FM EOR Pt Presentation

Patient will present as → a 43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings (seen here) demonstrate peripheral "pruning" of the large pulmonary arteries

**Peripheral "pruning" of the large pulmonary arteries is characteristic of pulmonary hypertension in severe emphysema

Patient will present with → rectal bleeding, cramps and abdominal pain. Obstruction may occur with a large lesion

Colonic polyps

Patient presents → as a smoker with hemoptysis and an abnormal chest X-Ray showing a large central solitary tumor.

Squamous cell carcinoma lung

Patient will present as → a 75-year-old with a foreign body sensation and tearing of his right eye. On physical exam you note a red, irritated, right eye in association with an inverted eyelid.

Entropion

70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.

Hypoglycemia

Patient will present as → a 19-year-old female who has lost 40 pounds over the last 6 months. Her body mass index is 16. When asked about her most recent meal, the patient reports that she ate an apple the previous morning.

Anorexia nervosa

Patient will present as → a 40-year-old married promiscuous male patient who admits to having recent intercourse with a male prostitute during a recent trip to Las Vegas. On physical exam you note several raised, cauliflower-like lesions in clusters on the shaft of his penis. He is very concerend stating that his wife will probably divorce him if she finds out.

Condyloma accuminata

52-year-old male who reports that he has been feeling very tired lately and his wife thinks that he looks pale. You orders a complete blood count, which shows: Hgb 8.5 g/dL (normal 13.5-17.5); WBC 1,200/microliter (normal 4,500 - 11,000); platelets 70,000/microliter (normal 150,000 - 400,000). The patient is referred for bone marrow biopsy, which shows myeloblasts with Auer rods.

AML

Patient presents → as a non-smoker, with an incidental finding, with a small peripheral lesion; A 72-year-old man presents complaining of a cough, chest pain, and shortness of breath for the past couple of weeks. He was not concerned enough to seek care until he started noticing bright red blood in his sputum the past couple of days. His weight is down from the last visit.

Adenocarcinoma lung cancer

Patient will present as → a 65-year-old woman with palpitations. Her past medical history is notable for COPD for which she has been hospitalized once in the last year. On exam her T 98.4F, HR 86, BP 105/70, RR 18, SpO2 94% on room air consistent with her baseline. The ECG demonstrates low-amplitude fibrillatory waves without discrete P waves and an irregularly irregular pattern of narrow QRS complexes.

Afib

Patient will present as → a 61-year-old male presents with a recent history of increased fatigue with mildly increased exertional dyspnea. Patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear an early diastolic, soft blowing decrescendo murmur with a high pitch quality, especially when the patient is sitting and leaning forward. No thrill is felt.

AR

Patient will present as → a patient brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally and frothy pink sputum. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there is no cardiomegaly or pleural effusion noted. Oxygen saturation is 70% A 36-year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops rapid onset of profound dyspnea. Initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. Follow-up chest xray shows confluent bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient?

ARDS

Patient will present as → a 29-year-old at 36 weeks gestation who arrives at the emergency department with a sudden onset of back pain with uterine contractions that are very close together, one after another. She describes PAINFUL, bright red vaginal bleeding. There is pelvic tenderness on examination which reveals a closed cervix and no evidence of rupture of the membranes.

Abruptio placentae heavy painful vaginal bleeding in the 3rd trimester

Patient will present as → a 13-year-old obese male who is being seen for his routine physical. His skin examination reveals velvety, hyperpigmented, papillomatous lesions of the neck and axillae. The remainder of the examination is unremarkable. The patient has a strong family history of diabetes. Laboratory analysis reveals a Hgb A1C - 5.9 (high), Insulin level - 18 (normal); lipids, CMP, T4, TSH, and cortisol are all normal.

Acanthosis Nigrans

Patient with neonatal acne will present as → a 2-week-old male with comedones (blackheads) and, papules, pustules, nodules, and cysts on the face, neck, upper chest and back. Patient will present as → a 14-year-old boy with dozens of erythematous papules, pustules, and cysts. On closer exam, he also has atrophic scars on the lateral forehead, consistent with permanent scarring from previous acne lesions. He is started on topical retinoids and topical benzoyl peroxide. You suggest that he also consider a systemic retinoid if this topical therapy does not work.

Acne

Patient will present as → a 69-year-old man with male-patterned baldness is concerned because the skin on his scalp is no longer smooth. He describes it as feeling rough, like "sandpaper." While he is now retired, he was a gardener and often spent hours working under the sun. Physical exam reveals discrete yellow-brown, scaly patches on sun-exposed areas of the face, scalp, ears, forearms, and the dorsum of the hands.

