presents with a 4-month history of worsening fatigue. Physical examination is remarkable for right-sided posterior cervical and anterior clavicular lymphadenopathy. He has splenomegaly. Lab results reveal a WBC count of 250,000/mm3 (normal: 5000-10,000 mm3) with 77% lymphocytes (normal: 20-40%). Peripheral smear demonstrates small-but-mature-appearing lymphocytes. A subsequent bone marrow biopsy reveals variably infiltrated small mature lymphocytes that stain for CD5 and CD19. Philadelphia chromosome is negative.

Chronic lymphocytic leukemia (CLL)

An 8-year-old boy presents with left ear pain. His father reports that he had two ear infections as a baby, but he cannot remember which ear. The visit occurs during the summer months, and the father says that the patient has been swimming almost daily in a neighbor's pool. Physical examination of the ears bilaterally reveals left ear canal erythema and edema and pain with manipulation of the left pinna. No other physical examination findings are abnormal.

Ciprofloxacin/dexamethasone topical solution

A 1-month-old full-term male infant has been diagnosed with tetralogy of Fallot. His disease is being classified as moderate, and he has been admitted to the neonatal intensive care unit for monitoring. He is now stable and is doing well. During a consultation between the infant's parents and the pediatric cardiologist, treatment options are being discussed.

Closure of ventricular septal defect and pulmonary valvulotomy

A 35-year-old man presents with recurrent headaches. They occur on one side of his head and feel like sharp stabbing pain just above his left eye. He notes eye redness and watering with the headaches. Each headache lasts for 2 hours, and they have been occurring daily for 2-3 weeks. He reports a similar pattern of headaches last year. He denies any known family history of headaches similar to his or migraines. Physical examination is within normal limits.

Cluster headache

A 35-year-old man presents with headaches; he describes them as occurring on one side of his head with a sensation of a sharp stabbing pain just above his left eye. The episodes last for 2 hours, have occurred daily for 2-3 weeks, and have been presenting in this pattern every 3-4 months for the past 2 years. The patient describes his nose as feeling congested during these periods; his left eye also appears red. Aggravating factors appear to be alcohol and stressful situations. He denies any family history of migraines or headaches similar to his. Diagnostic and laboratory studies are pending.

Cluster headaches

While rounding on a 2-hour-old male neonate at the hospital, his mother remarks that although her pregnancy and delivery were unremarkable and the baby was term, she has attempted to initiate breastfeeding even though the neonate "doesn't seem interested." On heart auscultation of the neonate, a late systolic murmur that radiates to the back is appreciated. Vital signs while the baby is awake are BP 90/50 mm Hg in the right arm and 58/42 mm Hg in the right lower extremity, HR 140, RR 40, axillary temp 37.0° C, and O2 sat 90% on room air.

Coarctation of the aorta

A 22-year-old primiparous woman at 10 weeks gestation presents to the office. She works in an office, but she maintains a regimen of swimming and moderate weightlifting 3-4 times per week. She has had no vaginal spotting, and the pregnancy is progressing normally. She would like to continue with her exercise routine but is concerned about reports from friends that exercise has an adverse effect on pregnancy. Past medical history is otherwise unremarkable. Vital signs are normal, and examination is consistent with a 10-week gestation.

Continue current exercise regimen.

A 17-year-old boy presents for a follow-up regarding fatigue and dizziness. After his initial presentation, he had some general blood work drawn, including a complete blood count (CBC) showing a low hemoglobin and hematocrit. MCV is low.

Craving to eat ice

A 10-year-old girl presents with recurrent bronchitis. Her past history is significant for polypectomy, nasal polyps, failure to thrive, and repeated attacks of bronchitis. Examination reveals clubbing and diffuse rhonchi on respiratory auscultation. Investigations reveal subnormal lung function, decreased exercise tolerance, and a sweat chloride concentration of 62 mEq/L (normal: <40 mEq/L).

Cystic fibrosis

A 72-year-old man—well known to your practice—presents with a severely itchy rash. His medical history includes Parkinson's disease for the past 10 years. At first, he thought the rash was just eczema, but the areas have progressed to significant hives, and itching has substantially worsened. On examination, you note multiple bullae that are 1-3 cm in size; they are tense, and they appear on an erythematous base. The bullae are noted to be located on the patient's trunk and the bilateral axillary and inguinal folds.

Corticosteroids

A 3-year-old boy is admitted to the emergency room in acute respiratory distress. The patient has a body temperature of 40°C, a respiratory rate of 70/min, and a pulse of 130/min. Auscultations of the lungs are unremarkable. An examination of the throat reveals an exudate in the posterior pharynx that is yellowish and membranous. Bleeding occurrs when it is scraped and removed. The parents of the child reveal that the child has no prior immunizations. A throat culture was ordered and worked up specifically for an organism that selectively grows on cystine tellurite agar.

Corynebacterium diphtheriae

A 57-year-old Caucasian man is brought to the emergency department following an episode of palpitations and syncope. The patient is initially evaluated by the ED physician, then by a cardiology PA. While the PA is recording the patient's history and physical exam, the patient develops sustained monomorphic ventricular tachycardia at 120 beats per minute but with stable pulse and blood pressure. The PA contacts the on-call cardiologist, who arrives promptly. Intravenous anti-arrhythmic medication is initiated, but the patient remains in sustained monomorphic ventricular tachycardia. Two additional intravenous anti-arrhythmic medications are administered before the patient converts to normal sinus rhythm 45 minutes later. The patient is admitted to the hospital for further evaluation and treatment. The patient undergoes electrophysiology testing and an ablation procedure for ventricular tachycardia 2 days later; he is discharged from the hospital 4 days after admission.

Critical care services (CPT codes 99291 or 99292)

Upon inspection of an 18-year-old man's scrotum, you note that the left side is underdeveloped and a testis is not palpable. There is no scrotal tenderness, swelling, or nodularity.

Cryptorchidism

A 5-year-old girl presents after falling off a shopping cart, tripping, and then falling onto her right arm. On examination, temp is 98.7, pulse 97, respirations 18, blood pressure 127/80 mm Hg. She is alert, oriented, and in no acute distress. Significant findings related to the right arm, which was mildly swollen, deformed, and diffusely tender. There was decreased range of motion of the right elbow due to pain. Sensation was intact. Pulses are within normal limits bilaterally. A radiographic examination was performed.

Cubitus varus

A 16-year-old boy presents for a physical. His mother is concerned that he is gaining weight but not growing taller. She has noticed his face is more round and he now has stretch marks on his abdomen. The physician notices a large amount of truncal fat and relatively thin limbs. The patient has acne on his cheeks bilaterally.

Cushing syndrome

A 67-year-old woman presents with shortness of breath and chest pain. She admits to getting home yesterday from a 2-day car ride after visiting her grandchildren. Her heart rate is 110 beats/minute and respirations are 22 breaths/minute. Blood pressure is 125/85 mm Hg. Her oxygen saturation is 99% on room air and temperature is 98.9°F. With additional information provided, her Wells' Criteria Score is calculated to be 4.5.

D-dimer

A 53-year-old man was recently diagnosed with a pituitary adenoma. He has been experiencing excessive thirst and large volume polyuria, as well as headaches and an increase in nocturia from once nightly to 3-4 times nightly.

Desmopressin acetate

A 10-year-old boy has a history of problems at school and at home. Teachers report he rarely can focus on one task for longer than a few minutes, and they describe his behavior as chaotic. His mother states that he never gets tired of running, talking, and playing around the house; she usually has to repeat instructions over and over because he seems to not listen. She also reports that he failed at school and is now repeating the fourth grade. A psychostimulant, an indirect-acting adrenergic receptor agonist that centrally releases dopamine (DA), serotonin (5-HT), and norepinephrine (NE) to the synaptic cleft, is prescribed.

Dextroamphetamine

A 66-year-old man presents to the office with polyuria and erectile dysfunction. He denies any other symptoms or significant past medical history. Physical examination reveals an obese male, Tanner stage 5 of the external genitalia, balanitis of an uncircumcised penis, and slightly enlarged symmetrical smooth prostate.

Diabetes mellitus

A 45-year-old man presents to the emergency department due to acutely worsened chronic low back pain. Pain is described as sharp with radiation to left knee, intensity reported as 15 on a scale of 1-10. He has previously been seen in your emergency department, where another provider prescribed him a short course of oxycodone. On review of your state's prescription drug monitoring system, you notice multiple recent prescriptions and fills for oxycodone. Prescriptions are from multiple providers and multiple local emergency departments. His most recent fill was 2 days ago for oxycodone 10 mg 30 tablets. Upon questioning, he states his pain was "so intense he took all 30 tablets in the past 48 hours." His urine drug screen is presumed positive for opioids.

Diagnose opioid use disorder and arrange for outpatient addiction management.

A 40-year-old man with no significant past medical history presents with a 2-day history of alternating fever and rigors, diaphoresis, fatigue, and a productive cough. He admits to mucoid sputum of moderate quantities. He denies a history of smoking, alcohol use, recent travel, or sick contacts. He further denies chest pain, palpitations, hemoptysis, rashes, abdominal pain, nausea, vomiting, or diarrhea. On physical exam, he is found to be tachypneic and was observed to be intermittently coughing. The pulmonary exam was notable for bronchial breath sounds over the right anterior fourth, fifth, and sixth intercostal spaces. A chest radiograph revealed a right middle lobe consolidation.

Dullness to percussion

A 16-year-old Amish girl presents to an urgent care for evaluation of vaginal spotting. She has been experiencing it for the past 2 days and is concerned she may be pregnant. She has not experienced any nausea, vomiting, or fatigue. All vitals are within normal limits. Physical exam is normal. A urine pregnancy test is negative and urinalysis is unremarkable. The PA inquires if the patient uses birth control. She states that she is Amish and it is against her beliefs. "It does weird things to my body," she states.

Educate patient regarding physiology of vaginal spotting.

A 26-year-old HIV-positive man presents after a series of strange dreams and lack of concentration. He started on antiretrovirals 1 week ago. For his HIV infection, he takes zidovudine, lamivudine, and efavirenz. For pneumocystosis prophylaxis, he takes trimethoprim/sulfamethoxazole. He also takes a multivitamin.

Efavirenz

A 43-year-old woman who works as a secretary and spends most of her day typing on the computer has symptoms of carpal tunnel syndrome.

Electromyogram

A 19-year-old woman presents with vaginal pruritus, dysuria, and dyspareunia. On exam, a profuse frothy yellowish-green vaginal discharge with reddened vaginal mucosa is noted.

Evaluate vaginal discharge under microscopy.

A 24-year-old man is brought to the emergency room in shock. A quick history from his girlfriend reveals that he has had a "blister on his left foot" for the past couple of days. According to the girlfriend, the patient developed a fever earlier in the day; he felt weak and eventually collapsed. He last passed urine the evening prior to presentation. On examination, his BP is 70/40 and pulse is 130/minute; his hands feel cold and clammy. Except for a swollen left foot, systemic examination is normal. His lab values are as follows: Total WBC count: 21,000/mm3Neutrophils: 55%Lymphocytes: 25%Hemoglobin: 11.0 g/dLCRP: 165 mg/LSerum Creatinine: 2.3 mg/dLUrine Myoglobin: positiveSerum K: 5.9 Meq/dLSerum Na: 133 Meq/dLECG: sinus tachycardia

Extensive early surgical debridement

A 46-year-old woman presents because she has not had her period for almost a year, has hot flashes, and feels fatigued most of the time. She complains of insomnia, and states that she keeps smoking despite trying many times to quit. Her libido is low and she does not use any hormone-based birth control. Her blood analysis indicates a TSH (thyroid-stimulating hormone) level of 3.1 mcU/mL and a FSH (follicle-stimulating hormone) level of 55.3 mIU/mL.

FSH level is consistent with menopause.

A 65-year-old Caucasian man presents for a routine physical. He states that he is concerned about the development of prostate cancer. His history is significant for benign prostatic hyperplasia (BPH), for which he underwent a transurethral resection of the prostate (TURP) 3 years ago. His social history is significant for a 50 pack-year smoking history, and he worked for 40 years as a coal miner. His father died of prostate cancer at age 76.

Family history

A 55-year-old Latina woman presents to establish care. She recently went to a health fair, where she had some basic serum chemistries drawn. Her serum creatinine was 1.5 mg/dL. On a questionnaire she completed in your waiting room, she noted that she has no known past medical history except for occasional muscular aches, for which she takes indomethacin (2-3 times in the past 8 months). There is no family history of renal disease. Her BP is 142/82 mm Hg, and her body mass index is 31 kg/m2.

Fasting serum glucose level

A 4-year-old girl has always been below 3% for her height and weight. Her mother says she eats three meals a day with healthy snacks. The family tries to maintain a low-fat high-fiber diet. Her parents and sisters are of above average height and average weight. Other than occasional upper respiratory infections and one episode of pneumonia last winter, the girl has been fairly healthy. Her failure to thrive workup is normal, other than a sweat test, which reveals a high chloride concentration.

Fat-soluble vitamin supplements

A 50-year-old woman presents with "swelling in my right groin" when she stands. On physical examination, you note a reducible bulge that is 3 cm below her right groin crease and is lateral to her pubis. The bulge is on the ventromedial surface of the anterior thigh.

Femoral hernia

A 62-year-old woman with a history of breast cancer and rheumatoid arthritis presents with stiff neck and severe headache that started a couple of days ago; symptoms are worsening. Upon awakening the morning of presentation, she felt nauseated and vomited twice. Your neurological examination shows right-sided hemiparesis and dilated and non-reactive left pupil.

Fundoscopic examination

A 48-year-old Caucasian woman with multiple comorbidities presents with worsening hearing loss and tinnitus in her right ear. She states this first began about 3 months ago and was initially bearable; it has now progressed to where she cannot hear anything out of her right ear, and the tinnitus is unrelenting and constant. The patient is worried because she is now experiencing balance and coordination issues. An MRI is ordered, revealing an enhancing lesion of the right internal auditory canal.

Gamma Knife radiosurgery

A 45-year-old man presents with a 30-minute history of substernal chest pain. He describes the pain as burning. He denies any trauma to the chest. He has had similar episodes like this many times. He denies any additional symptoms such as shortness of breath or diaphoresis, but he states that his voice is often hoarse. His medical issues include diabetes mellitus and heavy alcohol use.

Gastroesophageal reflux

A full-term female newborn has facial defects affecting the eyes, nose, and upper lips. She is the first child of non-consanguineous parents. The mother has a history of gestational diabetes, which began at the start of pregnancy. She contracted German measles a month before delivery. During the course of infection, her self-prescribed daily treatment was 3 tablets of aspirin, at least 6 cups of herbal tea, and a double dose of folic acid. Imaging studies showed prosencephaly.

Gestational diabetes

A 14-year-old girl presents with a 4-day history of flatulence, foul-smelling stools, and abdominal distention. Her appetite has also been decreased. She has not seen any blood in her stools. She returned from a 2-week camping trip in the mountains of the western United States 1 week ago. Others in her expedition group are asymptomatic. Her physical examination reveals a well developed and well nourished adolescent with slight abdominal distention and tenderness; otherwise, everything is within normal limits.

Giardia lamblia

A 3-year-old boy is evaluated for a 24-hour history of diarrhea. His mother reports that he had five episodes of foul-smelling watery diarrhea associated with decreased appetite. A few other children at the same daycare center have presented with the same problem. On physical examination, the child is well hydrated and his abdomen is tender. Stool microscopy shows the presence of motile trophozoites representing the etiological agent.

Giardiasis

A 19-year-old man presents with pain and deformity of his right dominant shoulder after a sudden jerking movement to that shoulder from a wrestling competitor approximately 1 hour ago. He was unable to continue wrestling and has pain with any movement of the right shoulder. On exam, you see a loss of normal shoulder contour anteriorly. There is no focal joint or bony tenderness.

Glenohumeral dislocation

A 16-year-old girl presents with sore throat and headache. She started feeling poorly when she woke up this morning. Her immunizations are current. Temperature is 102°F. Physical examination is remarkable for erythema in the posterior pharynx and palatal petechiae. She also has tender anterior cervical lymphadenopathy.

Group A Streptococcus

A 4-year-old girl is brought by her mother to the ED for swelling and redness of the left elbow. The mother tells you that the child fell onto the elbow 4 days ago and sustained a small abrasion. The child scratched and picked at the wound for 2 days and subsequently developed redness around the site and purulent drainage from the wound. Yesterday, the elbow became quite swollen and the child had a fever of 103°F. The mother states that the area of redness has increased rapidly over the past 24 hours.

Group A Streptococcus

An 8-year-old girl presents with a 3-day history of fever, generalized muscle weakness, bilateral knee pain, and chest pain. You suspect acute rheumatic fever (ARF).

Group A Streptococcus infection

A 20-year-old woman presents with a 3-day history of fever, sore throat, and enlarged glands in her neck. She denies any cough or runny nose, but she has malaise, body aches, and headaches. She has no other medical problems and does not take any medications. She works in a daycare center; she takes care of children 3-4 years old. On examination, she has a temperature of 101.5°F; pulse is 102/min, and BP 110/70 mm Hg. Oral exam reveals swollen tonsils with plenty of exudates. There is no nasal congestion, and lungs are clear. Cervical lymph nodes are enlarged bilaterally and tender. Abdomen is unremarkable. Throat swab is obtained by the physician.

Group A streptococcus

A 50-year-old man presents with a 4-day history of increasing exertional dyspnea. He has had a chronic cough for the past 3 years and attributes it to cigarette smoking. The cough had been productive of watery sputum, but it has changed to a yellowish color over the past week. He has no known allergies and reports no family history of asthma. On general appearance, he is wheezing. His temperature is 101°F, P 105/min, BP 136/86 mm Hg, and RR 30/min. Respiratory system examination reveals decreased chest wall excursion. Auscultation reveals a prolonged expiratory phase with crepitations and generalized rhonchi. Chest X-ray reveals irregular bronchovascular markings. Laboratory results reveal Hb 15 g/dL, WBC 12,000/uL, and platelets 300 x 109/L.

Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis

A 32-year-old woman presents with constipation, weight gain, and dry skin. She has been experiencing the symptoms for a few months. Examination findings include dry rough skin, diffuse thyroid enlargement, bradycardia, and edema of hands and feet. A thyroid profile is performed and shows elevated thyroid-stimulating hormone (TSH) and the presence of thyroid autoantibodies (antithyroid peroxidase and antithyroglobulin).

Hashimoto's thyroiditis

A 55-year-old man presents for re-evaluation of his blood pressure; he has no significant past medical history. At his visit 3 weeks ago, his blood pressure was 145/90 mm Hg. He admits to somnolence, confusion, and non-specific bilateral visual disturbances over the past month; he denies any eye pain, blindness, ocular discharge, or floaters. His blood pressure today is 185/110 mm Hg. His fundoscopic exam reveals the following. Refer to the image.

Headache

A 12-year-old Jewish girl is brought in by her father. The father reports that the child started to bleed profusely following tooth extraction 2 hours ago. Further questioning reveals that there is a history of bleeding disorder in the child's maternal uncle and aunt. Examination reveals tachycardia and bleeding from the site of tooth extraction. Coagulation profile reveals prolonged activated partial thromboplastin time (aPTT), normal prothrombin time (PT) and thrombin time (TT), and deficiency of factor XI. The child was treated with fresh frozen plasma (FFP) and fibrin glue.