Actinic keratosis

Patient will present as → a 37-year-old male complaining of rapid onset of severe mid-epigastric pain with radiation to the back after eating a large meal. The pain typically lessens when the patient leans forward or lies in the fetal position. Physical exam shows low-grade fever, epigastric tenderness, diminished bowel sounds, and bruising of the flanks. Abdominal CT scan (seen here) shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity

Acute Pancreatitis Chronic: fat malabsorption & steatorrhea: triad of pancreatic calcification, steatorrhea, and DM

Patient will present as → a 7-year-old boy is brought to his pediatrician for evaluation of a sore throat. The sore throat began 4 days ago and has progressively worsened. Associated symptoms include subjective fever, pain with swallowing, and fatigue. The patient denies cough or rhinorrhea. Vital signs are as follows: T 101.4 F, HR 88, BP 115/67, RR 14, and SpO2 99%. Physical examination is significant for purulent tonsillar exudate; no cervical lymphadenopathy is noted.

Acute pharyngitis Centor criteria: 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy Not suggestive of strep - coryza, hoarseness, and cough

Patient will present as → a 69-year-old female who presents to the emergency department with sudden, severe onset epigastric pain that began while she was watching television. On physical exam is an unkempt female with pain upon palpation of the epigastric region. Labs are drawn and the patient has an elevated amylase and lipase. The patient is made NPO, an NG tube is placed, and the patient is given IV fluids. The patient is noted to be experiencing hallucinations. On her second hospital day, the patient has a seizure.

Alcohol-related disorders

Patient will present as → a 4-year-old female with spots of hair loss that has been progressively worsening. According to the patient's mom, her daughter lost all the hair on her head, including eyelashes and eyebrows, 2 years ago. Her hair grew back and now new spots of hair loss are appearing.

Alopecia

Patient will present as → a 70-year-old gentleman is brought to his primary care provider by his son. He states that it seems like he has struggled more and more with every day living. Initially, he forgot simple things such as dates and addresses, but this has progressed over the last few years to an inability to pay his own bills. He has even gotten lost coming home from the library which is two block away from his house 84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with difficulty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.

Alzheimer's 4 A's: Amnesia, Apraxia, Aphasia, and Agnosia

Patient will present as → a 25-year-old male is brought into the ED by his own volition as he has been unable to sleep for the past 5 nights and is concerned. He says he feels as if he doesn't need to sleep but came in at the request of his friend. He has been studying all night for finals and says he has been, "in the zone," and been unable to stay up all night with no need for sleep.

Amphetamines: methamphetamine, dextroamphetamine (Dexedrine), methylphenidate (Concerta).

Patient will present as → a 45-year-old man with severe rectal pain when he defecates, lasts for several hours and subsides until the next bowel movement. He has been constipated for the past 6 months and when he does have a bowel movement the stool is covered with bright red blood. A sentinel pile is noted on physical exam.

Anal fissure

Patient will present as → a 62-year-old male with a history of chronic kidney disease complains of weight loss, fatigue, and weakness. Iron studies reveal decreased serum iron, increased ferritin, and decreased TIBC. Peripheral blood smear shows normochromic RBCs.

Anemia of Chronic Disease

Patient will present as → a 35-year-old female with a complaint of worry which she cannot control for the last year. She tells you that her symptoms daily consisting of sleep disturbances, difficulty concentrating, and irritability. She reports her symptoms started around age 17 but have worsened.

Anxiety disorders

Patient will present as → a 73-year-old female with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe, tearing, knife-like back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 98.6 F, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97% on room air. An abdominal CT with contrast is obtained and is

Aortic Dissection

Patient will present as → a 22-year-old complaining of a painful sore for 2 days. He denies any alcohol or tobacco use and otherwise feels fine. The examination is significant for a 2-mm round ulceration with a yellow-gray center surrounded by a red halo on the left buccal mucosa

Aphthous ulcers

Patient will present as → a 25-year-old male recently started on phenytoin for seizure disorder is complaining of a low-grade fever, fatigue, and weakness. Physical exam reveals a temperature of 99.2°F, purpura, pallor, and gingival bleeding. There is no hepatosplenomegaly. His blood tests show WBC 1100/μL, platelets 35,000/μL, Hb of 4.0 g/dL; MCV 90 fl; and 1% reticulocyte count. A bone marrow biopsy is obtained, showing hypocellularity and increased adipose tissue.

Aplastic Anemia

Patient will present as → a 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient's mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leucocytosis with a shift to the left.

Appendicitis

Patient will present as → a 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes.

Asthma

Patient will present as → a 45-year-old female with post coital bleeding and painful intercourse. On exam, you notice a friable, bleeding cervical lesion. The cytological evaluation shows a high-grade squamous intraepithelial lesion (HSIL/CIN2/3). She is referred for colposcopy and directed biopsies.

Cervical cancer

Patient will present as → a 70-year-old man with difficulty initiating a stream and post-void dribbling. He also reports having increased urinary urgency, nocturia, and a weak urinary stream. Medical history is significant for hypertension. The patient is not on medication. On digital rectal exam, his prostate is enlarged, non-tender, firm, and smooth. Urinalysis is unremarkable and prostate-specific antigen is elevated.

BPH

Patient will present as → a 71-year-old male who was admitted to the acute care hospital two days following a massive CVA with possible brainstem infarct. Because he was also experiencing secondary respiratory failure, he was intubated and placed on mechanical ventilation. He was subsequently transferred to the neurointensive care unit where he was stabilized. His present vital signs are: respiratory rate 14 (ventilator rate), temperature 100.4 F. His SpO2 is 95%. His rating on the Glasgow Coma Scale is 5. A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday.

Bacterial pneumonia (ventilator)

Patient will present as → a 35-year-old female who arrives at the ED with impaired memory, poor concentration, and extreme drowsiness. Pupils are not dilated on the exam and the patient is minimally responsive. Of greatest concern is the patient's respiratory rate of 5/min.

Barbiturates

Patient will present as → a 45-year-old fair-skinned woman who is concerned about a "pink mole" on her cheek. On physical examination you note a 7 mm pearly papular lesion on the right cheek with surface telangiectasias, rolled border and a central erosion.

Basal cell carcinoma

44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea.

Benign positional vertigo *Positive findings with Dix-Hallpike maneuver; episodic vertigo without hearing loss

Patient will present as → a 45-year-old female with a PMH of anxiety and panic attacks was brought in by her husband for being "unresponsive for about 30 minutes now." He states that the patient had been "popping Xanax" because she was "having one of her episodes of panic attacks." On physical exam, she is hypotensive with a respiratory rate of 4/min.

Benzodiazepines Patient with CNS depression and a history of anxiety or panic disorder

Patient will present as → a 33-year-old man who complains of left anterior shoulder pain for 4 weeks. The pain is made worse with overhead activities. On examination, you note maximal pain in the shoulder with palpation between the greater and lesser tubercle. Pain in the shoulder is exacerbated when the arm is held at the side, elbow flexed to 90 degrees, and the patient is asked to supinate and flex the forearm against your resistance.

Biceps tendonitis

Patient will present as → a 27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient's girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient's vital signs are within normal limits.

Bipolar I Disorder

Patient will present as → a 19-year-old male who has had bouts of sadness for a course of 1 year in which he says that often he cannot even get out of bed so he tells his parents he is ill. Jim states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he did become irritable and others stated that he was louder than usual and wondered if he took something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is not sure how he will pay them off before he goes to school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed which has continued to be a struggle today.

Bipolar II Disorder

Neurologic manifestations - May not see much at bite site: toxic reaction: nausea, vomiting, HA, fever, syncope, and convulsions

Black widow bite

Patient will present as → a 34-year-old female with crusting, scaling, red-rimming of eyelid and eyelash flaking along with dry eyes. The patient has a history of seborrhea and rosacea.

Blepharitis

Patient will present as → a 78-year-old man with a history of hypertension, diabetes, and coronary artery disease presents with a 2-day history of diffuse abdominal pain, nausea, and several episodes of emesis. He has not been able to tolerate any oral intake. His bowel movements have been normal up until the previous day when he had a liquid bowel movement. He has not had any flatus for at least 2 days. On physical exam, his abdomen is distended and tympanitic, he has hyperactive bowel sounds, and diffuse abdominal tenderness without guarding. He has a midline abdominal scar and a right subcostal scar. He has had multiple abdominal surgeries including an open aortic aneurysm repair, a cholecystectomy, and a right hemicolectomy for colon cancer. Laboratory examination is significant for a white blood cell count of 8.2 × 10 3 /μL , hemoglobin 17 g/dL, hematocrit 51 %, sodium 141 mEq/L, potassium 2.9 mEq/L, chloride 93 mmol/L, bicarbonate 31 mEq/L, BUN 30 mg/dL, and creatinine 1.2 mg/dL. Upright abdominal x-ray shows air-fluid levels.