Hemophilia C

A 48-year-old Caucasian woman with a past medical history of hypertension and hypercholesterolemia was diagnosed recently with a cerebral aneurysm. The treatment plan for the aneurysm is endovascular coiling. Among other complications, this patient has an increased risk of thromboembolism postoperatively.

Heparin

A 43-year-old woman presents with 4 days of fever and cough. She is diagnosed with right lobar pneumonia with mild pleural effusion and is admitted to the hospital for IV antibiotics and hydration. Past medical history includes hypertension, systemic lupus erythematosus, and arthritis. On day 2 of hospitalization, she is afebrile but still has a productive cough and shortness of breath. She reports left arm pain and swelling, and her physician is concerned about a possible upper extremity thrombosis. She is given a bolus of IV heparin and started on a heparin infusion. 5 days later, her labs show Hb 12 g/dL, WBC 11,000, and platelet count 56 micro/L (down from 250 on admission). Her EKG is normal sinus rhythm, and CXR show decreased consolidation with a resolving pleural effusion.

Heparin-induced thrombocytopenia

A 50-year-old man presents with a 3-month history of weakness, fatigue, and abdominal discomfort. He acknowledges a lack of sexual desire. He denies any photosensitivity. On physical examination, his liver is enlarged, and his spleen is palpable. He has abnormal skin pigmentation on his face, neck, and elbows that gives his skin a metallic gray hue.

Hepatocellular carcinoma

A 41-year-old woman presents due to worsening symptoms. She was diagnosed with idiopathic pulmonary hypertension about 2 years ago; she is on home oxygen therapy. She has longstanding fatigue and dyspnea, but she is now experiencing profound dyspnea with exertion, swelling in her ankles, some discomfort in her right upper abdomen, and the inability to breathe well when lying down. She has always been thin, but her weight has increased by 10 pounds in the last month. She denies fever and chills. She recently had an electrocardiogram (ECG), but she has not seen a healthcare provider to discuss the results. The ECG report indicates peaked P waves, right axis deviation, and tall R wave in V1.

Hepatojugular reflux

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and swelling in her ankles. Symptoms started around the time of her son's wedding 6 weeks ago. She dismissed them as stress-related, but symptoms have worsened in intensity and frequency. Now she becomes very short of breath with any exertion, such as climbing stairs in her home. She feels like she may pass out and has to sit when she gets lightheaded. Her breathing is more difficult when lying down. She denies productive cough, fever, or chest pain. She has had no medical care for several years. Her past medical history is unremarkable, with no known medical conditions and no surgeries. She is menopausal and does not take any medications, nor does she have any allergies. She denies the use of tobacco, alcohol, and drugs. Vitals are shown in the table. Physical exam was performed by the provider on an earlier shift, and the patient's care was turned over to you.

Hepatojugular reflux Untreated hypertension

A 32-year-old man is admitted to the hospital following loss of consciousness. The patient had been ill with fever and headache for several days, then developed double vision, confusion, and loss of consciousness. He has been otherwise healthy with no past medical conditions. Imaging reveals edema of the frontal lobe.

Herpes simplex virus

A 35-year-old woman presents to the endocrinology clinic with results of a thyroid nodule fine needle aspiration (FNA) performed by a radiologist not associated with your practice. Upon review of her results, she is initially relieved to learn her needle aspirate is negative for thyroid cancer. After some thought, however, she begins to question her results and asks about the probability of a false negative test and that she does have thyroid cancer. You reassure her, stating with high probability her FNA results are truly negative.

High negative predictive value

A 27-year-old woman presents with cramping abdominal pain and vaginal bleeding. Further history reveals amenorrhea for the past two menstrual cycles. On examination, she is found to have left lower abdominal tenderness and an adnexal mass. Lab values reveal an elevated beta HCG level.

History of PID

A 44-year-old Caucasian woman is admitted to the hospital with a severe nosebleed. The patient states that there was no history of trauma, and she has never had nosebleeds before. She also reports a history of upper respiratory infection (URI) symptoms 1 week ago. The patient's blood work is notable for a platelet count of 10,000/mm3. The patient is treated with steroids for her presumptive diagnosis. The patient's platelet count is refractory, and a splenectomy is performed.

Howell-Jolly bodies

A 38-year-old man with uncontrolled facial movements states that he has noticed himself over the last few months making expressions without even realizing it or being able to control it. Further questioning reveals that he also has noted an inability to intentionally move his eyes quickly without blinking. Very recently, he noted an inability to sustain physical movements, such as grasping objects with his hands. Physical examination reveals a puppet-like gait and obvious chorea. The patient admits that he does not know anything about his family history due to the fact that he was adopted when he was 4.

Huntington's disease

A 2-week-old male infant presents with his father for evaluation of enlarged scrotum. The father states that the scrotum was a little larger in the first few days after birth than it is now, but it has not reduced in size enough to make him feel comfortable that it is normal. Physical examination reveals normally developed penis with abnormally large scrotum that transilluminates on the right side when light is shined on it.

Hydrocele

A 33-year-old African American woman with a PMH of sarcoidosis presents with loss of appetite. She reports constipation and lethargy. She thinks that her urine output has increased. On physical examination, some muscle weakness and hyporeflexia are present. Laboratory tests are ordered and are pending. An EKG shows a shortened QT interval.

Hypercalcemia

A 37-year-old overweight woman presents for a follow-up after an ER visit 4 days ago; her ER visit was the result of a fainting episode. Except for a blood pressure of 140/100, vital signs are all within normal limits. The patient denies a prior history of hypertension. Although the patient had an elevated BP, the ER physician felt that her fainting episode was more likely due to stress and poor eating habits; she had been attempting to lose weight before her wedding, which is occurring in a month. She was released from the ER with instructions to follow up with her PCP for evaluation and treatment of high blood pressure.

Hypertriglyceridemia

A mother brought her 2-month-old infant son to a pediatric clinic because, during micturition, urine ran from the opening at the bottom of the midline groove of the scrotum instead of from the tip of the penis.

Hypospadias

A 57-year-old Caucasian man presents with worsening shortness of breath. While obtaining his history, you uncover that he has noted increasing shortness of breath with minor exertional activity and a persistent but non-productive cough. The patient admits to being a former smoker with a 34 pack-year history, admitting to cessation at age 50. He denies any known caustic occupational exposures and states he worked in an office his whole life. He admits to an uncle having some kind of breathing issues, although he is unsure of a definite diagnosis. Patient denies weight loss, fever, or significant recent illness. Physical examination is pertinent for significant clubbing of the fingers, inspiratory squeaks auscultated during the pulmonary exam, and a right-sided gallop found during the cardiac exam.

Idiopathic pulmonary fibrosis

A 59-year-old man starts to notice that he no longer has the energy for his morning jog. He starts to develop back pain, so he completely stops exercising, but this does not seem to help. He is always tired and seems to have a lot of aches and pains. One day, his back pain is particularly bad, so he sees his primary care physician. He also acknowledges constipation and polyuria. On physical exam, his doctor notes that he is pale. His laboratory tests are as follows:

IgG

A 5-year-old boy has three honey-colored crusted lesions with surrounding erythema on his legs. The swabs taken from the lesions were sent to the microbiology laboratory. The results show yellow colonies grown on blood agar with hemolysis. The colonies are coagulase-positive and mannitol-positive.

Impetigo

A 64-year-old man with a history of a remote myocardial infarction and congestive heart failure presents for his 3-month follow-up. A recent echocardiogram reveals severe left ventricular dysfunction.

Implantation of a cardioverter-defibrillator device

An 18-year-old pregnant woman presents with nocturia and increased urinary frequency. She is at 18 weeks gestation and she has no past medical history. She has no suprapubic fullness; her fundal height is appropriate for her weeks of gestation.

Increased GFR

A 17-year-old male college freshman presents with fatigue, back pain, and stiffness. The pain has been present for the past several months, but it appears to be worsening. The back symptoms are worse at night and first thing in the morning; they improve somewhat during the day. He reports the pain improves with exercise. He is having difficulty staying productive at school because he is always tired.

Increased erythrocyte sedimentation rate

A 26-year-old woman has been trying to conceive over the last few months. She is married and has one child. She also has a history of one miscarriage. Her past medical history is significant for hypothyroidism, which is treated with levothyroxine (Synthroid) 125 mcg PO per day. Her last thyroid-stimulating hormone (TSH) level, performed 3 months ago, was normal. Today, she presents with a 6-week history of amenorrhea. A urine pregnancy test is positive. You estimate that she is 6 weeks pregnant.

Increasing levothyroxine dose

A 40-year-old man presents with ongoing back pain; there is increased stiffness in the morning, and the pain has been going on for a few months. The patient reports that it can take him up to 30 minutes after waking up for the discomfort to improve. Physical examination and diagnostic testing confirms the diagnosis of ankylosing spondylitis.

Indomethacin

You are currently on an inpatient pediatric hospitalist team; you see a preterm infant who has signs of failure to thrive. Other signs and symptoms found during the history and physical examination include tachypnea, bounding peripheral pulses, and a rough machine-like murmur.

Indomethacin

A 4-year-old boy presents with skin eruptions, fever, and diarrhea. Skin eruptions developed 1 week ago after exposure to multiple mosquito bites that left weepy crusted areas. Over the past 2 days, the boy has become quiet, sleepy, and febrile and has had a few loose stools. His past medical history is non-contributory, and his immunizations are current. On examination, you find a child in a mild distress; his temperature is 39°C. Heart rate is 100/min, and respirations are 22/min. On the skin of the arms and trunk, you notice multiple excoriations: a few fragile thin-roofed flaccid transparent bullae with a clear yellow fluid that turns cloudy and dark yellow. Several bullae are ruptured, leaving behind rims of scales around erythematous moist bases, but no crusts. You also notice patches of skin of brown-lacquered appearance, with collarettes of scale and peripheral tube-like rims.

Inhibition of peptidoglycans synthesis

A 55-year-old man became intoxicated at a bar after a serious argument with his wife about his diet and habits (he is overweight and a heavy smoker). On the way back home, he developed chest pain radiating to the left shoulder, shortness of breath, sweating, and anxiety. ECG shows pathological Q wave and ST elevation. Laboratory results are remarkable for an elevated troponin.

Injury to myocardial cell membrane

You are responsible for managing patients on a general medicine ward overnight. One of the patients under your care is a frail elderly woman with a history significant for advanced dementia admitted. She was admitted for hospital-acquired pneumonia, as she resides in a long-term memory care facility. Over the past several minutes, you have received numerous frantic pages from various nursing staff regarding this patient. Nursing reports this patient has become agitated, has had hallucinations, will not remain in bed, and has urinated on the floor. The nursing staff has requested you come and evaluate the patient.

Initiate non-pharmacologic management.

A 32-year-old Caucasian woman has a past medical history of Hashimoto's thyroiditis, type 1 diabetes mellitus, and pernicious anemia; she presents with a 2-year history of insidious and intermittent fatigue, anorexia, involuntary weight loss, nausea, abdominal pain, vomiting, and dizziness that is associated with position changes. Her physical exam is noteworthy for postural hypotension, with a maximum systolic blood pressure of 104 in the supine position. Additionally, she has a low-grade fever and a generalized pigment change to her skin.

Instructions on self-administration of IM hydrocortisone on an as-needed basis.

A 37-year-old Caucasian man presents with shortness of breath. History reveals that the patient has been extremely fatigued the last few weeks, experiencing excessive night sweats with a worsening cough, chest pain, and general aches and pains. He is not taking any medications and is allergic only to penicillin. He has a history of on-and-off intravenous drug use and admits to last using around 1 month ago. Along with an urgent inpatient admission, you plan to initiate orders to have the patient undergo an echocardiogram and obtain blood cultures, among other actions.

Intravenous vancomycin

A 33-year-old woman comes to your office after a 6-month sabbatical working in caves in the eastern part of the South America. Upon questioning, the patient reports fever, chills, productive cough, and joint stiffness that started 1 month before her return. Physical exam reveals 3 ulcerated lesions on her inner cheek.

Itraconazole

A 12-year-old boy presents with fatigue and jaundice. History obtained from the patient and his mother is negative for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On eye examination using a slit-lamp, you note brown-yellow rings encircling the iris in the rim of the cornea bilaterally. You order a serum ceruloplasmin level, which is reported as low.

Kayser-Fleischer rings

A 17-year-old girl presents with a sore throat and weakness; she has a fever of 100°F. There is cervical lymphadenopathy on physical exam, and the Monospot test is positive. After 14 days, the patient develops acute abdominal pain. During the abdominal examination, guarding is noted in the upper left quadrant. The patient is becoming increasingly pale, sweaty, and cold.

Laparotomy

A 56-year-old man presents with a history of persistent and progressive unrelenting hoarseness for the last few months. He is a 50 pack-year smoker but quit 1 year ago. Physical examination demonstrated a 2-cm firm non-tender right anterior cervical lymph node.

Laryngeal cancer

A 79-year-old man presents with severe chest pain and dyspnea. He has a past medical history of diabetes mellitus, hypertension, and hyperlipidemia. He appears pale, apprehensive, and diaphoretic. He is in a confused state and agitated. His pulse is weak and tachycardic, with a systolic blood pressure of 60 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, and significant jugular venous distention. His lungs are free of crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads.

Leading contributory cause is myocardial ischemia.

A 33-year-old G5P4 woman presents to her gynecologist. She has been using condoms and would like to discuss alternative birth control options. She has regular periods and is not currently trying to get pregnant. She is sexually active with one partner. Past medical history includes asthma, deep vein thrombosis during her first pregnancy, and a C-section for her fourth pregnancy. She has no known drug allergies.

Levonorgestrel IUD

A 55-year-old woman with a 15-year history of type 2 diabetes presents for follow-up. Her spot albumin/creatinine ratio was 100 mg/g 4 months ago and was confirmed at 100 mg/g yesterday. Her urinary analysis shows no cells, casts, or blood. Her creatinine is 0.7 mg/dL, and her estimated glomerular filtration rate is 95 mL/min/1.73 m2.

Lisinopril

A previously healthy 35-year-old man has had right flank pain radiating to his right groin for the past 3 hours. CT shows a 11 mm uric acid stone in his right proximal ureter.

Lithotripsy

A 56-year-old man presents with primary hypertension. His additional medical history includes only nephrolithiasis. Past analysis of his kidney stones has revealed a calcium oxalate composition.

Loop diuretics

A 49-year-old man presents with chronic fatigue, headache, fevers, and muscle and joint pain. He describes the initial rash occurred on his arm with a red circular rash with central clearing. He describes transient "reddish spots" that can be quite large and have appeared on his skin then faded away. His symptoms developed about 4 months ago with no apparent cause; they have gradually gotten worse with the recent addition of the musculoskeletal pains. He is married and monogamous, and he lives in a small rural community; nevertheless, he is concerned that he may have somehow contracted a communicable STD.

Lyme disease

You are evaluating a 34-year-old African American man for a 5-week history of increasing right groin pain. He denies any injury or history of similar pain. The pain is worse with movement and has progressed to the point that the patient has severe pain with bearing weight. He denies fever, chills, urinary symptoms, or any other issue at this time. He has a past medical history of sickle cell disease and hypothyroidism. Physical exam reveals tenderness upon palpation of the groin with increased pain on both active and passive range of motion of the hip. Homan's sign is negative. Distal pulses and sensation are intact and normal.

MRI of the right hip with and without contrast

A patient presents with deteriorating work and feelings of worthlessness and hopelessness; symptoms have been worsening over the past month. The patient also gives history of excessive fatigue and loss of interest in pleasurable activities. They also have trouble eating and sleeping, and they are increasingly withdrawing from family and friends. These symptoms have been present for more than 2 months.

Major depressive disorder

A new female patient presents to your clinic to discuss upcoming travel plans. She was born in the Dominican Republic and emigrated the United States 10 years ago. She is planning on returning the Dominican Republic to visit relatives. She plans to spend some time outdoors trekking near her family's home. She is up-to-date on her influenza vaccination and other age-appropriate preventative health screenings and vaccinations. She is not pregnant or trying to become pregnant. She is otherwise healthy without any chronic medical conditions.

Malaria prophylaxis

Examination of a newborn revealed an abnormal appearance of the back. There is a presence of hairy patch with central dimple present on the lower back.

Maternal folic acid deficiency in first trimester

A 5-year-old boy presents to his pediatrician's office due to a temperature of 103°F, cough, runny nose, and a rash for 5 days. His mother reports they are orthodox Jewish and traveled to Israel 2 weeks ago. Due to his religious beliefs, he is unvaccinated. His heart rate is 102 with a blood pressure of 100/65, pulse 102 beats per minute, and respiratory rate of 22 breaths per minute. On exam, he is lethargic and ill-appearing with a maculopapular rash on his face. He has clear nasal discharge and red conjunctiva. He has tiny white spots with bluish-white centers on a red background found inside the mouth on the inner lining of the cheek.

Measles, mumps, and rubella vaccine for all close contacts

A 25-year-old man is referred to you for evaluation. He has no history of psychiatric disturbance, and there is no family history of psychiatric illness. During the evaluation, he states that he has seen people following him and he has been having difficulty concentrating. He believes that he is in danger and that the people following him are FBI agents. When asked about the onset of the symptoms, he states that they began about 1 month ago and they have persisted ever since. The patient is not currently taking any psychiatric drugs, but he has been taking antihistamines to treat allergies for about 1 month.

Medication-induced psychotic disorder

A 16-year-old boy presents with acute onset of stiff neck, fever, headache, and vomiting. On exam, he appears lethargic, has limited range of motion of his neck, and a petechial rash is noted. Fever is 103°F. The patient's medical history is non-contributory.

Meningococcus

A 54-year-old woman presents for her annual pelvic examination. Her last menstrual period was 1 year ago, and her last few cycles were extremely irregular. She describes multiple daily episodes of severe, intense heat in the face and trunk accompanied by sweating. She states that these "heat episodes" have been occurring 4-6 times daily for 4 months, and they interfere with her everyday activities and sleep. She reports no other symptoms. She has received yearly annual pelvic examinations and clinical breast exams and mammograms without any significant findings. Her past medical history is negative for cardiovascular disease, blood clots, and breast cancer. Her pelvic examination has findings of excessive dryness and apparent vaginal wall atrophy.

Menopausal hormone therapy

A 15-year-old girl presents with a 3-day history excessive vaginal discharge without itching or burning. She denies ever being sexually active. Her last menstrual period was 10 days ago. On examination you find a thin, white, homogeneous discharge that has a distinct amine odor when potassium hydroxide is added. On saline wet mount, epithelial cells are covered with bacteria.

Metronidazole

A 50-year-old woman comes in for follow-up of newly diagnosed type 2 diabetes mellitus. She has no other contributory past medical history. She drinks alcohol rarely. She has been working on dietary changes over the last 6 months. Most recent A1c is 7.6%.

Metformin

A 25-year-old woman presents for an annual gynecological visit. Menses onset was at age 12; duration of menses is 6 days, every 30 days. She is nulliparous with no history of abnormal pap smears or diagnosed STIs. She does not smoke and has been in a monogamous relationship with 1 partner for the past year. The patient mentions a whitish-gray vaginal discharge that increases after intercourse, accompanied by a distinct musty odor; she denies pain from this discharge. Physical examination and a positive result of a whiff test support the suspected diagnosis.

Metronidazole by mouth

A 22-year-old woman presents with headache. The pain is located on the right side of her head and is described as throbbing. The headache has lasted for approximately 10 hours and has been unrelieved by acetaminophen and ibuprofen. The pain worsens with movement, exposure to light, and loud noises. Neurological examination is within normal limits.

Migraine headache

A 27-year-old man with Marfan syndrome presents due to exercise intolerance and heart palpitations. On exam, you note a mid-systolic click and late systolic murmur heard at the apex of the heart. The click and murmur are noted later in systole with squatting and earlier in systole with sudden standing.

Mitral valve prolapse

A 36-year-old woman presents with chronic dyspnea that is worse while lying prone. The patient reports progressive worsening of the symptoms. On physical examination, a heart murmur is detected upon cardiac auscultation, heard best with the bell over the apex. The murmur is a non-radiating low-pitched diastolic rumble. A loud S1 and opening snap can also be heard in addition to an apical thrill and decreased pulse pressure. An EKG is done and shows atrial fibrillation.

Mitral stenosis

A 35-year-old African American woman presents to urgent care with fatigue and intermittent vomiting of 2 weeks' duration. She recently came back from a month-long trip to Central America. She has also experienced symptoms of intermittent fevers, headaches, and brief "yellowing of her skin."

Mosquito

A 23-year-old woman presents with increasing fatigability and muscle weakness. On further questioning, she reveals that she has experienced difficulty swallowing over the past month, and there have been episodes of double vision as the day progresses. Several of her professors have expressed concern because she looks sleepy during the day. A CT of the chest reveals an anterior mediastinal mass.

Myasthenia gravis

A 65-year-old woman presents with general weakness for the past few days; it gets worse as the day progresses. She says she has been having double vision, and you notice she has poor posture. A blood test reveals the presence of antibodies to acetylcholine receptor. A repetitive nerve stimulation test showed a decremental response.

Myasthenia gravis

A 24-year-old man presents with a 2-day history of skin rash on his back. He notes pain in his joints and tiredness. He has just returned from a camping trip. Vital signs are normal. Examination reveals an expanding lesion with a concentric circle of erythema.

Myocarditis

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never experienced heartburn as bad as she does currently. She is treating it with over-the-counter histamine-2 receptor antagonist, famotidine, 1 tablet daily. The patient denies any other significant past medical history and is currently taking a daily multivitamin and an antihistamine for seasonal allergies. She recently admits to having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days; she hopes that her headaches will subside after finals are finished. She also states that she was given amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stool, use of tobacco or alcohol, or coughing up blood. Physical examination is unremarkable.

NSAID

A 58-year-old woman presents for a follow-up accompanied by her adult daughter. A few months ago, the patient had gone to the emergency department via ambulance after the daughter discovered her mother confused and shaking at home. The patient underwent several days of inpatient treatment for alcohol withdrawal. Initial symptoms included hallucinations, tremor, nausea, anxiety, insomnia, and a seizure. The patient denies current symptoms and admits increased tolerance to greater amounts of alcohol and loss of control with a frequent need for the substance. Her work and home relationships suffer due to her condition. The patient has no other medical conditions, is menopausal, has had no surgeries, takes no medications, and has no allergies. The patient readily admits alcohol abuse and dependence with a desire to prevent relapse. She has not used any other substances, and has been abstinent of all substance use since hospital discharge. She is currently in individual and group programs to assist her in relapse prevention. She would like pharmacological help to maintain her sobriety.

Naltrexone (ReVia/Vivitrol)

A 13-year-old girl presents 2 weeks after an upper respiratory infection with diarrhea, sweating, and increased heart rate. Physical examination reveals a tremor and a swollen, tender, painful thyroid gland. Pulse rate is 110/min and blood pressure is 130/60 mm Hg.

Naproxen

A 19-year-old man presents for evaluation of excessive daytime sleepiness. Despite getting a full night's sleep, his coworkers have repeatedly noticed him suddenly dozing off at his desk, during meetings, and sometimes mid-conversation. Upon further questioning, the patient admits that he occasionally experiences nighttime episodes of feeling unable to speak or move. The remainder of the history and physical exam are unremarkable. Aside from the occasional ibuprofen for shoulder pain, he does not take any medications.

Narcolepsy

A 23-year-old man presents with a 2-day history of watery nasal discharge, malaise, sneezing, and nasal congestion. On examination, you notice inflammation of the nasal mucosa; pulse is 80/min, BP is 130/84 mm Hg; temperature is 98.8°F. The rest of the examination is normal.

Nasal decongestants and non-pharmacologic remedies

A 44-year-old woman with diabetes presents with a 2-week history of lower extremity edema. She has no other symptoms. Physical examination of her lower extremities reveals bilateral 2+ pitting edema.

Nephrotic syndrome

A 45-year-old woman is constantly thirsty and consumes large amounts of water. She has a history of sarcoidosis. In addition, her urine output is in the range of 7 liters per day; she wakes up several times a night to urinate. Upon administration of aqueous vasopressin, her urine osmolarity rises above the value of her plasma osmolarity.

Neurohypophysis

A 43-year-old woman with non-insulin dependent diabetes presents because the "sore on the bottom of my foot doesn't heal and gets my socks wet." The patient states that the "sore" presented gradually and has slowly worsened. The patient's past medical history is negative with the exception of type 2 diabetes. Physical exam of the right foot shows a 1 cm partial thickness ulcer present on the plantar aspect of the fifth MTPJ. The borders are well defined with white hyperkeratosis and clear serous drainage. There is no pain upon palpation.

Neurotrophic

A 30-year-old woman presents for routine analysis of cholesterol levels. The results show plasma cholesterol levels of 300 mg/100 mL. You prescribe the drug simvastatin (Zocor). She is reluctant to take drugs to treat her hypercholesterolemia. After further discussion, she agrees to take a vitamin to treat the elevated cholesterol. She also has questions concerning familial hypercholesterolemia.

Nicotinic acid

A 45-year-old woman presents with chest pain. The pain developed about an hour prior to arrival in ED and was precordial. No positional or pleuritic component was present. Nitroglycerin relieved the pain. Her EKG reveals ST elevations. She undergoes cardiac catheterization; all of her vessels are clean and no revascularization is performed.

Nifedipine

A 51-year-old woman presents with difficulty swallowing. She reports a 2-month history of problems swallowing liquids and solids and bringing up undigested food. X-ray reveals a bird's beak appearance of the esophagus.

Nifedipine

A 28-year-old man presents with rectal bleeding. He had noticed blood with bowel movements 3 times. The blood is described as bright red in color and small in amount. He also complains of rectal pain, especially with passing hard stools. He has tried some over-the-counter hemorrhoid creams without relief. The patient admits episodic constipation. He denies dark tarry stools, easy bruising, and prior episodes of rectal bleeding. He has not noticed blood in his urine or with brushing his teeth. He denies nausea, vomiting, diarrhea, fevers, and weight loss. He has no known medical conditions. Family history is negative for gastrointestinal disorders. Social history reveals he is in a heterosexual relationship and denies anal intercourse. On physical exam, abdomen is normal. The anus has no visible protrusions or rash, but there is a very small erythematous and tender area that appears like a "paper cut" or crack in the skin. The patient experiences pain with digital rectal exam (DRE). No masses are noted in the rectal vault.

Nitroglycerin ointment

A 31-year-old man presents with a tick bite. He describes locating a tick in the left axillary area while showering in the evening, and he denies that the tick was present the previous evening. He removed the tick with forceps and cleaned the wound with alcohol. Examination of the bite shows local erythema and mild induration 3-5 mm diameter. The tick is identified as an adult female Ixodes scapularis.

No treatment needed

A 24-month-old boy is brought in by his mother. Although he has been fairly healthy, she is concerned about his speech and language development. The mother says the boy's 4-year-old sister was talking in three- to four-word sentences and asking and answering questions with an extensive vocabulary when she was 2 years old.

No use of two-word phrases

An 82-year-old woman presents with her anxious daughter who lives with her. The daughter has noticed recent "lapses in memory" and feels that her mother has become forgetful lately. Her lapses in memory usually relate to people's names and recollection of past events and recent conversations. According to her, she is otherwise healthy; she takes calcium and vitamin D for osteoporosis, aspirin for her heart, and vitamin B complex. She has no history of trauma, strokes, or CNS infections. Her lapses in memory mostly affect short-term memory. She is able to carry out activities of daily living and is well oriented to time, place, and person. Her husband passed away 18 months ago, and she sometimes finds it difficult to sleep when she remembers his death. She feels "lonely" and "desperate" at times. Her BP is 130/80 mm Hg, and other vitals are normal. Neurological, cardiac, respiratory, and abdominal exam are normal. Her MMSE score is 28/30.

Normal aging

A 17-year-old boy presents with intermittent bouts of shortness of breath, coughing, and chest tightness. The symptoms most often occur during football practice, sometimes when he is just standing outdoors in cold weather. He denies palpitations, fever, and chills. Past medical history is non-contributory. He is a non-smoker. Physical exam is unremarkable. Vital signs are as follows: BMI 19 kg/m2, BP 116/70 mm Hg, HR 80 bpm, SpO2 99% on room air. His physician orders pulmonary function testing (PFT) and a chest X-ray (CXR).

Normal chest x-ray

A 50-year-old Caucasian man with diagnosed peptic ulcer disease (PUD) has nausea and severe vomiting for 2 days. Physical examination shows a patient with confusion, pale skin, tachycardia of 140 bpm, and blood arterial pressure of 90/50 mm Hg. Further evaluation reveals hypochloremic hypokalemic metabolic alkalosis.

Normal saline

A 62-year-old man was diagnosed with multiple myeloma 1 year ago; he is currently hospitalized with intractable nausea and vomiting. Since he was asymptomatic at the time of diagnosis, he has not been treated for his cancer. His wife reports he has not eaten in several days, but he is constantly drinking water. He appears confused and lethargic. When adjusted for the albumin level, serum chemistries reveal an elevated level of calcium (12.0 mg/dL).

Normal saline

A 35-year-old man presents with a groin mass. The patient states that the mass is painless; there is no known trauma to the region. The mass is present when the patient stands, and it disappears when the patient is lying flat. Past medical history is significant for obesity, hypertension, and hyperlipidemia. Past surgical history is significant for lipoma removal from the left shoulder. The patient denies tobacco use; he tells you that he drinks about 6 beers per week. In office ultrasound confirms diagnosis and surgical repair is scheduled.

Obesity

An 88-year-old man with abdominal pain presents to the emergency room with his wife. A mini-mental status exam reveals pronounced forgetfulness and confusion. The patient is discovered to have acute appendicitis requiring immediate surgery. He is unable to understand the situation and cannot provide informed consent.

Obtain consent from his wife to perform surgery.

A 34-year-old woman presents to your office to establish care. Her past medical history is significant for gastritis. She has no other medical problems. As part of your new patient assessment, you perform a neurological examination. On confrontation with visual field testing, you note bilateral temporal field defects, specifically a bitemporal non-homonymous hemianopsia. The remainder of your neurological evaluation is unremarkable.

Order an outpatient MRI of the brain.

A 49-year-old woman presents with a 1-month history of a rash on her right breast. She reports that it has not been responding to the creams that she has been applying and she is having some burning and itching at the rash. On examination, she has an erythematous area that is sharply demarcated with scaling and vesicles over her right areola and nipple. There is a nontender lump in the upper outer quadrant. Her left breast is normal.

Paget's disease

A 75-year-old woman presents due to intense pruritis of the vulva and occasional bleeding. She is unsure if the bleeding is caused by her scratching. She has tried some OTC preparations to alleviate the itching without relief. She denies vaginal discharge or dysuria. On physical examination, you notice excoriations and some scattered lesions that look like eczema on the vulva; they do not scrape off. Also noted was inguinal lymphadenopathy. You decide to do a punch biopsy. The pathology report reveals large eosinophilic cells.

Paget's disease

A 34-year-old man presents for evaluation of right calf pain after being struck by a car. He reports burning pain in his calf and numbness and tingling in his right foot. Physical exam is remarkable for calf swelling, increased pain with passive muscle stretching, and muscle weakness and decreased sensation in his right ankle and foot.

Pain out of proportion to exam

A 23-year-old woman presents due to palpitations, numbness, shortness of breath, and sweating. She reports that these episodes have been occurring once or twice a week for the past several months and that she cannot discern any consistent pattern or trigger. Although the symptoms occur seemingly at random and independent of social situations, she reports that she has begun to limit her social activities for fear of having an episode while she is away from home. Physical exam and laboratory findings are within normal limits.

Panic disorder

A 2-week-old female neonate presents for her scheduled newborn visit. The mother notes that the newborn has been feeding poorly and seems to have difficulty catching her breath when crying. On examination, a continuous machine-like murmur is heard at the left first intercostal space.

Patent ductus arteriosus

A 25-year-old woman is admitted to the hospital with a 3-week history of headaches accompanied by palpitations and sweating. The episodes occur several times daily and last for 15 minutes. Heart rate is 125 beats/min and blood pressure is 220/100 mm Hg. Physical examination is remarkable for diaphoresis.

Plasma fractionated metanephrine

Mandatory newborn screening has been conducted on a neonate born 36 hours ago. The abnormality found in the screening has resulted in counseling on initiating lifelong modification to the newborn's diet. It is explained to the mother this action must be taken in order to help decrease the incidence of severe intellectual disability, hyperactivity, and even seizures.

Phenylalanine

A 12-year-old girl presents with a 1-week history of a rash on her trunk. The patient has not been ill or exposed to anyone ill. On examination, there are scattered lesions on her trunk; they look like they form a Christmas tree. The girl states that the lesions are itchy at times, but they are generally not bothersome.

Pityriasis rosea

A 17-year-old girl presents with a rash. She states she noted a single oval patch several days before a more generalized rash erupted. She indicates that the rash mildly itches. On physical examination, the initial lesion appears as an erythematous (salmon-colored) plaque with a collarette on the trailing edge of the advancing border. You note a fawn-colored rash that follows the cleavage lines on the posterior trunk. This rash is most prevalent on the trunk, and the proximal upper and lower extremities.

Pityriasis rosea

A 29-year-old woman, G4P2011, LMP 9 months prior, presents with sudden onset of severe lower abdominal pain. The pain is sharp and tearing and was not preceded by the contractions she recalls from previous deliveries. She also endorses vaginal spotting prior to presentation. There is no history of prior medical problems or surgery, and she is on no medications. All previous deliveries were vaginal. She has smoked 1 pack of cigarettes a day over the past 10 years. She denies alcohol use but does admit to a remote history of heroin abuse by insufflation. On physical examination: Temp 99.4°F; BP 110/70 mm Hg; Pulse 85/min; RR 20/min. Pertinent findings on the PE were relegated to the pelvic exam; fundal height measures 39 cm, and there is profuse bleeding from the vagina. Fetal monitor shows contractions every minute with elevated baseline uterine tone. Fetal tachycardia is evident at 180 beats/minute, and late decelerations are also present.

Placental abruption

A 17-year-old male high school football player presents after being tackled and slammed onto his right dominant shoulder forcefully 2 hours ago during a game. He had immediate pain but was able to continue playing. He has full active and passive range of motion, but some pain (6/10) with abduction. There is no obvious deformity, and the skin over the shoulder is intact and not tented.

Plain film radiograph

A 55-year-old man visits his family physician for an accidental cut to the forearm with a rusty wrench. He works as a tank mechanic for the US Army and has been an Army recruit since age 18. The patient received his influenza vaccine a few months ago. He also received tetanus and diphtheria toxoid approximately 2 months ago when he had an unrelated injury. The patient has been consuming a lot of alcohol over the past few years. He admits wanting to cut down. He currently drinks a half bottle of red wine every day. He also admits to taking a shot of vodka in the morning to "tide" him through the day. The wound is cleaned and dressed appropriately, and his liver function is tested:

Pneumococcal vaccination, hepatitis A and B

A 22-year-old man presents with a sudden onset of shortness of breath and right-sided chest pain. Symptoms began yesterday, and he felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He is a 1 pack-per-day smoker; otherwise, he has a noncontributory past medical history. On physical exam, the patient is in mild respiratory distress, with a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal. A chest X-ray is obtained, and a pleural line is visible.

Pneumothorax

A 22-year-old postpartum woman presents with a loss of interest in eating, increased sleepiness, and fatigue at her first-week checkup. It was her first pregnancy. She has been happily married for 2 years; she has a stable job and good family support. Out of her hearing range, her husband reports that she seems more irritable, snapping at him for trivial things. She broke down sobbing when asked about her parents, who passed away in a car accident 1 year earlier.

Postpartum blues

A 65-year-old African American man presents in your office for a follow-up for hypertension. 3 months earlier, you prescribed furosemide. He checks his blood pressure daily and states that it is markedly lower since he has been on the medication, but it feels like his heart is skipping a beat once in a while.

Potassium

An 18-year-old woman presents with nausea, vomiting, drowsiness, and abdominal pain. She has Kussmaul respirations, ketotic breath, dry tongue, and loss of skin turgor. Her laboratory studies show the following results:

Potassium

A 50-year-old man is evaluated for non-productive cough and shortness of breath. He reports a progressive cough that has worsened over the past year. Over the last 2 weeks, he has increasing cough, chest pain, and low-grade fever. His occupational history reveals coal mining for 25 years. He denies any smoking, alcohol consumption, travel history, or sick contacts. He also denies sore throat, otalgia, abdominal pain, peripheral edema, rashes, or pruritus. A chest radiograph was performed. Refer to the image.

Prednisone

A 52-year-old woman presents with left hip pain. There is no known history of trauma to the area. Past medical history includes Crohn's disease, type 2 diabetes, and hypertension. She is currently taking metformin, metoprolol, and mesalamine. She recently completed a prednisone taper for her Crohn's disease. She also finished a course of ciprofloxacin, which she took for a urinary tract infection. An X-ray is obtained, revealing a collapsed left femoral head.

Prednisone

A 66-year-old man presents with monoarticular arthritis. He has stage 3 chronic kidney disease. His affected joint is warm to the touch. You suspect gout. He is allergic to aspirin.

Prednisone

A 16-year-old girl has moderate facial acne vulgaris that you plan to treat with topical retinoids.

Pregnancy

A 40-year-old male recreational tennis player presents with pain in his playing-side elbow since a tournament last weekend. He played five matches of singles and two matches of doubles games. He cannot even hold a pen without pain. He says he needs to get better fast because he has another tournament coming in a week. On exam, he has pain with extension against resistance of his affected side wrist.

Prescribe an NSAID of choice and recommend skipping the next tournament.

A 48-year-old man presents with a 5-year history of hand tremor. The tremor was initially mild and has progressed over the last year. It diminishes at rest, but it intensifies with intentional movements and upon emotional stress and fatigue. He is unable to write or drink from a cup during stressful situations. He never drinks alcohol, and he does not currently take any drug except metformin for non-insulin-dependent diabetes mellitus. Family history is negative. Physical exam is unremarkable. His gait, speech, and posture are normal.

Propranolol

A 54-year-old man is admitted to the intensive care unit and intubated on a ventilator after a serious motorcycle accident where he sustained multiple fractures, spinal cord trauma, and a liver laceration. On his fifth week of hospital admission, blood cultures from a central line reveal staphylococcal septicemia. After another month in the intensive care unit, the patient is found to have ascites and pitting edema. Vitals are within normal limits. Ultrasound demonstrates a fatty liver and unremarkable gallbladder. Echocardiogram shows no structural defects and a normal ejection fraction.