Bowel obstruction

Patient will present as → a 32-year-old lactating female with breast pain, swelling, fever, chills and a fluctuant mass of her left breast. The area directly above the lesion is warm, erythematous and tender to touch.

Breast abscess

Patient will present as → a 66-year-old female with concern over a mass she felt in her left breast on recent breast self-examination. She denies any nipple discharge and reports a negative family history of breast or other cancers. Physical examination confirms the presence of a painless, firm, irregular and immobile lump in the superolateral quadrant of the left breast; there are no evident overlying skin changes and there is no notable axillary lymphadenopathy on palpation. A mammogram is performed with results seen here.

Breast cancer

Patient will present as → a 23-year-old-female with a one week history of cough productive of whitish sputum. This was preceded one week prior by an URI. She denies chills, night sweats, shortness of breath or wheeze. Temperature is 99.9°F (37.7°C). A 63-year-old male, heavy smoker, presents to your office with a low-grade fever and sudden onset of dry cough for the past 6 days.

Bronchitis

Necrotic wound - Local tissue reaction causes local burning at the site for 3-4 hours → blanched area (due to vasoconstriction) → central necrosis erythematous margin around an ischemic center "red halo" → 24-7 hours after hemorrhagic bullae that undergoes Eschar formation → necrosis

Brown recluse bite

Patient will present as → a 14-year-old is female who is brought to your clinic by her mother who claims to hear the child vomiting after dinner in the evenings. The patient reportedly denies vomiting and feels fine. On physical exam, you notice petechial hemorrhages of the soft palate and conjunctiva. Further exam reveals scars on her knuckles, swollen parotid glands, dental erosions. Her weight is normal. Lab tests reveal hypochloremia and hypokalemia.

Bulimia nervosa

Patient will present as → a 75-year-old female who presents to the clinic with a large number of pruritic, tense, subepidermal bullae across her upper thighs. There was no mucosal involvement and skin biopsy showed subepidermal bullae filled with eosinophils and neutrophils

Bullous pemphigoid

Patient will present as → a 21-year-old male complaining of pain on urination and a watery discharge from his penis. Gram stain of the discharge is negative for bacteria but shows many neutrophils. When questioned about his social history, he says that he uses condoms most of the time but occasionally has unprotected sex. The patient responds to treatment with azithromycin.

Chlamydia

49-year-old healthy male complains of no symptoms, but on a routine complete blood count (CBC) has a markedly increased white blood cell count of 40,000 per uL (normal 4500 - 11,000). A peripheral blood smear demonstrates leukocytosis with myeloid cells present at various stages of differentiation, with more mature cells present at a greater percentage than less mature cells. The cytogenetic analysis is positive for the Philadelphia chromosome.

CML

Patient will present as → a 17-year-old male is brought to your office by his parents due to his behavior - increased appetite, lack of motivation, and paranoia. When interviewing the patient, the physician notes a slowed speech and conjunctival injection.

Cannabis-related disorders

Patient will present as → a 58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced

Cholangitis

Patient will present as → a 49-year-old female with a 2-day history of right-upper-quadrant, colicky abdominal pain, as well as nausea and vomiting. Examination shows significant pain with palpation in the right upper quadrant. Laboratory findings include an elevated WBC count, alkaline phosphatase, and bilirubin level.

Cholecystitis

Patient will present as → a 43-year-old woman who comes to the emergency department with a 12-hour history of right upper quadrant (RUQ) abdominal pain. The pain is severe now but waxes and wanes and is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She feels warm but has not checked her temperature. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. The patient has no similar history in the past. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 100 ° F and pulse of 102 beats/ minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals marked upper abdominal tenderness with guarding, especially in the RUQ. On palpation of the RUQ of the abdomen when the patient is asked to take a deep breath, there is a marked increase in pain. The bowel sounds are present but seem slightly sluggish. The patient has no drug allergies and is not taking any medications at present.

Cholelithiasis

Patient will present as → a 33-year-old female with watery, nonbloody diarrhea and abdominal cramps for the past 2 days. She also reports a low-grade fever. She returned from a medical mission trip to South America yesterday. While on the trip she spent time in a remote area and is uncertain of the quality of the water she drank. She also ate shrimp one night for dinner. On examination, the stools are liquid with flecks of mucus. Physical exam reveals sunken eyes, dry mucous membranes and decreased skin turgor. The patient is afebrile. Blood pressure is 90/60 mmHg.