Protein deficiency

A 12-year-old girl presents to the emergency room with worsening foot pain. 2 weeks ago, she stepped on a nail while wearing rubber-soled tennis shoes. The area was thoroughly cleaned, but she has developed worsening pain, redness, and drainage from the area. X-ray shows periosteal changes at the site of the wound. A wound culture is obtained.

Pseudomonas aeruginosa

A 52-year-old man presents with rectal pain during bowel movements. He describes the pain as tearing. Physical examination reveals a tear in the anal mucosa.

Psyllium

A 16-year-old girl presents with a 4-hour history of loss of consciousness. Her older sister states that the patient has been depressed and was found with an empty bottle of tuberculosis medication. The patient has now begun having generalized tonic-clonic seizures. Examination reveals a developed teenage girl responsive only to painful stimuli; there are intermittent tonic-clonic movements of the extremities.

Pyridoxine

A 74-year-old multiparous woman with a history of breast cancer has been referred to a gynecologist due to a sensation of vaginal fullness and pressure, sacral back pain with standing, coital difficulty, lower abdominal discomfort, and urinary frequency and incontinence. She states that she feels "a bulge" in the lower frontal vaginal area. She denies any fever, chills, flank pain, history of infectious diseases, changes in weight, dysuria, or hematuria. The physical exam is remarkable for an obese body habitus and non-tender bulge located anterior within the vaginal introitus that becomes more pronounced upon Valsalva and standing.

Recommend pelvic muscle exercises.

A 40-year-old woman undergoing a gynecologic workup for metromenorrhagia presents with a several-week history of fatigue and lightheadedness. Laboratory evaluation reveals a hemoglobin of 11 g/dL (12-16 g/dL), hematocrit of 34%, MCV of 70 fL (80-100 fL), and MCH of 24 pg (27-33 pg). Further studies reveal a ferritin level of 25 ng/mL (12-300 ng/mL), TIBC of 500 mcg/dL (250-450 mcg/dL), and an iron level of 45 mcg/dL (60-170 mcg/dL). The patient is diagnosed with iron deficiency anemia. She is prescribed ferrous sulfate 325 mg po tid. Several days later, she presents to the ER. She reports resting dyspnea and chest discomfort. Oxygen and nitroglycerin are given. Cardiac enzymes are pending. The patient's hematocrit is 23% with hemoglobin of 7.5.

Red blood cell transfusion

A 41-year-old man presents for evaluation of hearing loss. He states that he is having more difficulty in his right ear than his left. He began to notice this about 6 months ago when, while talking on his cell phone, he had to routinely switch to his left ear because of difficulty understanding the words while listening with his right ear. He states that he has had ear drainage for approximately 6 months. He also states that he was in the Navy for a few years and took up scuba diving as a recreational activity. He recalls multiple ear infections during his time in the Navy.

Referral to an otolaryngologist for surgical intervention

A 72-year-old man presents for worsening shortness of breath, orthopnea, and chest pain for the last few weeks. He admits some chronic heart problems, fatigue, dyspnea, and non-productive cough, but he feels like symptoms have worsened recently. He denies fever, chills, and productive cough. On physical exam, he has mildly increased respiratory effort but does not appear in distress. He is barrel-chested. Breath sounds are diminished bilaterally, with dullness to percussion over right and left lower lungs. No pleural friction rub noted. S3 gallop, mild tachycardia (110 bpm), clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention are noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on chest X-ray.

Renal sodium and fluid retention leading to increased capillary pressure

A 29-year-old man and his wife have been trying to have a child for the past 3 years. The wife was thoroughly evaluated for infertility; the workup revealed no abnormalities. Examination of the man's inguinal region reveals an ill-defined tortuous swelling that increases with standing and coughing. Ultrasonography is suggestive of varicocele. His initial semen analysis reveals mild oligospermia.

Repeat semen analysis

A 32-year-old nulliparous woman presents for a routine gynecological exam. She has been married for 5 years and plans to start a family in the near future. Menarche occurred at age 11. Menstrual cycles are regular, occurring every 28-30 days, and lasting for 4-5 days each. She denies menorrhagia and dysmenorrhea. She has used oral contraceptive pills since age 18; she recently discontinued them and began taking prenatal vitamins. On physical examination, you palpate a mass on the left side. A transvaginal ultrasound confirms a 3 cm complex cystic mass on the left ovary, without free fluid detected within the pelvis. The patient has no family history of any malignant tumors.

Repeat ultrasound in 2-3 months

A 15-year-old girl is referred to a cardiologist's office for workup of hypertension. Her mother reports a normal pregnancy and birth. There is no family history of heart disease. On physical exam, BP 140/70 left and right upper extremities, 90/70 left and right lower extremities, HR 85/min, RR 20/min. Brachial and femoral pulses are incongruent. There are pulsations in the suprasternal notch. Cardiac auscultation reveals a III/VI systolic ejection murmur.

Rib notching and a notch in the aorta

A 72-year-old woman presents with a severe unilateral headache, jaw pain, and scalp tenderness. The patient states the headache is of a piercing quality; her jaw hurts only when she chews, and feels better a few minutes after she stops chewing. A pulsation of the temporal artery on the same side as her headache cannot be appreciated, and prednisone is prescribed until the patient can see a specialist.

Risk for blindness

A 50-year-old woman has had a facial rash and a 10-year history of reddening of her face that comes and goes. On physical exam, you note erythema, telangiectasia, red papules, and tiny pustules on both cheeks.

Rosacea

A 55-year-old woman presents with weakness, bone pain, and lethargy. A 24-hour urine sample reveals a spike of M protein. Based on the most likely diagnosis, what additional finding on bone marrow aspirate would support the diagnosis?

Russell bodies

A 47-year-old man presents with numbness, tingling, and pain anterior and to the left side of his left thigh. Pain is provoked even with light touch, and tingling continues for several minutes after the touch. Symptoms started a couple of months ago and worsen when he wears a belt and walks down slopes and stairs, as well as after prolonged standing. Symptoms are relieved when he puts a pillow between his thighs. Patient also assumes hunched posture while standing to avoid unpleasant sensory symptoms. His BMI is 40, and he has a protruding pendulous abdomen.

Sensory loss in anterolateral thigh down to left upper knee

A 22-year-old man presents with what he describes as a change in his heart rate. He indicates that his heart rate seems to speed up and then slow down for the past few hours. He adds no other symptoms. An EKG is ordered: irregular rhythm, a PR interval of 0.16 seconds, a P to QRS ratio of 1:1, heart rate of 75 bpm when exhaling and 86 bpm when inhaling, PP interval varies >0.12 seconds, and an RR interval that is noted to accelerate and decelerate during the respiratory cycle similar to the way the patient described.

Sinus arrhythmia

A 7-year-old boy presents because he is fidgety, impulsive, and unable to sit still. The patient is observed running around. There is no evidence of any hallucinations or delusions. The mother notes that the child speaks excessively and loudly, makes simple arithmetic errors, and has short-term memory deficiencies. He finds it difficult to wait in lines or wait his turn in games or group situations.

Stimulant medications are considered first-line pharmacologic therapy.

A 42-year-old man is angry, frustrated, disillusioned, and disappointed with his wife's involvement with his best friend. He enrolls himself in a men's tennis club to relieve his negative emotions. What defense mechanism is he using?

Sublimation

A 23-year-old woman presents with an extremely painful right arm. She also reports numbness and tingling of her right hand and fingers. She burned her arm on the stove 1 week ago and was prescribed a silver-containing cream. Physical exam is remarkable for swelling and tenderness of the right forearm. She also has decreased sensation in her right hand and weakness of the right thenar muscles. Tissue pressure in the arm is 55 mm Hg (normal <8 mm Hg).

Surgery

A 32-year-old woman presents to the emergency department due to abdominal pain for the past 4 hours. The triage nurse reports she has had similar pain in the past that has resolved on its own, but the pain today is more severe. When you enter her room, she is sitting in bed comfortably and is fully covered in traditional clothing except for her eyes. Her husband is present and requests a female provider. In this scenario, you are a male provider responsible for this module today, but you have female colleagues working in other modules.

Take a brief history first to determine urgency.

A 28-year-old man presents with a 1-week history of an itchy scaly rash on his elbows. When he scratches it hard, scales come off and the rash bleeds. Examination reveals the elbows are affected bilaterally. The lesions appear as 3-4 cm annular whitish scales on an erythematous base that is irregular and well-demarcated. The antecubital fossae are unaffected.

Topical fluorinated glucocorticoids

A 23-year-old man diagnosed with type 1 diabetes 5 years ago presents for a regular examination. Upon physical examination, temperature is 98.1°F, blood pressure is 120/80 mm Hg, and there are no signs of edema. He explains that recently he has been noticing that his urine seems a little darker and foamy, but he has no discomfort while urinating. Blood tests indicate an A1c level of 6.7%.

Urine albumin measurement

A 28-year-old man presents with severe headaches. He states that they began a few weeks ago and that he has been taking over-the-counter medications with some relief. He reports that he has AIDS. You ask what the patient was doing prior to experiencing these headaches. He says that he was taking care of the neighbor's cat while they were on vacation. Concerned, you order a CT scan; it demonstrates multiple ring-enhanced lesions.

Toxoplasma gondii

A 32-year-old woman presents with a 3-month history of right hand pain and paresthesia of the thumb, index, and middle fingers. She works in a retail sales office and spends much of the day typing.

Thenar atrophy

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and a tremor in her hands for the past 3 months. She has also noted weight loss. You note the presence of bulging eyes.

Thyroid gland

A 34-year-old woman presents to your clinic with a 3-month history of a mildly tender mass on the dorsocentral aspect of her dominant right wrist. She says the lump "comes and goes," but this time it has stayed and become tender. She denies any known trauma of the wrist or hand.

Transilluminating the mass

A 32-year-old woman with no significant past medical history presents with a 4-day history of "thin, light-grayish, uniform consistency" vaginal discharge. Her last sexual intercourse encounter was 1 week ago; it was unprotected. She is not in a monogamous relationship. She denies any fever, chills, swollen glands, dysuria, hematuria, urinary frequency, dyspareunia, or back pain. She denies any vulvar or vaginal pruritus. Physical exam is significant for a pungent ammonia-like scent with an associated thin gray-white vaginal exudate, but it is otherwise unremarkable. Microscopic evaluation of the vaginal exudates is remarkable for the presence of clue cells.

Vaginal pH of 5.2

A 52-year-old man presents with a 3-day history of persistent diarrhea. He reports seven watery, non-bloody bowel movements daily. He has associated lower-abdominal cramping and mild nausea. He denies recent travel out of the country. He does not recall eating anything unusual, and none of his family members are sick. Past medical history is significant for GERD, for which he takes pantoprazole daily. He recently completed a course of oral levofloxacin for pneumonia. A stool sample is negative for ova and parasites, but PCR testing is positive for Clostridium difficile.

Vancomycin

A 72-year-old man is admitted with an acutely severe myocardial infarction. His status quickly deteriorates. His symptoms include hypotension, altered mental status, cold clammy skin, and metabolic acidosis seen on laboratory tests.

Vasopressors

A 4-year-old uncircumcised boy presents with a 2-day history of penile pain. The patient is afebrile and vital signs are stable. On genital examination, his foreskin is retracted proximally and the glans is edematous and cold. You are unable to reduce the proximal foreskin distally over the glans penis; it is strongly suspected that arterial flow is compromised. The only urologist available will arrive in 1.5 hours.

Vertical incision of the constricting band

A 50-year-old woman with a family history of colon cancer underwent a total colonoscopy per screening guidelines for colon cancer. 2 polyps, 5 mm each, were noted on exam. The doctor advises the patient to repeat her colonoscopy in 3 years due to her polyp pathology.

Villous adenoma

A 32-year-old woman presents with a 1-month history of bleeding gums when brushing her teeth. She also reports that her wounds are taking longer than usual to heal. She is a stay-at-home mother and is breastfeeding her 6-month-old twins. On examination, you note multiple splinter hemorrhages on her nails and ecchymoses over her lower limbs.

Vitamin C deficiency

A 6-year-old girl presents with frequent and prolonged bilateral nosebleeds. Her parents are concerned because there is a family history of a bleeding disorder. Her father, paternal grandmother, and a paternal aunt are all affected. Bleeding time, platelet count, and clotting time are within reference ranges. Ristocetin cofactor activity is decreased, and coagulation factor assays show slight decrease in factor VIII, but reference range factor IX levels.

von Willebrand disease

A 6-month-old infant is brought in for routine vaccination. The mother saw information about a measles outbreak online. There is no known measles outbreak in the state. The mother is asking for more information about this vaccine. She would like her child to receive it now.

12-15 months, 4-6 years

A 53-year-old woman presents for an annual examination. She has a history of asthma for which she takes inhaled steroids and ß-agonists. She has no history of bone fractures and no family history of osteoporosis. She exercises regularly. Her menses used to be regular, but have just started to show some irregularity. She believes she might be entering menopause and asks for advice to prevent osteoporosis.

1200 mg of calcium and 800 IU vitamin D daily

A 7-year-old boy presents to the emergency department with new-onset rash, fever, and coryza. It is determined that the patient has not received vaccinations since birth. To reduce the risk of transmission, he is placed in a negative pressure isolation room. The patient will be discharged home to remain under isolation for the next 4 days.

2 hours

A 48-year-old woman with a past medical history of obesity presents with a 4-hour history of moderate severity epigastric and right upper quadrant pain. The pain is intermittent and occurs in "waves." She also notes nausea, vomiting, and radiation of pain to the right shoulder. Her physical exam reveals normal vital signs, but tenderness is noted in the right upper quadrant. There is no guarding or rebound. A bedside ultrasonography is obtained. Refer to the image.

A low-fat, low-cholesterol diet is recommended.

A 63-year-old woman presents with acute onset of abdominal pain that describes as a steady deep discomfort in the left lower quadrant. She was constipated initially, but she is now experiencing diarrhea. On physical examination, she has a temperature of 38°C. The abdomen is tender in the LLQ with guarding and rebound tenderness. She has positive fecal occult blood.

Abdominal CT

A 48-year-old obese woman presents to the emergency department with right upper quadrant pain. She also has nausea and right shoulder pain. She recently started a high-fat, low-carb diet. Her temperature is 100.2°F, pulse is 87 beats/min, and blood pressure is 129/84 mm Hg. Physical examination is remarkable for an ill-appearing female with right upper quadrant epigastric tenderness and a positive Murphy sign.

Abdominal ultrasound

A 45-year-old woman presents with a skin lesion. She states she noticed a lesion on her cheek for the past few weeks and it will not go away. She has a history of laying out in the sun at her home in Florida since she was a teenager. Upon physical exam, the patient has a wart that appears to be elevated and pink with a sandpaper texture.

Actinic keratosis

A 65-year-old man presents to his general surgeon's office with recurrent abdominal pain. He recently had an exploratory laparotomy 7 days ago. On exam, he is afebrile. Blood pressure is 136/78 mm Hg, heart rate of 80 bpm and regular, BMI of 45. He has a large incision in the abdomen with evidence of early dehiscence at the proximal incisional site with clear drainage noted.

Adipose tissue

A 33-year-old woman presents with a 1-day history of urinary frequency and dysuria. She is sexually active with one partner and uses a diaphragm with spermicide for contraception. Based on positive leukocyte esterase dipstick test and abnormal urine culture, she is diagnosed with a urinary tract infection (UTI). During a follow-up visit, she tells you that this is the third episode of UTI in the past few months and asks you what she can do to reduce future risk.

Change contraception method.

An 8-year-old girl presents with her mother to the pediatrician's office with persistent clear nasal drainage and nighttime cough for the past month. Her physical examination reveals clear rhinorrhea, dark circles under her eyes, and a transverse nasal crease.

Allergic rhinitis

A 52-year-old woman recently diagnosed with acute myelocytic leukemia presents to her oncologist's office to discuss chemotherapy. She is hesitant to start chemotherapy, as she had an aunt pass away while undergoing chemotherapy for breast cancer. She is seen by the oncology physician assistant, who knows the patient well. Chemotherapy is discussed in detail.

Alternatives to chemotherapy

A 28-year-old man presents with "burning mouth." The patient states he has had an unusual burning sensation on the inside of his right cheek for the last 3 days; he feels that the burning is worsened with hot, spicy, or acidic foods. After performing a comprehensive oral exam, you note three lesions on the buccal mucosa on the right side of the oral cavity. You further document the description of these lesions as the following: three round lesions, each measuring approximately 3 mm in diameter with presence of a white-yellow center surrounded by a red halo.

Aphthous ulcers

A 72-year-old man presents with progressive shortness of breath over the years. He denies chest pain or a history of smoking. The patient was in the construction business for many years, and before that he worked as a shipbuilder. Chest X-ray reveals marked interstitial fibrosis and calcified pleural plaques on the lateral chest wall.

Asbestos

A 73-year-old man presents to the emergency department after a suspected overdose. History is unobtainable; he is currently febrile; his blood pressure is 125/76 mmHg, respiratory rate 30 with increased breathing depth, heart rate 105; and laboratory results are as follows:

Aspirin

A 26-year-old woman at 29 weeks gestation presents with a 1-week history of vaginal discharge and dysuria. On genital exam, she has mucopurulent cervicitis. A cervical swab is obtained and results are positive for Chlamydia trachomatis infection.

Azithromycin

A 3-year-old boy presents due to severe bouts of coughing for the last 10 days that started as a common cold. During coughing, his face becomes red. The episode of cough often ends with a loud sound during breathing or vomiting. He also has low-grade fever off and on for the last 10 days. Immunization records of the child are not available. Blood count shows leukocytosis with lymphocytosis.

Azithromycin

A 22-year-old woman presents with increased vaginal discharge. She is sexually active with two male partners and she uses birth control pills for contraception. Her last menstrual period was 12 days ago, and she has noticed an increased whitish vaginal discharge for the past week. Physical exam reveals a soft non-tender abdomen. On pelvic exam, she has a light-yellow cervical discharge with erythema of the cervical os. There is no cervical motion tenderness and no adnexal masses or tenderness. Wet mount of the vaginal discharge reveals epithelial cells and WBCs, and no yeast or protozoa. Gram stain of the vaginal discharge reveals many leukocytes. A urine pregnancy test is negative.

Azithromycin 1 g PO once and ceftriaxone 250 mg IM once

A 60-year-old man presents with a 6-month history of dysphagia to solids, regurgitation of undigested food, and halitosis. He denies a decrease in appetite, abdominal pain, weight loss, or change in bowel habits. His past medical history is significant for a total hip replacement. His lab work is as follows:

Barium swallow

An 8-month-old boy presents to the pediatrician in mid-January with 2 days of cough and nasal congestion. His mother reports decreased breastfeeding over the last day and difficulty breathing. The infant's temperature is 38.2°C (100.8°F), heart rate 120/minute, respiratory rate 34/minute, and oxygen saturation 95% on room air. Physical exam is remarkable for intercostal retractions.

Bilateral expiratory wheezing

A 32-year-old woman presents for magnetic resonance imaging of the head due to visual changes and galactorrhea. A mass is found in the sella turcica.

Bitemporal hemianopsia

A 26-year-old woman presents to her gynecologist's office with a 4-month history of amenorrhea. She has had some breast tenderness, but she denies nausea, vomiting, fatigue, and abdominal pain. She was sexually active until about 6 weeks ago when she broke up with her boyfriend, but she states that they used condoms.

Bluish appearance to cervix

You have inherited three adolescent patients who had different early childhood malignancies that were treated in different ways according to the type and grade of cancer. They have been in remission now for over 5 years. In reviewing their charts, you consider the need to monitor for late effects of childhood cancer.

Bone and soft tissue sarcoma

A 62-year-old woman well known to you presents with a severely itchy rash. The patient's medical history includes Parkinson's disease that was diagnosed around 7 years ago. The patient thought that the rash was just eczema initially, but the areas have morphed into severely tense, large blisters; they are extremely pruritic to the patient. On examination, you note multiple bullae 1-3 cm in size that are tense and appear to be sitting on an erythematous base. The bullae are located on the patient's lower abdomen in both lower quadrants and in the bilateral axillary and inguinal folds.

Bullous pemphigoid

A 15-month-old toddler presents with sudden onset of generalized tonic and clonic convulsions for the last 30 minutes. Parents report that the patient was irritable in the minutes preceding the events, but there is no history of trauma, fever, or vomiting before the onset of convulsions. This is the first episode of seizure, and there is no history of convulsions in the family but the father has a history of cerebral aneurysm requiring surgical clipping. The patient's birth history, neonatal period, and developmental milestones are normal.

CT scan of the head

A 48-year-old man presents for an annual physical exam. He has a past medical history of obesity and a 5-year history of hypertension that is currently not well-controlled. He was also recently diagnosed with type 2 diabetes mellitus (DM). He is a 20 pack-year smoker and drinks 2-3 beers per night. On exam, his BMI is 41, and BP is 145/92 mm Hg. The remainder of his exam is unremarkable.

Cigarette smoking

A 35-year-old woman presents to your outpatient clinic due to left knee pain. She slipped on ice and struck her knee several days ago; pain has persisted since her fall. Her physical exam is remarkable for a large knee effusion, tenderness to palpation, and decreased range of motion. As part of your investigation, you decide to obtain an X-ray of her left knee. When ordering her X-ray, you inadvertently order an X-ray of her right knee.

Contact the patient yourself and explain the imaging order error.

A 25-year-old Caucasian male landscaper presents with a 2-week history of generalized malaise and an "unusual rash" on his right thigh. The patient reports that this rash has been widening, but he denies any pruritus or pain in association with his complaints. In the past week, he has also noticed a constant headache and mild fever. The past medical history is unremarkable. The physical exam reveals vital signs within the normal limits, enlarged non-tender diffuse lymph nodes in cervical and inguinal areas, and an erythematous rash with central clearing and few satellite lesions.

Early localized

A mother seeks medical attention for her 7-year-old son. For the last 8 months, he has not acted like his three older brothers. The mother indicates that her son has said on repeated occasions he wants to get rid of his male genitalia and he would prefer to be a girl. She has found him wearing his sister's clothing on numerous occasions. More history shows that he prefers to play with dolls and only spends time with female friends. Teachers relate that he turns down invitations from the boys in the class to join in sports activities. His male classmates are now teasing and embarrassing him in class, and it has begun to affect his schoolwork.

Gender dysphoria

A 38-year-old woman of northern European origin is brought to the emergency room by her relatives who report abnormal behavior. The patient denies the accusation and reports numbness and a tingling sensation in both her hands and feet (gloves and stockings) and recurrent diarrhea. Physical examination shows an atrophic tongue (glossitis), and a neurologic examination reveals a loss of her sense of vibration and fine touch. Endoscopic examination shows atrophic gastric mucosa and fasting achlorhydria.

Megaloblastic erythropoiesis in bone marrow

Your patient is a 55-year-old African American man with bilateral foot edema that started 1 week ago and has progressively worsened. He has a 5-year history of type 2 diabetes, but his last physical exam was 2 years ago. He does not take any medications because he prefers to "control the health with a healthy lifestyle." On examination, you find pale male patient with bilateral ankle edema. His temperature is 37°C, blood pressure 155/100 mm Hg, heart rate 80, and respirations 15/min. He is otherwise well-developed and well-nourished; BMI is 25 mg/m2.

Protein restriction

A 5-year-old boy presents with a 6-day history of fever, fatigue, and rash. He has no significant past medical history. His vaccinations are current, except for varicella, which his parents have refused in the past. On exam, his temperature is 101.3°F, heart rate is 110 bpm, and blood pressure is 94/62 mm Hg. He has bilateral conjunctival injection, an erythematous pharynx without exudate, cracked red lips, and an erythematous right tympanic membrane. He has shotty enlarged anterior cervical lymph nodes bilaterally, the largest nodes measuring 1.6 cm on the right side and 1.5 cm on the left side. His lungs are clear, and his heart has a regular rhythm. His abdomen is soft. He is in no acute distress, and he has a generalized maculopapular rash.

Sterile pyuria, leukocytosis

A 38-year-old man presents with a 2-day history of a mass and severe pain in his scrotum. Physical examination reveals that his right testicle appears much larger than his left. On palpation, you note a small hole in his inguinal canal, and you are unable to place the contents into the canal. The contents of the hernia appear ischemic.

Strangulated

A 17-year-old male high school football player presents after being tackled and slammed onto his right dominant shoulder forcefully 2 hours ago during a game. He had immediate pain but was able to continue playing. He has full active and passive range of motion, but some pain (4/10) with abduction. There is no obvious deformity, and the skin over the shoulder is intact and not tented.

Tenderness over the acromioclavicular joint

A 29-year-old Caucasian man presents for a routine physical examination. He has a history of right-sided cryptorchidism corrected by orchiopexy at age 6 months. He has no problems at present. His physical exam reveals bilateral gynecomastia and a painless, firm right testicular mass approximately 1.5 cm in diameter. The right testicular mass does not transilluminate, nor does it disappear when the patient lies supine. There is no femoral or inguinal lymphadenopathy and no palpable hernia.

Testicular malignancy

A 6-week-old boy presents with his mother, who reports that he has episodes of turning "blue all over," especially when eating or when he becomes upset. Physical exam reveals cyanosis of the lips when he is crying. Cardiac exam reveals a harsh systolic crescendo-decrescendo murmur in the left upper sternal border. A chest X-ray reveals right ventricular hypertrophy.

Tetralogy of Fallot

A 4-year-old child presents in cardiopulmonary arrest after being found at the bottom of a swimming pool. CPR is administered by paramedics, and an intraosseous needle and endotracheal tube are inserted. What confirms that an intraosseous needle is correctly inserted into the marrow cavity?

The needle remains upright without support

An 86-year-old man has been experiencing fatigue, leg swelling and loss of appetite. His exam shows dependent edema, hepatomegaly, and JVD. Diuretics have been given to the patient and have worsened his renal function.

Tricuspid valve

A 44-year-old obese woman presents with increased nighttime urination. She has never had issues with having an increased urge to urinate nocturnally before, and it is extremely bothersome to her. She states that she has been waking up at least 3 times a night despite lifestyle modifications designed to help reduce this number. The patient admits to increased fatigue, worsening blurry vision, and two vaginal yeast infections in a span of 3 months.

Type 2 diabetes

A 3-month-old Caucasian male infant presents for a well-baby check. There have been no other changes since the last visit. Upon exam, the infant is pink and well-appearing. Cardiovascular exam reveals a grade III/VI high-pitched, harsh pansystolic murmur heard best at the left sternal border, fourth intercostal space (ICS). No additional murmurs are heard. The remainder of the exam is unremarkable.

Ventricular septal defect

A 22-year-old woman with a history of gradual right-sided hearing loss presents seeking help. She has been experiencing some ringing in her right ear, vertigo, and a feeling of fullness in the ear. Upon physical exam, the patient appears frustrated and keeps tugging on her right ear. MRI displays a tumor that has developed in the right inner ear.

Vestibular schwannoma

A 33-year-old man presents with a 2-day history of severe diarrhea and vomiting. He had been on a business trip to Asia 3 days ago, and he reports eating food bought from street vendors. He describes his stools as watery and not bloodstained. He is allergic to seafood, and he takes antacids for peptic ulcers. On examination, he is moderately dehydrated; temperature is 37°C, PR is 100, and BP is 120/60 mm Hg.

Vibrio cholera

A 36-year-old woman presents with a 24-hour history of sudden severe diarrhea described as profuse, gray, cloudy, watery stools without blood or fecal odor. She was recently in Bangladesh for work and returned yesterday, which was when the diarrhea began. She is also experiencing a mildly elevated temperature with a very dry mouth, headache, and severe fatigue.

Vibrio cholerae

A 3-year-old boy presents with his mother; she reports that he is unable to walk without support. He is an only child who rarely leaves his tenth-floor apartment home. On examination, he has a rachitic rosary and genu valgum.

Vitamin D deficiency

A 17-year-old girl presents to the clinic due to chronic fatigue. Her past medical history is unremarkable. There is no history of surgeries. Review of systems reveals heavy monthly menses since menarche at age 13. She admits to using more than 20 tampons on each of the heaviest 3 days of her menstrual cycle. Her last menstrual cycle commenced 1 week ago. There are no recent medications. Exam is within normal limits, with no vaginal discharge. Labs: pregnancy test negative; cervical cultures negative; thyroid studies within normal limits; Hb 10 g/dL, WBC 9000/μL, platelet count 250 x 103/μL. Peripheral blood smear is consistent with microcytic hypochromic anemia. Prothrombin time, partial thromboplastin time (PT, PTT), and fibrinogen are normal. Bleeding time is prolonged.

Von Willebrand disease

A 21-year-old man with a history of cocaine and methamphetamine abuse is brought to the emergency department after being found unconscious. He is placed on a non-rebreather mask and admitted to the ICU with findings of acute heart failure. Echo shows enlarged left ventricle, decreased cardiac contractility, and systolic dysfunction. He vastly improves over 24 hours. He is currently awake and alert. No history of cardiac disease. BP 132/88 mm Hg, HR 86 and regular, RR 20, Temp 98.2°F, and O2 sat of 100% on 3L via nasal cannula. Physical exam reveals no murmur, clear lung sounds, and no peripheral edema.

Wean oxygen

A 70-year-old man on vacation in the US presents for what appears to be suspicious skin lesion on his cheek. He has had a longstanding discolored patch; it has recently enlarged in size, and there is crusting. A biopsy confirms your suspected diagnosis. After undergoing treatment, he wants to take measures to prevent a recurrence.

Wear protective clothing and avoid midday sun.

A 24-year-old man with no significant past medical history presents with a 3-month history of progressive hearing loss of his left ear. He states that he has the greatest difficulty in hearing high-pitched sounds. He denies trauma, recent travel, sick contacts, pressure changes, headache, nausea, otorrhea, otalgia, fever, chills, vertigo, swollen glands, rashes, sore throat, vision changes, or rhinitis. He states that he enjoys listening to music on his personal music device and attends concerts frequently. An otoscopic speculum exam reveals no observable abnormalities.

Weber test

A 25-year-old man presents to you with an acute otitis media with serous otitis in the right ear. You perform the Weber and Rinne tests.

Weber—sound is heard louder in right ear; Rinne—bone conduction exceeds air conduction in right ear

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate is 120 bpm, and respiratory rate is 34/min. Physical examination findings include neck negative for bruits/JVD, lungs clear to auscultation, regular heart rhythm, normal S1/S2 with an S4 present, and a grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray is obtained.

Widening of the superior mediastinum

A 36-year-old G1P1001 woman presents with a 4- to 5-week history of pain along her right lateral wrist; the pain worsens when she tries to grasp something. There was no trauma. She gave birth 6 weeks ago and carrying her baby is difficult secondary to pain. She is right-handed and has never had any issues like this before. On exam, there is tenderness and edema over the radial styloid. You then have the patient fully flex her thumb, adduct, and grasp it with that hand. You then place her hand in ulnar deviation, which reproduces the pain described above.

de Quervain tenosynovitis

You are evaluating a 17-year-old Caucasian boy on his high school's cycling team. He admits that he has been injecting himself with erythropoietin (EPO)—provided to him by a recent graduate from the team—once every 2 weeks for the past 3 months. While he is convinced that he has achieved the desired increase in endurance needed to win consistently, he is concerned by stories he has heard regarding the side effects of this drug. Past medical history is unremarkable and there is no history of tobacco, alcohol, or recreational drug use. Growth and development have been normal and immunizations are current. Vital signs are normal. The examination is unremarkable.

"Serious medical risks exist in connection with the use of this substance."

A 32-year-old woman presents for a follow-up visit. She was diagnosed with hyperthyroidism 2 weeks earlier, after presenting with tremors, heat intolerance, weight loss, and diarrhea. You prescribed propranolol for her, pending the results of her test during her last visit. She feels slightly better now. She denies any family history of thyroid disorder and has no drug allergies. She has a supportive husband. She does not smoke, drink alcohol, or use illicit drugs. Her physical examination is normal. She has been reading about management of hyperthyroidism; she prefers the 131I treatment.

"Take a pregnancy test prior to starting therapy."

A 17-year-old football player (punter) was tackled and forcefully slammed onto his right dominant shoulder 2 hours ago during a game. He had immediate pain, but it has subsided; he now experiences the same level of pain when he carries a heavy object. He wants to continue punting. He has full active and passive range of motion, but some pain (4/10) with abduction. There is no obvious deformity, and the skin over the shoulder is intact and not tented. There is no crepitus on palpation while moving the arm. Most of his tenderness seems to be on the superolateral right shoulder.

"You can continue to play if you are pain-free."

You have been employed as a PA for a hospitalist group for several years. You have recently been invited to serve on a hospital committee taskforce. The mission of this task force is to make recommendations regarding system-wide initiatives to improve patient satisfaction for the healthcare system.

Communication skills training for providers

A patient requests their medical records be forwarded to another provider. They also want to have a printed copy of the records. Your practice policy is that they pay a fee for the printed records and provide identification. Policy requires consent in an electronic patient portal to forward records. The patient must allow up to 7 days for the request to be completed.

Consent in an electronic portal

A 67-year-old man presents with dyspnea and chest pain 3 days after flying home from Europe. His past medical history is unremarkable. Workup reveals a pulmonary embolism. The patient has required 6 L of O2 to maintain a saturation above 90% and he remains tachycardic.

Low molecular weight heparin plus coumadin

A 78-year-old woman is an inpatient status post-colectomy for colon cancer. On postoperative day 3, her oral temperature is noted to be elevated to 100.6°F. Chest X-ray and urinalysis are both negative for signs of infection. An infectious disease consult is placed in order to better define the patient's new fever. You suspect superficial thrombophlebitis.

Erythema and tenderness along the vein with IV insertion

A 61-year-old man presents with a recent history of increased fatigue with mildly increased exertional dyspnea. The patient denies any significant past medical history but states that he had some heart problems as a child; he was never clear as to what the problem was. On cardiac examination, you hear an early diastolic soft decrescendo murmur with a high-pitched quality, especially when the patient is sitting and leaning forward. No thrill is felt.

Aortic regurgitation

A 25-year-old man presents for evaluation of intermittent chest pain. He reports a burning sensation in his chest 1-2 days per week after eating. The symptoms are worse with large meals, eating late at night, and excessive alcohol consumption. He denies difficulty swallowing, weight loss, night sweats, chest pain, use of tobacco, or coughing up blood. His vital signs and physical examination are unremarkable.

H2-receptor antagonists

A 60-year-old man presents with difficulty initiating voiding, incomplete emptying, and increasing urinary frequency over the past few months. He has no history of stones, cancer, surgery, diabetes, or AIDS; he takes no medications. His physical exam shows a temperature of 98.6°F, a blood pressure of 128/78 mm Hg, suprapubic fullness, an enlarged prostate, and no peripheral edema. The remainder of his exam is normal. He has been referred to urology.

.

A 25-year-old healthy male newly employed PA reports to the occupational health clinic for required testing. Based on his immunization history, it is recommended that he receive the full hepatitis B vaccine (Recombivax HB).

0, 1 month, 6 months

A 49-year-old woman presents with dysphagia. She is having difficulty swallowing liquids and solids, and she notes regurgitation of undigested food. X-ray reveals a bird's beak appearance of the esophagus.

Achalasia

A 10-year-old boy presents with a 1-week history of progressing joint pain. The pain started in his ankles, and then progressed to his knees; his hips are now starting to hurt. His ankles feel slightly better. He had contact with someone who had strep throat within the past couple of weeks. The patient's heart rate is 130. On exam, there is erythema and edema over the knees and hips as well as minimal edema over the ankles. A high-pitched holosystolic murmur is noted over the apex and radiates to the axilla with a noted friction rub.

Acute rheumatic fever

A 19-year-old man presents with hair loss described as localized oval patches for the past month. Upon examination, the patches are sharply demarcated without tenderness, erythema, or scaling noted.

Alopecia areata

A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a longstanding history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure, mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Echocardiogram reveals concentric left ventricular hypertrophy without significant valvular abnormalities.

Angiotensin-converting enzyme inhibitor

A 20-month-old boy presents for a routine visit. He is eating well and drinking at least a bottle of cow's milk daily, which he has done since age 8 months. His history and physical are normal except for mild pallor. Urinalysis is normal.

Anisocytosis

A 26-year-old woman presents with dysmenorrhea that has become more bothersome over the last 3 months. She has difficulty taking ibuprofen (Motrin) due to a stomach ulcer.

Applying warm compresses locally

A 60-year old woman has a history of stress-related migraine headaches. Many conventional treatments have failed.

Biofeedback

A 71-year-old Caucasian man has been "peeing red" for 3 days and presents after being urged by his spouse. He is not having pain with urination. Pertinent history includes a 100 pack-year smoking history, quitting 5 years ago after having a successful heart catheterization. He has a history of benign prostatic hyperplasia, for which he is taking tamsulosin 0.4 mg once daily. The patient denies any acute trauma, injury, urinary frequency, or urgency.

Bladder cancer

A 55-year-old man presents with a 2-day history of confusion, increased respiratory rate, rapid pulse, notable malaise, thirst, and less-than-normal urination. In the morning, his wife gave him a multivitamin pill hoping that it would help; she tells you that he has long-standing hypertension and he injured his neck in a car accident 1 week ago. On examination, you find BP 92/41 mm Hg, HR 150, RR 35, rapid and weak pulse, cutis marmorata, cold edematous extremities, and bluish discoloration of the tongue and nails.

Cardiogenic

A 23-year-old man presents with burning on urination and a light greenish-yellow penile discharge. He is afebrile but otherwise well. He admits to having unprotected anal sex with a man.

Ceftriaxone 250 mg IM once and azithromycin 1 g now

A 51-year-old man with a history of Marfan syndrome presents to the emergency department with tearing chest pain that radiates to the back and neck. On examination, the patient is hypertensive; a high-pitched decrescendo diastolic murmur at the left sternal border and diminished peripheral pulses are noted.

Computed tomography scan of the chest and abdomen (CT scan)

A 45-year-old man goes to a party and enjoys several glasses of an alcoholic cocktail. His past medical history is significant for headaches. The drinks trigger a unilateral right-sided headache. The headache is behind his right eye and spreads to his forehead. He also notices that his right nostril has a watery discharge and his right eye is tearing. He describes the pain as if he were "being stabbed in my eye."

Cluster headache

A 58-year-old woman presents with a 3-month history of postprandial abdominal pain that always occurs 30 minutes after eating. Due to these symptoms, the patient has lost 30 pounds and is afraid to eat. Her past medical history includes hypertension treated with enalapril and coronary artery disease for which she has undergone a right coronary artery stent; she underwent a carotid endarterectomy for symptomatic carotid stenosis. She has smoked 2 packs of cigarettes a day for 30 years.

Computerized tomography angiography

You are performing a physical examination on a patient with longstanding COPD. Significant findings include wheezing respirations, cyanosis, and distended neck veins; a left parasternal lift and a tender liver are both noted on palpation.

Cor pulmonale

A 32-year-old woman presents with a 3-day history of irritation, burning, itching, and redness of both eyelids. She denies fever, visual changes, and photophobia. On physical examination, you note the presence of scales clinging to the eyelids bilaterally.

Daily cleaning with a damp cotton applicator and baby shampoo

An 80-year-old woman is diagnosed with dementia of the Alzheimer's type as a result of comprehensive testing. You believe she is in the very early stages of the disease and you want to try a medication to possibly slow disease progression.

Donepezil (Aricept)

A 64-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, abdominal pain, nausea, vomiting, diarrhea, or peripheral edema. His physical exam reveals a widespread friction rub upon inspiration, absent lung fremitus, and reduced lung sounds over the thoracic cavity.

Dullness to percussion

A 23-year-old woman presents to her psychiatrist's office for a follow up regarding her 2-year history of bulimia nervosa. Until this time, she has been undergoing cognitive behavioral therapy (CBT) several times per week. She has shown great improvement, but she would like to consider additional measures to control her disorder.

Fluoxetine (Prozac) 60 mg daily

A 66-year-old man presents with a 2-month history of bone pain and weight loss. Lytic lesions were discovered on a routine X-ray. You order additional lab work.

Hypercalcemia

A 78-year-old man with known left-sided congestive heart failure presents due to cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms?

Increased pulmonary venous pressure

A 50-year-old man presents to the emergency department with epigastric pain. Pain is sharp with radiation into the back and accompanied by nausea and vomiting. On exam, the patient exhibits tenderness to palpation of the upper right quadrant and upper left quadrant without rigidity or guarding. Laboratory findings reveal the following:

Intravenous normal saline

You are evaluating a 26-year-old man; he is suspected of being infertile. His past medical history is unremarkable. On examination, you note he is 6'4"; he has mild gynecomastia, sparse body hair, and small soft testes.

Klinefelter syndrome

A 76-year-old African American man with a past medical history of diabetes, hypertension, and hyperlipidemia is referred to a urologist for the evaluation of supranormal PSA readings associated with a reduction in urinary stream, back and hip pain, hematuria, and weight loss. He has not yet been managed for these symptoms. A pelvic X-ray done in office reveals osteoblastic sclerotic areas of pelvis and femurs bilaterally.

Leuprolide

A 29-year-old woman is taking D-penicillamine for Wilson's disease. Today, her laboratory findings (including liver function tests) are within normal limits; there are no neurological signs. Her work requires frequent travel (3-5 days per week), including international overnight travel all over the world. She wants contraception that is both effective and convenient in terms of application.

Levonorgestrel-releasing intrauterine system

A young woman presents with her daughter, who appears to be about 6 years old. You note that the child's eyes are downcast and she is scratching her scalp. On closer inspection, you note a tiny white wingless insect and tiny eggs attached to the hair shafts. The child's mother also notes that the same insects are present in the girl's eyelashes.

Lice

A 66-year-old man presents to the clinic with a complaint of not being able to hear the beeping of his microwave. Knowing that the beeping is high pitched and the age of the individual, you suspect hearing loss in this patient that is typically associated with aging.

Loss of cochlear hair cells

A 37-year-old woman was diagnosed as HIV-positive 3 years ago; she is unable to work and is physically debilitated, so she asks you to provide her with medications with which to take her own life.

Major depressive disorder

A 21-year-old woman presents with urinary frequency. Her BMI is 41. A urinalysis is positive for glucose. Her random blood sugar is 257 mg/dL, hemoglobin A1c is 8.5%, and C-peptide is 1.5 ng/mL. She is diagnosed with type 2 diabetes; diet and exercise are recommended.

Metformin (Glucophage)

A 54-year-old man presents with a recent lump in his scrotum. After answering questions about possible symptoms and undergoing a thorough genitourinary examination, it is determined that the lump is actually a collection of fluid in the patient's tunica vaginalis.

Nontender fluid-filled lesion that transilluminates

A 25-year-old woman has a 2-month history of "episodes" that occur more than 3 times a week. She describes the episodes as a pounding heartbeat, breaking out in a sweat, and difficulty catching her breath. Occasionally, she will feel dizzy and faint with a "tingling" sensation throughout her body.

Paroxetine

A 16-year-old girl with a 2-year history of ulcerative colitis presents with signs of an acute exacerbation: abdominal pain and frequent passing of large quantities of blood and mucus from the rectum. It is treated with sulfasalazine, glucocorticoids, and intravenous alimentation. Diarrhea decreases markedly, but her status continues to deteriorate. Tachycardia, volume depletion, and electrolyte imbalance develop; temperature is 101.8° F. Physical examination finds abdominal tenderness but no mass. Plain radiography shows the transverse colon is dilated up to 7 cm.

Perform colectomy.

A 45-year-old man with no significant medical history presents with what he refers to as "anxiety attacks." He describes them as recurring bouts of palpitations, headaches, anxiety, and sweating that he has experienced for a few weeks. Last night, his wife witnessed him having an episode during dinner. She was concerned and immediately took his blood pressure: 195/105 mm Hg, so she brought him in today. On further questioning, he comments that he sometimes gets lightheaded when he stands up too rapidly; his mother had similar problems. On physical examination, his blood pressure is 165/90 mm Hg and his heart rate is 80 beats/min. A 24-hour collection of his urine test is positive for vanillylmandelic acid.

Pheochromocytoma

You are reviewing incoming test reports while your supervising physician (SP) is out of town. There are two reports for a 46-year-old man shown in the table.

Polyuria and polydipsia

A 15-year-old girl has been dieting for 6 months and has lost over 30 pounds. She tells you that she still feels fat. She is afraid to eat for fear of becoming obese. Her last menstrual period was 3 months ago. On physical exam, the patient is cachectic and slightly pale. Her heart rate is 50 beats/minute, her blood pressure is 90/60 mm Hg, and her temperature is 95.5°F. Her weight is 92 lb and her height is 5'6".

Reduced luteinizing hormone (LH)

A 6-year-old boy is brought to the emergency room with chest pain and signs of respiratory distress. His mother states he has been ill with an upper respiratory infection that suddenly worsened with temperature elevation. Physical examination reveals an increased P2 and systolic ejection murmur. Chest X-ray shows lobar infiltrates. Labs show a leukocyte count of 18,000/mm3, hemoglobin 7 g/dL, and reticulocytes 12%.

Sickle cell disease

A 40-year-old Caucasian man presents to your office to ask for advice regarding the inability of his wife to conceive. She is younger than him by 8 years and he believes she is in good health. Additionally, she has two children from a previous marriage, both pregnancies without complication. He was also married once before, but his first wife did not conceive children. He has not yet undergone any fertility tests.

Spermatogenesis and motility

A 45-year-old woman presents with a lesion on her calf. She states that she has had it for a while and that it has not gotten bigger, but it does not heal and it bleeds occasionally. On exam, the lesion is a pink sharply demarcated scaling plaque.

Squamous cell carcinoma

A 29-year-old man presents 1 hour after stepping on a sharp nail. The nail penetrated deep into his foot; his last tetanus immunization was at age 6.

Tdap vaccine plus antibiotics

A 22-year-old woman is started on methimazole for the treatment of her hyperthyroidism. She has been diagnosed with Graves' disease and has been symptomatic for the last 6 months. She is otherwise healthy and does not take any other medications. You receive a call 2 weeks later from the patient; she tells you that she has had a mild sore throat for the past 2 days and has been feeling like she is coming down with the flu. She states that the symptoms of her hyperthyroidism are a little bit better.

Tell her to present ASAP for total and differential blood count.

You are employed by a cardiology practice as a PA; the majority of your responsibilities are in the hospital setting. As you are making hospital rounds one morning, your supervising physician asks you to remove the pericardial drain from one of the patients. The patient had a pericardiocentesis 2 days ago due to a large pericardial effusion with cardiac tamponade, and the catheter was left in place to facilitate continued drainage of fluid from the pericardial space. You locate supplies, including sterile gloves, needed to perform the procedure. Just before entering the patient's room, you decide not to proceed.

The procedure is not included in your hospital privileges.

A 75-year-old patient comes in with SOB, chest pain, and left lower extremity swelling. She recently went on a 5-hour plane trip to see family and returned yesterday. A bilateral lower extremity ultrasound reveals a left deep vein thrombosis. You are writing admission orders for this patient and prescribe heparin 80 u/kg IV once STAT followed by 18 u/kg/hr. The patient 2 hours later is noted to have hematuria, hemoptysis, and a nose bleed.

The use of u abbreviation

A 29-year-old woman presents with a previous history of mitral valve prolapse with murmur of regurgitation confirmed on echocardiogram with prosthetic valve replacement 1 year ago.

Tooth extraction

A 4-year-old boy presents with a 1-month history of weight loss, fevers, cough, and night sweats. He and his family moved to the United States from Africa 3 months ago. He is a thin pale boy in no acute distress. His heart rate and rhythm are regular, his lungs are clear to auscultation, and he has no organomegaly.

Tuberculin skin test

A 75-year-old woman presents with heartburn and dyspepsia. She was diagnosed with osteoarthritis 4 years ago. For the past 18 months, she has been managing pain with naproxen. The gastroenterologist suggests that the patient be tested for Helicobacter pylori infection.

Urea breath test

A 3-year-old girl is brought to the clinic by her mother, who tells you that the child has not been eating well over the past month and has developed swelling in the abdomen. On exam, the child has a smooth abdominal mass that is the size of a baseball on the left side. Vital signs reveal a blood pressure of 134/82 mm Hg, temperature of 99.8°F, and respirations of 16 breaths per minute. Urinalysis shows only 1+ red blood cells, and CBC and CMP are within normal limits.

Wilms tumor

A 12-year-old boy has jaundice, non-tender hepatomegaly and splenomegaly, and tremor. He has been healthy and is on no medications. He is afebrile. Golden-brown rings on the peripheral corneas are noted on slit lamp eye exam. Laboratory studies reveal low levels of serum ceruloplasmin and elevated 24-hour urine copper excretion.

Wilson disease

A 28-year-old woman presents with malaise. She is known to be HIV positive. Her CD4 count is unchanged at 350 cells/field, and her viral count is undetectable. She is afebrile and has a normal exam. She takes zidovudine, indinavir, potassium, hydrochlorothiazide, and glyburide.

Zidovudine

A 25-year-old sexually active man notices that he has burning and pain while urinating. He also notices some urethral discharge. He sees you in your office for a consultation, and you order several laboratory tests. One of the tests that you order is a Gram stain and culture on a sample of the discharge. The results are negative, and gonorrhea is ruled out.

Chlamydia trachomatis

A 33-year-old woman presents with joint pain and morning stiffness that lasts more than an hour. Her past medical history is significant for postpartum depression 2 years ago. Her BMI is 18. Physical examination is remarkable for bilateral pain and swelling of her metacarpophalangeal (MCP) joints and ulnar deviation. Laboratory evaluation reveals positive antibodies to citrullinated peptide.

Sex

A 5-year-old boy presents with his mother with a history of fever, hemorrhages, and repeated bacterial infections. On exam, lymphadenopathy and hepatosplenomegaly are present. Blood work shows a white blood cell count of 50,000/µL.

Acute lymphocytic leukemia

A 52-year-old woman presents for a routine checkup. She has two children, and she attained menopause 1 year prior to presentation. Pap smears, mammogram, and DEXA bone scan are normal. She is a non-smoker. Her previous biennial checkups were always normal. Her BP is 142/86 mm Hg, and pulse is 72 bpm. Her lab values are as follows:

Diet and exercise

An 18-year-old man presents for a screening physical exam to join his college freshman lacrosse team. He reports no medical problems, and he does not take any medications. Physical exam is unremarkable. His immunizations are current, and he denies sexual activity or smoking. Review of routine labs reveals an elevation in unconjugated bilirubin. His total bilirubin level 4 mg/dL. Liver enzymes, serum electrolytes, complete blood count, and conjugated bilirubin level are within normal limits.

Gilbert's syndrome

A 64-year-old man presents with progressive dyspnea, fatigue, chronic dry cough, and exercise intolerance. His symptoms have worsened over the past year. Pulmonary function testing reveals an FEV1/FVC ratio >0.7, decreased total lung capacity, and decreased residual volume.

Idiopathic pulmonary fibrosis

A 47-year-old man presents with abdominal pain and difficulties breathing. He has a history of alcohol abuse and confirmed cirrhosis of the liver. On examination, you see a malnourished and jaundiced patient with a distended belly. Percussion of the abdomen reveals a huge amount of fluid and wave sign.

Portal hypertension

The 26-year-old HIV-positive man has a CD4 count <200. While he was in the hospital for the treatment of his miliary Tb, he developed smooth skin-colored umbilicated papules on his face. The lesions are asymptomatic, but they are spreading gradually to other parts of the body and causing cosmetic problems to the patient.

Poxvirus

A 1-month-old premature male infant with bronchopulmonary dysplasia (BPD) remains intubated and monitored in the NICU. He has been doing relatively well and is being gradually weaned from the respirator. Suddenly, his O2 saturations and heart rate plummet, and he becomes very dusky. On quick exam, there are decreased breath sounds on the right with an asymmetric chest rise.

Tension pneumothorax

An 18-year-old male high school dropout recently set a fire in his old school classroom because he was dared to do so by other students. He has been sent to you for evaluation. You interview him and find that he had a number of problems related to truancy and fighting in school; he has been found with liquor in his locker at school, and he always seems to feel that someone else is responsible for his having done something. When he was 10, the patient burned down a barn; last year, he and some friends threw rocks at passing cars on the expressway. Past medical history is non-contributory. He denies any recreational drug use.

Antisocial personality disorder

A 6-month-old healthy male infant presents with an inability to sleep through the night. He has 3-4 nighttime awakenings, and his parents spend a long time getting him back to sleep. Both parents work, and their sleep remains disrupted, which affects their work performance the next day.

Approximately 25-50% of 6- to 12-month-olds have nighttime awakenings.

A 5-year-old boy presents with an erythematous skin rash associated with intense itching. The boy's mother has noticed that her son's rash has been recurrent, with 3-4 episodes per year. The itching and rash increases after consumption of certain foods. On examination, erythematous raised papules are seen on the cheek, trunks, and upper arms.

Asthma

A 65-year-old woman presents with weight gain, fatigue, and aching limbs that have been bothering her for 2 months. She has also been having intermittent runny noses, constipation, and dry skin. Physical exam reveals heart rate 56, respiratory rate 18, blood pressure 138/102, temperature 97.9°F, and weight 210 lb. On heart exam, there is a grade II systolic murmur heard best at the right sternal border, second intercostal space. Skin exam shows cool, dry, somewhat pale skin with scattered cherry angiomas.

Blood pressure of 138/102

A 77-year-old Caucasian woman is admitted to the hospital for episodes of dizziness. Her symptoms have been present for approximately 4 months, and they have been progressively worsening. She has no dizziness when sitting or lying down. She does note some rapid heart rate associated with her dizzy spells. The dizziness becomes severe enough that she must sit down and is unable to proceed with walking, which is now significantly interfering with her functional activities. She denies associated chest pain, shortness of breath, or nausea. Past Medical History: Hypothyroidism, single episode of atrial fibrillation 2 years ago. Usual home medications: Aspirin 81 mg daily, Levothyroxine 88 mcg daily. Social History: Patient is married and has 2 adult children. She denies any history of smoking, alcohol use, or use of recreational drugs. Review of systems: Notable only for occasional cough, occasional headache, and mild anxiety. Vital signs: Temp 98.2°F, pulse 98 and regular, respirations 16, blood pressure 94/62 mm Hg (sitting, right arm).

Blood pressures lying, sitting, and standing

A 60-year-old woman is referred to you for a bizarre fixation. She has become preoccupied with the issue of having breasts that are too small, and she has been shopping for plastic surgeons to fix the problem. She has become so fixated on her problem that she stays in the house, does not socialize with others, and tries to constantly hide the perceived problem by wearing clothes that enhance her breasts; sometimes, she even wears prosthetic breasts. She has become paranoid about what people are saying about her appearance.

Body dysmorphic disorder

A 55-year-old Caucasian man was brought to the emergency department for evaluation of sudden chest pain. He was at a barbecue eating ribs when he developed sudden substernal chest pain with nausea and left arm numbness. An EKG demonstrated 2 mm ST elevations in leads V3, V4, and V5. He was diagnosed with acute myocardial infarction. Cardiology was consulted and angioplasty was recommended. The procedure and potential risks were explained in detail to the patient. The patient declined angioplasty, opting for medical therapy alone. He is discharged and dies a few hours after discharge. His family sues the PA and cardiologist for malpractice.

Breach of duty

A 7-year-old girl was playing at a local playground near her home in Louisiana. She was playing kickball and retrieved the ball from a pile of rocks. After several minutes, she noticed a red lesion on her right forearm. She rushed home and told her mom. The mother looked at the lesion and noticed a small red area and sprayed the area with a local antiseptic that she had in her medicine cabinet. The child only noted that it burned. A few hours later, the mother looked at the area and noticed that a white area appeared. She thought nothing of it and placed a bandage over the bite. Before the child went to bed that night, she removed the bandage and noticed that the area had darkened. The mother then took the child to the ER for further evaluation.

Brown recluse spider

A 36-year-old man presents with nasal congestion, headache, fatigue, facial pain, and chronic post-nasal drip. He has had similar episodes in the past, occurring 2-3 times a year for the last several years. He has been diagnosed with acute sinusitis and antibiotics have been prescribed, providing him with relief for a brief period. This time, however, his symptoms have bothered him on and off for the last 3 months. He was given a 14-day course of antibiotics, but he experienced only partial relief. He is tired of the recurrent episodes and wants a cure. On exam, he is afebrile, nasal mucosa is inflamed, and there is mucopurulent secretion in the nasal cavity. The right maxillary sinus is tender on palpation. Lungs are clear.

CT scan of the sinuses

A 24-year-old man presents with a painless, localized swelling of his left lower eyelid; it has developed over a period of weeks. He is seeking medical attention because it is now producing a foreign body sensation in his left eye; it is also hindering his path of vision. On physical examination, his visual acuity is normal; there is no evidence of injection or discharge. You palpate, and you observe a nontender, localized nodule on the lower eyelid.

Chalazion

An 18-year-old girl has had a small slightly tender swelling in her left upper eyelid for 10 days. For the first day or two, it was red and a little painful. Now it is painless, but it has grown in size. There has not been any drainage, visual changes, or itching noted. She has been well otherwise. On exam, vitals are normal, extraocular muscles are intact, and pupils are equal and reactive to light. Her left upper eyelid has a 1.5 cm round non-tender swollen mass that is mildly erythematous without any drainage. The underside of the lid is grayish-red.

Chalazion

A 27-year-old unemployed Latina woman is living in California as an undocumented immigrant. She is married with 4 young children at home. Although her husband is employed, he is also an undocumented immigrant, and the family does not have health insurance. She describes herself as poor and requests your help in locating prenatal care. She states that she just took a home pregnancy test 2 days ago that indicated she is pregnant.

Children's Health Insurance Program

You are evaluating a 78-year-old man who lives in a nursing home due to moderate Parkinsonism. The patient does not have any specific complaints, but nursing home staff have noticed that he does not seem as alert as usual and is spending more time in his room sleeping. He is also eating less and has dropped 2 lb in the last 2 weeks. The patient's temp is 100.8°F; pulse 100 bpm; respiration 25/min; and bp 120/70 mm Hg. On exam, he is aware of the place, but not the exact time or date. His HEENT exam is unremarkable. His cardiac exam reveals tachycardia, but no murmurs or rubs. His lung sounds are decreased at the bases.

Complete blood count

A 52-year-old man stepped on a piece of glassyesterday. On exam, his wound appears clean, and it is not infected. He has never had the primary series of tetanus immunization. The patient asks if he needs tetanus immunization.

Complete tetanus immunizations plus TIG

A 40-year-old woman presents with a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting, but she does admit to having a Colles fracture in this arm around 2 months ago. She denies any injury to her back, neck, or other musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing with an extremely diffuse, uncomfortable aching accompanying it. She further states that this limb has become extremely sensitive to touch and cold; it does appear somewhat more swollen than her left arm. The patient is very upset; she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker. She does not drink, and she exercises 3 times a week. Physical examination conducted of the extremity reveals a slightly cyanotic, mottled right arm with generalized pain of the entire extremity. Pulses are faint (1+) and ROM is limited. Radiograph studies are obtained and reveal spotty areas of apparent osteopenia of the right upper extremity.

Complex regional pain syndrome

A 67-year-old man is recovering following an uncomplicated total hip arthroplasty. His past medical history is significant for hypertension and mild asthma. On postoperative day 2, he begins to note stiffness in his right leg. On exam, his right calf is noted to be swollen and slightly warmer than the left leg. The remainder of the exam is unremarkable. He is afebrile, and his vital signs are stable.

Compression ultrasonography

A 3-month-old male infant presents with history of noisy breathing since birth; the noise is gradually increasing. There is no history of fever or running nose, but there is bark-like cough present. Physical examination reveals a low-pitched expiratory wheeze loudest over the trachea. Wheezing increases during crying, feeding, and when the infant is laid in supine position. There is no cyanosis, subcostal or intercostal retraction, or hoarseness of voice. Wheezing has not shown any response to bronchodilators.

Congenital tracheomalacia

A 73-year-old man presents with worsening shortness of breath with activity over the last few months. He is not able to complete as many physical activities during the day as he could manage 3 months ago. Physical examination reveals hypotension, tachycardia, extremities that are cool to the touch, expiratory wheezing, and rhonchi auscultated during the pulmonary exam; there is also a diminished first heart sound with an S3 gallop heard during the cardiac exam.

Congestive heart failure Diuretic Limiting salt

A 58-year-old man with recently diagnosed type 2 diabetes on metformin has developed Stage I hypertension over the past 3 months. When deciding what antihypertensive medication to begin for this patient, what is the primary reason for using an ACE inhibitor?

Delay the progression to end-stage renal disease

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse is 94/min, BP is 110/70 mm Hg, temperature is 101°F.

Direct fiberoptic laryngoscopy in operating room

A 4-year-old Caucasian boy is seen for a 2-week history of purulent nasal discharge. He has been afebrile and has had no respiratory symptoms. Past history is unremarkable except for his mother's assessment that "he gets into everything." Examination revealed only a right-sided purulent nasal discharge, which was greenish-brown in color and extraordinarily foul-smelling.

Direct visualization of the right nasal vestibule

You are evaluating a 24-year-old woman for bilateral eye pain. She describes red itching irritated eyelids for several weeks. She states she has had "several bouts" of similar symptoms over the last few years. Exam is consistent with blepharitis. She does not wear contacts, and she occasionally wears eye makeup. She denies any other infectious complaints.

Discuss good eye hygiene and eyelid scrubbing.

A 20-year-old woman presents to the emergency department (ED) for evaluation of amenorrhea. She has not menstruated for 7 weeks. A urine pregnancy test done in the ED is positive and confirmed with a transvaginal ultrasound revealing a viable intrauterine pregnancy. She is unemployed and uninsured, and she reports she could not afford a pregnancy test, contraception, or preventative care. She also expresses that she does not want to continue with this pregnancy. You refer her to the nearest free clinic for further management.

Elective termination of pregnancy

A 33-year-old woman presents due to a 15-pound weight gain over 2 months; there is also muscle weakness, menstrual irregularities, amenorrhea, infertility, skin bruising, memory loss, and periods of depression. She denies any medication use or dietary changes; she has tried to lose weight unsuccessfully through increased exercise. She denies any headache, vision changes, hearing changes, chest pain, abdominal symptoms, polyuria, polydipsia, or breast discharge. Her physical exam reveals a blood pressure of 145/94 mm Hg. Her skin physical exam is remarkable for the findings in the image. Refer to the image.

Elevated urinary free cortisol (UFC) levels

A 79-year-old man with a past medical history of coronary artery disease, diabetes mellitus, hypertension, smoking, alcohol use, and hyperlipidemia presents with severe chest pain and dyspnea. He appears pale, apprehensive, and diaphoretic. He is in a confused state and agitated. His pulse is weak and tachycardic, with a systolic blood pressure of 60 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, and significant jugular venous distention. His lungs are free of crackles. Bedside electrocardiogram revealed anterolateral ST segment elevations and "tombstones" across the precordial leads.

Eliminate smoking and alcohol.

A 30-year-old man presents with a 1-hour history of severe nausea and vomiting. Before falling ill, he was at a party where he ate pudding and other food. Physical examination reveals a normal temperature with mild diffuse tenderness of the abdomen. The organism isolated is a gram-positive coccus that occurs in grape-like clusters, is catalase- and coagulase-positive, and forms a golden-yellow colony on agar.

Enterotoxin

A 1-month-old infant is evaluated for rapid breathing, feeding difficulty, lethargy, and poor weight gain. Physical exam is notable for tachypnea, tachycardia, a cardiac gallop, and a medium-pitched systolic murmur best heard posteriorly in the interscapular area with radiation to the left axilla, apex, and anterior precordium. A prominent anterior chest heave is also observed. The lower extremities demonstrate a 12 mm Hg pressure difference compared to the upper extremities. There are delayed femoral pulsations; upper extremity pulsations are normal.

Evaluation by a cardiovascular surgeon

A 16-year-old girl has had acne breakouts since age 10, and both she and her mother have noted the breakouts worsening significantly every year. She notes worsening of her breakouts around her menses each month, but she states she has multiple lesions consistently throughout the month. She has a history of using diet modification, topical retinoids, benzoyl peroxide, and two types of oral antibiotics without improvement. Physical examination of the patient reveals extensive open and closed comedones on the forehead, cheeks, and chin. Painful cystic lesions are present throughout. Isotretinoin is now considered.

Every 4 weeks

A 13-year-old boy presents with pain in his right leg, present for about 2 months but worsening over time. He has developed a low-grade fever. He denies any known injury to the area. On examination, there is tenderness and mild swelling near the right fibula. X-ray reveals an invasive lesion involving the right fibula, with a periosteal onion-skin reaction.

Ewing's sarcoma

A 3-year-old girl is presented by her mother with sinus problems. The mother has a history of airborne seasonal allergies. The patient has sneezed frequently for 4 days and has increased nasal congestion, nasal discharge, and irritability. The mother denies noticing shortness of breath, problems breathing, or fever; the child has not been in close contact with any sick contacts. Physical examination reveals unilateral purulent nasal drainage from the left nare and an obvious foul odor.

Foreign body

A 20-year-old woman presents with 2 weeks of anorectal pain. She notes streaks of blood on her stool and toilet paper. She reports "a tearing pain during each bowel movement." She dreads having a bowel movement, and she attempts to hold it as long as she can. She broke her leg in a skiing accident 4 weeks ago and was prescribed oxycodone/acetaminophen (Percocet) for the first few days due to her pain. An anoscope reveals an acute anal fissure.

High-fiber diet and stool softeners

A 4-year-old girl presents with her mother to discuss treatment of her atopic dermatitis. She was diagnosed as an infant, but her case appears to be getting worse despite frequent lubrication with thick emollient creams and medium-potency topical corticosteroid use. The mother states that the patient is itching a lot more, especially during the night. Large, single patches of erythematous scaly excoriations measuring about 3 cm x 4 cm are present in the flexor surfaces of both elbows.

High-potency topical corticosteroids

A 27-year-old male accident victim with a head injury is admitted to the ICU and kept on mechanical ventilatory support. On the seventh day after admission, he is clinically diagnosed with pneumonia. Blood samples and lower respiratory secretions are submitted to the laboratory for culture; empiric antimicrobial therapy is started.

Klebsiella pneumoniae

A 69-year-old woman suffered a massive stroke 6 weeks ago. She is now recovering from the stroke, but she has residual paralysis and sensory impairment of her right arm. She is also unable to speak and unable to turn her eyes to the right.

Left middle cerebral artery

A 30-year-old woman presents with a 2-week history of itchy pimples on her wrist. On examination, there are violaceous papules with a network of gray lines on their surface; they are found on the medial aspect of her right wrist.

Lichen planus

A 32-year-old man is brought to the emergency department after falling off a roof at a construction site. He is unresponsive and intubated, requiring mechanical ventilation. Computed tomography (CT) scan of the head reveals an uncal herniation and mass effect due to intracranial hemorrhage. Further testing reveals no brain activity. His girlfriend reports he wanted to donate his organs; no other family is present.

Living will

A 34-year-old woman presents with a 2-week history of severe fatigue, increased swelling in both feet, and slight pain in the right abdomen. She gives a history of shortness of breath on severe exertion. Exam reveals an afebrile patient with pedal edema and hepatomegaly. There are prominent A waves of the jugular venous pulsations (JVP). Auscultation reveals a tricuspid opening snap. A diastolic murmur is heard over the left sternal border, which increases on inspiration. A widely split S1 is also heard. Diagnostic testing reveals a normal CBC. Right atrial enlargement is seen on the chest X-ray, and the echocardiogram shows thickened tricuspid leaflets with limited mobility, increased velocity rough diastolic flow, and prolonged pressure half-time.

Obstructed venous flow to the right ventricle

A 55-year-old man presents with painless gross hematuria since last evening. Urine cytology and cystoscopy reveal transitional cell carcinoma of the bladder. He has had diabetes and hypertension treated with metformin and atenolol, respectively, for the past 10 years. He has never smoked but consumes alcohol: about 2 pints of beer every day. He worked as a car mechanic at a garage for 30 years. He recently visited several African countries; upon returning, he had diarrhea and was diagnosed and treated for amebiasis.

Occupation

A man has had 4 diagnosed sinus infections in the last 5 months, so you order a CT scan of his sinuses. He does not believe that any of the episodes completely resolved. The patient has a long history of excessive seasonal allergies; he treats them with daily oral OTC anti-histamines and he has repeatedly declined beginning allergy immunotherapy. He also has a history of asthma that is well controlled with daily inhaled corticosteroids.

Opacification

A 14-year-old boy presents for a sports physical. History is significant for a high degree of myopia bilaterally first diagnosed at age 4 and a dislocated shoulder at age 10 that was easily reduced. Family history is significant for several unidentified ancestors having died in their 40s of an unidentified cardiovascular disorder. Physical examination reveals normal vital signs, height of 6'1", and weight 145 lb. The upper to lower segment ratio is 0.65 (decreased). Arm span is 76". The palate is highly arched. Mild pectus excavatum was present. A 2/6 early diastolic murmur is present best heard at the second intercostal space at the right sternal border. Arachnodactyly of the fingers and toes and generalized loose jointedness and pes planus are also present. Echocardiography reveals a tricuspid aortic valve with grade 1 (out of 4) aortic regurgitation with a normal aortic root diameter.

Ophthalmology evaluation

A newly graduated physician assistant is working in a vascular surgery practice. The PA is replacing a practitioner with 10 years of experience. The collaborating physician asks the PA to place a central line. The PA has done this once before, but the doctor states their previous PA did it all the time. The PA is uncomfortable doing this procedure.

PA's experience

You are working in an adolescent health clinic. Protocols have been established to screen certain teenage patients for hepatitis B immune status with blood tests.

Patient B

A 10-year-old girl presents with her mother and reports "really bad dandruff that itches like crazy." The child states that all of her friends at school have it too. Upon physical examination of the hair and scalp, you note numerous oval grayish-white sesame seed capsules 1-2 mm in size deposited on the hair shaft near the scalp. Small red bumps and sores on the scalp appear to be due to the patient scratching.

Pediculosis

A 24-year-old woman presents with a 12-hour history of lower abdominal pain, nausea, and vomiting. She rates the pain at a 4 last night when it initially began, but she currently puts it at a 9; she states that the pain seems to be worsening with each passing hour. She states she had her menses 1 week prior, noting an irregular flow and excessive vaginal discharge since it ceased. She is single and admits to not being monogamous; she only occasionally uses barrier contraception during sexual encounters. She takes a daily oral contraceptive pill.

Pelvic inflammatory disease

An 18-year-old college student presents with a bright red rash on her left cheek area that has worsened since yesterday when it first appeared. It is now becoming more tender and she developed a temperature elevation of 100.2°F taken at home. She denies any new soaps or facial creams and wears occasional make-up. She denies any ill contacts. Vital signs are blood pressure of 110/72 mmHg, heart rate 86 bpm regular, respirations 18/min, and temperature of 100.4 °F. Your most likely diagnosis is erysipelas. She denies any medication allergies.

Penicillin VK 250 mg 4 times daily for 7 days

A 68-year-old man with a past medical history of congestive heart failure, hypertension, and hyperlipidemia has been admitted to the hospital for the evaluation of anemia due to a chronic gastrointestinal bleed. He takes oral enalapril and furosemide for CHF. While hospitalized, he developed polydipsia, dizziness, and decreased urine output; he notes that his urine is concentrated. His physical exam reveals orthostatic hypotension, poor skin turgor, dry mucous membranes, tachycardia, and peripheral edema. His bloodwork was remarkable for a hemoglobin of 7.0, hematocrit of 30, and serum sodium of 149. His BUN to creatinine ratio was 42 to 1, while the fractional excretion of sodium (FENa) was <1% and fractional excretion of urea (FEUrea) <35%.

Perform a red blood cell transfusion.

A 19-year-old man is brought into the ED following a motor vehicle crash in which he, the driver, sustained blunt trauma to the anterior trunk from striking the steering wheel and dashboard. The patient is alert, short of breath, hypotensive, and complains of acute chest pain. On auscultation, muffled heart sounds are heard.

Pericardial tamponade

A 17-year-old boy was in your clinic 4 days ago for evaluation of a 101.8°F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat is now worse. He has not been able to drink fluids and he has excruciatingly severe pain with swallowing. You recognize the muffled "hot potato" voice. On re-examination, you identify a right medial deviation of the soft palate with a 4+ right tonsillar swelling.

Peritonsillar abscess

A 19-year-old man without significant past medical history presents to the ED with a 2 cm laceration on his right calf with several small flecks of organic material within the wound. The patient is a hospital volunteer who reports that he obtained this injury while accompanying a hospitalized patient on a walk through the hospital gardens. He is unsure of his specific vaccination record, but he has received all required childhood vaccinations and recently received Tdap (booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis) vaccination required for college admission.

Provide wound care alone.

An 18-year-old female college student presents with a 2-day history of severe left ear pain. In the last 5 hours, the pain has become intolerable. Initially, the ear had an intense period of itchiness. Her history is significant for being a member of the college swim team. An examination of the ear canal is remarkable for the presence of edema and redness. A culture swab of the ear canal is performed. The patient is discharged with a course of treatment consisting of polymyxin with a steroid in an acid vehicle, and she is told to return if the symptoms do not subside within the next day. The next day, the microbiology laboratory isolates a gram-negative bacillus; it is oxidase positive and citrate positive. It does not ferment carbohydrates, and it produces a blue-green pigment.

Pseudomonas aeruginosa

A 67-year-old man presents with severe flank pain, fever, postural dizziness, dysuria, inability to pass urine for 1 day, and mild confusion. He has experienced two episodes of urine retention and incontinence over the previous 2 months, the most recent of which required urethral catheterization and outpatient antibiotic treatment for E. coli. His past medical history is significant for hypertension, prostatic hypertrophy, non-insulin dependent diabetes mellitus, and cognitive impairment that requires minimal assistance in activities of daily living. His temperature is 102.02°F (38.9°C); BP 80/50 mm Hg; pulse rate 114/minute; respiratory rate 43 breaths/minute. Physical examination reveals a tender distended bladder that drained 2700 mL of turbid urine.

Quantitative cultures of urine

A 23-year-old woman presents with fatigue and the recent onset of a yellowing of her skin. Her physical examination is remarkable for the presence of splenomegaly.

RBC membrane

Parents bring their 4-year-old daughter in because of knock-knee. She is otherwise healthy, and her height is in the 50th percentile for age. On examination, she has about 10 degrees of valgus.

Reassurance that this is normal for age

A 45-year-old woman presents with diarrhea and vomiting that started last evening. She says she warmed up leftover rice for supper last night and symptoms began shortly thereafter. She has no fever, and her blood pressure and pulse are within normal limits.

Reassure and send home with oral rehydration

A 16-year-old boy with no significant past medical history presents to learn the results of a lipid panel that was performed. The lipid panel was ordered due to periorbital and extensor tendon xanthomas on the patient's body. The patient consumes a low-fat and low-calorie diet, and he exercises daily. He denies any bothersome symptoms, and his physical exam is otherwise unremarkable.

Reduction in the amount of LDL receptors on hepatocytes

A 73-year-old man presents with the inability to actively raise his left non-dominant arm to retrieve plates from the kitchen cabinet. He further describes the inability to retrieve any objects with his left hand/arm because of the limited range of motion. He is worried because he is the only driver in his household, and he does not want to lose his driving privileges. He has a longstanding history of chronic shoulder impingement syndrome. On exam, he is found to have a (+) positive drop arm test.

Refer for physical therapy

A 16-year-old slightly overweight girl presents because she wants to lose weight. She read online that drugs for ADD can help with weight loss. She is unsure of the name of the drug she read about but wonders if she can use them as diet pills instead. Since she was told that drugs like meth have similar properties, she also wants to know if these are safe to take for weight loss. She is told to avoid them because they can become habit-forming and their effectiveness is short-lived.

Releases dopamine and norepinephrine stores

A male postsurgical patient in the hospital reports an acute increase in the amount and frequency of bowel movements. Patient reports 3-4 loose stools each day for the past 2 days and diffuse abdominal discomfort. Upon review of his medical record, you discover he received perioperative antibiotics and a recent 7-day course of antibiotics 2 weeks ago prescribed for a skin infection. His medical history is significant for gastroesophageal reflux disease controlled with omeprazole 20 mg daily. You order stool toxin testing for Clostridium difficile (C. diff.), which quickly returns positive. Soon after, you start appropriate antibiotic treatment and place the patient in a private room.

Remove gloves and wash hands after patient contact.

A 65-year-old man underwent an emergency laparoscopic cholecystectomy and arrives at the medical unit postoperatively with a Foley catheter. He is in stable condition, and his vital signs are stable. He is tolerating a regular diet, but his urine output is low, and he is admitted for monitoring. He has a foley catheter at this time to monitor urine output.

Remove the catheter and monitor urine output by other means.

An 18-month-old boy presents with a 2-day history of runny nose, slight cough, and low-grade fever. Over the last 24 hours, however, his condition has worsened; the child is tachypneic on exam. He is wheezing, and his breaths are associated with nasal flaring and chest retraction.

Respiratory syncytial virus

A 39-year-old man presents with a 1-week history of severe chest pain. He states that the pain seems to worsen when he lies down. He describes the pain as radiating to the back and worsening when he takes a deep breath. His vital signs are as follows: blood pressure 124/84 mm Hg, respiratory rate 18/min, temperature 101°F, and pulse 74 beats per minute. On auscultation of the chest, you cannot distinguish an S1 or S2 but hear a scratching or grating sound.

Rest and NSAIDs

A 2-week-old female infant is seen for her newborn well-baby exam after a normal birth and delivery. She has been nursing well, has regained her birth weight and her development appears normal for her age. Physical examination is normal with the exception that ophthalmoscopic evaluation reveals a faint white reflex in her right eye.

Retinoblastoma

The Nevada Test Site 65 miles northwest of Las Vegas was the site of 928 nuclear tests conducted by the US government between 1951 and 1992. These included 100 atmospheric tests and 828 underground tests. A spike in cancer rates was subsequently noted in a group of Mormon families (4125 people) residing in southwest Utah near the Nevada Test Site. A study comparing cancer rates in this group with those of all Utah Mormons was published in the Journal of the American Medical Association in January 1984.

Retrospective cohort study

A 35-year-old homeless man presents as a new patient. He received immunizations as a child and adolescent, but he has not received medical care for the last 10 years since becoming homeless. He is unemployed and spends the majority of his time among other individuals in community living shelters. In addition to obtaining a thorough history and physical examination and appropriate laboratory testing, you decide to update his immunizations.

Rotavirus

As part of a routine checkup, a 40-year-old man is evaluated by his family practitioner. He smokes 1/2 a pack of cigarettes a day, and he has an occasional glass of wine. For the past 5 years, he has been on SSRIs for mild depression. On general physical examination, his BP is 110/70, and his BMI is 25. The physician notes slight enlargement of his thyroid gland with a solitary left upper lobe nodule. Careful examination reveals cervical lymphadenopathy. An FNAC of the nodule shows large amounts of amyloid stroma and disorganized spindle-shaped cells with large vesicular nuclei.

Serum calcitonin levels

An 11-month-old African American boy presents with an acute onset of anorexia, irritability, unexplained bruising, and jaundice. On examination, you note pale conjunctivae, icteric sclerae, and splenomegaly. Laboratory studies reveal decreased hemoglobin and hematocrit and a significantly elevated reticulocyte count. Hemoglobin electrophoresis reveals the presence of hemoglobin S.

Sickle cell disease

You have recently been invited to serve on a hospital committee taskforce. The mission of this task force is to make cost-effective recommendations regarding system-wide initiatives to mitigate risk in the hospital. Potential risks to the hospital are ubiquitous and include:

Staff training in handoffs

A 75-year-old man is recovering from a pneumonia caused by Streptococcus pneumoniae; his condition suddenly deteriorates. He presents after developing a persistent fever, chills, cough, and diaphoresis. A CBC reveals leukocytosis with a left-shift. A chest X-ray demonstrates an air-fluid level in the pleural space, which is suggestive of an abscess.

Staphylococcus aureus

A 16-year-old girl is brought to the emergency room for evaluation of continuous seizures. The patient was first diagnosed with idiopathic epilepsy at age 10. She was started on valproic acid. Phenobarbital and carbamazepine (Tegretol) have been tried without success, and the phenobarbital resulted in transient severe personality changes. Two previous EEGs have been normal. This spell occurred abruptly at the dinner table without apparent warning. Past medical history has been normal. She saw her primary physician for nausea and vomiting 2 days ago. The physician believed she had the flu and started her on prochlorperazine, which relieved her nausea. Physical exam reveals a well-developed well-nourished young woman lying on a gurney; there is continuous but variable motor jerking of all four extremities. The jerking varies in intensity from side to side. The head intermittently turns from side to side. Eyes are closed tightly and cannot be passively opened. Deep tendon reflexes cannot be assessed. The response to plantar stimulation is withdrawal bilaterally. There are no signs of trauma to the head or elsewhere. Skin is warm and dry with normal color, and vitals are normal. The general medical exam is otherwise normal. Labs are done stat, and they include normal complete blood count and differential, normal chest X-ray, normal urinalysis on cath specimen, normal chemistry profile, and normal arterial blood gasses.

Stat electroencephalogram (EEG)

A 55-year-old man presents for a follow-up from a recent hospitalization. He had two coronary stents placed 3 days ago after presenting to the emergency department with chest pain and a 40 pack-year smoking history. He quit smoking 2 years ago. He was not on any medications when he presented to the ER. Lipid panel revealed total cholesterol 200 mg/dL, LDL cholesterol 100 mg/dL, HDL cholesterol 40 mg/DL, triglycerides 395 mg/dL.

Statin

A 22-year-old woman presents for evaluation of knee pain. The patient appears in moderate distress and is unable to fully bear weight as she moves to the exam table. Her physical exam reveals a swollen and tender left knee. She is tender at the lateral femoral condyle, lateral tibial plateau, and tibiofemoral joint line. Lachman and anterior drawer tests are positive. Posterior drawer, Apley grind, patellar grind, and McMurray tests are negative. There are no sag or apprehension signs. Valgus and varus stress tests are normal. An X-ray shows no fractures.

Sudden landing playing basketball

A consulting physician asks for a follow-up on a 35-year-old woman being treated for an acute migraine headache. Upon interview, she states that the physician gave her an injection about 20 minutes ago; she now has significant chest pain.

Sumatriptan

A 62-year-old man presents for evaluation of facial swelling that feels worse with bending forward. He states he has also experienced headaches, shortness of breath, and visual problems over the past few weeks. He admits that he has a 70 pack-year smoking history. Upon examination, you note swelling of the face and distention of neck and chest veins. You appreciate diminished breath sounds and tactile fremitus in the right upper lobe.

Superior vena cava obstruction

A 68-year-old man with a past medical history of hypertension, hyperlipidemia, cluster headaches, polymyalgia rheumatica, and type 2 diabetes mellitus presents due to a 2-day history of constant left-sided throbbing headache of moderate severity. He admits to associated symptoms, such as pain across his mandible when he eats, fever, fatigue, and muscle aches. Most alarming to the patient was a single episode of complete left eye blindness that lasted for 30 minutes but has since resolved. He denies extremity numbness, tingling, muscle weakness, incontinence, and changes in mental status. He further denies rhinorrhea, ocular discharge, nausea, and vomiting. The physical exam was remarkable only for a tender left scalp with a noticeable pulsation underlying the tender area.

Temporal arteritis

You are a PA employed on the evening shift by a 20-physician hospitalist practice in a 900-bed facility. You are responsible for admission H&P and initial orders on newly admitted patients, urgent consults, and phone calls from the various nursing floors regarding existing patients. You work until midnight every night, but your supervising physician typically departs from the hospital around 8 PM, remaining available by cell phone or pager. After the supervising physician departs, you are the practice's sole provider in the facility. At 11:30 PM one evening, you receive a phone call from a nurse regarding an inpatient who has begun vomiting up blood. The patient was admitted 2 days ago for pericarditis and has been treated with ibuprofen 600 mg every 8 hours and colchicine 0.5 mg every 12 hours. He has also been on apixaban (Eliquis) 5 mg b.i.d. for prevention of thromboembolism due to long-standing persistent atrial fibrillation. You order a stat GI consult. The GI consultant arrives 15 minutes later and makes arrangements for endoscopy at 6 AM the following morning. You depart the hospital at the end of your shift. The next morning, you learn that the patient expired prior to the endoscopy and that pre-endoscopy labwork obtained at 2 AM revealed a Hgb of 4.2. 4 months later, you learn that the patient's surviving spouse has filed a malpractice case that names the PA, the supervising physician, the attending physician, the gastroenterologist, and the hospital.

The PA was inadequately supervised.

A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 30 minutes ago. He notes seeing halos with his left eye. He is also experiencing nausea and vomiting. These symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His temperature is 36.9°C, pulse 90/min, BP 130/90 mm Hg, and respirations 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection.

Tonometry

A physician assistant is discharging a patient from the hospital when the electronic medical record system goes offline. The PA must resort to issuing handwritten prescriptions to this patient. What handwritten abbreviation has the highest risk of causing a medical error?

U (unit)

A 37-year-old man with an unremarkable past medical history presents during a cold winter day with a 10-day history of acute onset of productive cough with a moderate amount of yellow sputum. There is associated fever, shortness of breath, and malaise. He denies recent travel, sick contacts, occupational exposure, and a history of smoking or alcohol use. He denies arthralgias, chills, wheezing, abdominal pain, nausea, vomiting, diarrhea, edema, or rashes. His physical exam is remarkable for fever, tachypnea, reduced fremitus, dullness to percussion, and basilar crackles in the right lower lung field.

Unilateral sharp inspiratory chest pain and thoracic friction rub

A 69-year-old woman presents with a 3-month history of intermittent urinary incontinence. After further questioning, she reveals that she experiences leakage after having an intense need to void.

Urge

A 62-year-old man presents with persistent hematuria. He denies any dysuria, urgency, or frequency. The first episode of hematuria was discovered 4 months ago on a routine urinalysis for a workplace physical. A repeat urinalysis 6 weeks later again shows hematuria, confirmed by microscopic evaluation. The remainder of his urinalysis is within normal limits. His past medical history is remarkable for COPD and obesity. He has smoked 1.5 ppd x 45 years. He uses inhaled medications for his COPD and has NKDA. His physical exam is significant for a temperature of 100.5°F. Abdominal exam elicits mild tenderness in the left upper quadrant, but no masses are palpable (although his exam is limited by his obesity). Chest and abdominal CTs with contrast show a normal chest and a left renal mass enhanced by radiocontrast, suggestive of renal cell carcinoma (RCC). No metastatic disease was noted on imaging. A renal biopsy is pending.

Urologist for radical nephrectomy

A 25-year-old man from China presents with a 1-month history of an inability to see well while walking home from work at night. He also reports that he has been getting sore throats more frequently. He is a recent immigrant from his home country; he lives alone and eats mainly a rice-based diet. On examination, you note pericorneal and corneal opacities.

Vitamin A deficiency

A 50-year-old obese woman presents with severe left knee pain. She states the pain began about 8 months ago but has grown significantly worse in the last 3 months. The patient denies any trauma or event that initiated the pain. She notes stiffness in the knee first thing in the morning that lasts around 5-10 minutes. The knee pain is worsened with activity and is relieved with rest. The patient's medication list includes lisinopril 10 mg once daily for high blood pressure. She has a documented medication allergy to acetaminophen; she states this makes her break out in hives. Physical examination findings reveal a Caucasian female with a BMI of 40. There is limited range of motion of the left knee and severe crepitus.

Weight loss

A 62-year-old woman presents due to urine leakage for 2 years that has worsened. She leaks urine when she coughs or sneezes; she wears a pad daily as a result. The amount of leakage varies. The patient denies hematuria, dysuria, and pelvic pain. She sometimes feels vaginal pressure and fullness. She is considering quitting her job from embarrassment. Past medical history includes 4 vaginal deliveries. No other known medical conditions, medications, or allergies. She is married and works part-time at a call center; she denies tobacco, alcohol, and recreational drugs. On physical exam, she is obese, with an atrophic vulva/vagina. Pelvic examination reveals downward and forward rotation of the vaginal wall, with an anterior bulging when the patient is asked to strain. A dipstick urinalysis is normal.

Weight loss

A young couple presents for advice about infertility. They have been married for 4 years and have never used contraceptive methods. They are both 27 years old, and the wife has an 8-year-old daughter from a previous relationship. Both are very eager to have a child; the husband is somewhat anxious about the results of 2 semen analyses that show azoospermia. He states that when he was 14 years old he was evaluated for delayed pubertal development; at that time, he had a chromosomal analysis that revealed that the problem is genetic. He was prescribed testosterone, which he used for only a few months. He is 6'8'' tall and has unusually long legs. His facial skin is smooth; there is no beard. There is palpable breast tissue bilaterally. His right fifth finger is curved towards the fourth finger. His pubic hair is substantially decreased for his age, and both testes are small (approximately 5 cm) and firm in consistency.

47,XXY

A 31-year-old HIV-positive woman presents for ongoing care. She was diagnosed with HIV 2 years ago, and she began antiretroviral therapy. Her CD4 T cell count is 400 cells/mL, and she has a history of oral candidiasis. As part of her evaluation, a tuberculin skin test (TST) is performed using 5 TU of purified protein derivative (PPD). The test site is examined 48 hours later and the skin reaction is measured.

5 mm

A 17-year-old boy presents with a 5-day history of intermittent fever, joint pain, and redness and swelling of the joints. The patient gives a history of pain in the right knee and ankle. 3 days ago, he had pain and swelling in his left knee, but now it has improved. On examination, temperature is 102°F, pulse is 108/min, RR is 20/min, and BP is 110/80 mm Hg. The patient's right knee is swollen, tender, and warm. There is a limitation of range of motion due to pain. The right ankle appears swollen and warm. Other system exams are normal. Lab tests are ordered; during the follow-up exam, you note elevated erythrocyte sedimentation rate (ESR) and rising ASO titers.

5 years

A 45-year-old Caucasian woman presents because she is worried she may have skin cancer. While interviewing the patient, you note the patient has an extremely fair complexion. When you examine the lesions that the patient is concerned about, you note the following description in your documentation: "5 papules that vary in diameter from 0.3-0.6 centimeters dispersed on the skin around the sternal angle. Lesions vary in color from flesh-toned to slightly hyperpigmented, and when palpated have a sandpaper texture."

5-fluorouracil cream

A 60-year-old woman presents with a history of persistent cough. She is confined to her bed; walking over 10 paces causes severe breathlessness. She has no energy to carry out any regular activities. She has never smoked, and she drinks an occasional glass of wine. On physical examination, she is found to have decreased breath sounds and dullness to percussion over her right lower thorax. Further evaluation reveals an irregular mass in the periphery of the right lung base with a right-sided pleural effusion. A needle is inserted into the pleural space and divulges bloodstained fluid.

Adenocarcinoma

A 60-year-old woman is awaiting surgery for an anterior pituitary tumor diagnosed several months ago. She has no other medical problems. Preoperatively, she is given no diuretics or contrast dye; her fasting blood glucose is 80 mg/dL. Urinalysis at that time indicates no glucose, cells, nitrate, blood, leukocyte esterase, or casts; the patient has ready access to fluids, but she is not aggressively hydrated intravenously.

Central diabetes insipidus

A long-standing patient of yours is experiencing acutely worsening symptoms and signs of dilated cardiomyopathy. Symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, and clubbing. Physical exam is significant for an S3 gallop and jugular venous distention. Daily medications include a β-blocker, adult dose aspirin, and an ACE inhibitor.

Initiation of a diuretic

A 45-year-old man presents with extreme asthenia and weight loss. He has been suffering from celiac disease for the past 12 years. He is at the highest risk of developing what type of intestinal malignancy?

Intestinal lymphoma

A 32-year-old woman presents several hours after a grand mal seizure. Her husband states that she experienced headache, nausea, vomiting, fever, and "was not herself" a few days before the seizure. She is on glucocorticoid therapy due to a kidney transplant 1 year ago. On examination, you find a lethargic febrile (39°C) dysphasic patient; there is right-sided hemiparesis, and meningeal signs are present, but detailed examination cannot be performed because of lack of cooperation. EEG shows focal abnormalities over temporal lobes, and her CT is normal. A lumbar puncture is performed. Based on your suspected diagnosis, you initiate supportive care, anticonvulsants, and acyclovir. The patient improves over the following days.

Normal CSF: serum glucose ratio

A 49-year-old woman presents for a consultation 1 month after her 22-year-old son was killed in a fall at a construction site near her home. The patient is upset, restless, and reports feeling lonely. She lies awake at night. She does not feel like eating. She cries easily when she looks at their family pictures around the house. She wishes she could talk to him again, and she reports she sometimes thinks she sees him walking just outside their home. She says she wishes she would have died instead of him, but she denies any thoughts or plan of harming herself.

Normal grief reaction

A 34-year-old woman presents Monday morning with knee pain. She states that she was playing with her two children in their backyard over the weekend and fell onto solid ground, landing directly on her knees. She noted immediate and significant right knee pain. She notes significant swelling; it accompanies the knee pain, which she rates as an 8/10 on a numerical pain scale. Physical examination reveals significant obvious joint effusion and exquisite focal tenderness to palpation over the patellar area of the right knee; the left knee has no obvious abnormalities. Results of the anterior drawer, McMurray, and varus/valgus stress testing are within normal limits.

Patellar fracture

An 89-year-old man presents with pneumonia. You suspect lung cancer, which would require surgery and possibly chemotherapy. Upon hearing the news regarding his diagnosis, the patient becomes tearful and sad; he confides his thoughts of suicide. You notice the patient seems confused at times, not knowing the place and people who surround him. When the patient is asked to sign the informed consent for a scheduled thoracotomy, he vehemently refuses any and all treatments for his condition, stating that he is going to die anyway.

Principle of autonomy

A 33-year-old man with no past medical history presents with groin mass. He denies pain and trauma to the region. When the patient stands, there is a round swelling in the inguinal area. If the patient is supine, the mass disappears.

Referral to general surgeon

A 15-year-old boy presents for follow-up of previously diagnosed Asperger syndrome, now autism spectrum disorder. The patient is accompanied by his mother. He is considered high functioning. He attends public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions. The mother states she has noted a significant increase in the patient's anxiety symptoms that have become detrimentally disruptive to daily activities.

Sertraline

A 62-year-old man presents with shortness of breath, some chest discomfort, and palpitations. Upon examination, his pulse rate is 200/min; blood pressure is 100/75 mm Hg, and he has an oral temperature of 98.7°F. A 12-lead ECG examination reveals the wave patterns in the figure below (Refer to the image). He has a history of chronic bronchitis. He has been taking drugs to control his condition since he quit smoking 6 months ago.

Theophylline

A 65-year-old woman presents with bloating, early satiety, changes in her bowel habits, and an unintentional 10 lb weight gain over 3 months. Upon further questioning, you discover that she never had children and her sister passed away 20 years ago from some sort of cancer in her belly. On her physical exam, an adnexal mass is felt.

Transvaginal ultrasound

A 6-year-old boy presents with his mother, who is concerned because he wets his bed 2-3 times a week at night. He has no urinary symptoms during the day. He is the second child of three. He is in the first grade and is struggling with performance. He has had no medical problems; there is no history of developmental delay, and he was the product of a normal uncomplicated pregnancy and delivery. Since the birth of the third child, his behavior has been poor. The vital signs are normal, and examination of other body systems is unremarkable.

Urinalysis

An 8-month-old female infant presents with a 2-day history of increasing irritability and decreased appetite. She has also had some diarrhea and low-grade fever. On exam, she is afebrile, fussy, and hard to console, but she appears alert and active. She lies with her hips and knees flexed, crying harder with any movement. A few petechiae are noted on her skin. Leg X-rays are done to look for a possible fracture that shows a pencil-thin cortex and a ground glass appearance of the bones. Further history reveals that she has been given evaporated milk since birth to save money, and she has not yet been started on solids.

Vitamin C

A physician assistant is triaging patients in California following a severe earthquake. The patient currently being evaluated by the PA has an open femur fracture without major hemorrhage.

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