Cholera

Patient will present as→ a 43-year-old male with a "lifelong" history of chronic ear infections and episodic purulent drainage from his right ear canal. The patient currently is without symptoms. Examination of the ear shows a clear external canal, but the tympanic membrane is retracted and there is a pocket of white material and an opacity of the pars flaccida. The Weber test lateralizes to the right and Rinne shows air conduction > bone conduction on the left and bone conduction > air conduction on the right. Preparations are made to undergo a non-contrast computed tomography (CT) scan of the temporal bone.

Cholesteatoma

Patient will present as → a 60-year-old female with shortness of breath of recent onset. She has a six-year history of cough and rhonchi and is on oxygen at home. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9F. Her SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm.

Chronic Bronchitis

Patient will present as → a 65-year-old smoker who has 20 lb weight loss over the last three months that is associated with epigastric pain after eating, diarrhea, and jaundice. PE reveals a palpable non-tender gallbladder and clay-colored stool. Labs show total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150.

Jaundice

Patient will present as → a 63-year-old white male with a chief complaint of blood in his stool. He is accompanied by his wife who also reports weight gain, abdominal distension, and swelling of his legs. Physical exam reveals a healthy-appearing male with 3+ bilateral lower extremity edema and distended abdomen with evidence of shifting dullness. You also note several skin lesions seen here. The patient is hemoccult positive and has blood on his urine dipstick. He denies tobacco and illicit drug use but admits to drinking 1-2 x per week and has about 6 beers on each occasion.

Cirrhosis

Patient will present as → a 45-year-old man comes to your office with a 4-week history of recurrent headaches that wake him up in the middle of the night. The headaches have been occurring every night and have been lasting approximately 1 hour. The headaches are described as a deep burning sensation centered behind the left eye. The headaches are excruciating (he rates them as a 15 on a 10-point scale) and are associated with watery eyes, "a sensation of heat and warmth in my face," nasal discharge, and redness of the left eye.

Cluster HA Multiple attacks of unilateral, excruciating, sharp, searing, or piercing pain. Autonomic symptoms: parasympathetic hyperactivity signs (ipsilateral lacrimation, eye redness, nasal congestion) and sympathetic hypoactivity (ipsilateral ptosis and miosis) Attacks often occur at the same time each day, often awakening patients from sleep Patients often pace, rubbing their heads to try to alleviate the pain Symptoms usually remain on the same side during a single cluster attack Individual attacks last 15-180 minutes if untreated and occur from once every other day to 8 times per day Attacks usually occur in series (cluster periods) lasting for weeks or months separated by remission periods usually lasting months or years. However, about 10-15% of patients have chronic symptoms without remissions male > female (4:1)

Patient will present as → a 21-year-old male is brought into the ED by the police for an altercation. Last night, the patient was at a party and seemed much more active than usual according to his girlfriend. He punched another male at the party in the face claiming that he was hitting on his girlfriend. On exam, you see an agitated young male with dilated pupils, and his pulse is 128/min.

Cocaine Patient with pupillary dilation, aggression, diaphoresis, prolonged wakefulness, and sympathetic activation.

Patient will present as → a 65-year-old male with several months of weight loss, vague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST. A 48-year-old man comes to your office with a vague lower right-sided abdominal fullness (not pain). He describes to you a general feeling of "not feeling well," fatigue, and a somewhat tender area "down near my appendix." He states, "I have no energy. I'm tired all the time." He also suspects that his skin changed color, first to a pale color and then to slightly yellow. On direct questioning, he admits to anorexia, weight loss of 30 pounds in 6 months, nausea most of the time, vomiting twice, some diarrhea that seems to be mucus, and blood in the stool almost every day for the past 3 months. When you ask him what he makes of all of this, he tells you, "Maybe a very bad flu." On examination, the patient looks very pale. Examination of the abdomen reveals abdominal distention. You record the abdominal girth as a baseline. There is a sensation of "fullness" in the right lower quadrant of the abdomen. This area is also dull to percussion and is slightly tender. There is definite percussion of tympani on both sides of the area of dullness. The liver span is approximately 20 cm. The sclerae are yellow.

Colon cancer (1) a middle-aged man with nonspecific feelings of "ill health"; (2) there is a right lower quadrant mass on physical examination, raising suspicion of carcinoma; (3) the liver is enlarged, possibly indicating metastases; (4) the pale appearance suggests anemia; (5) icterus suggests elevated conjugated bilirubin; and (6) the clinically apparent abdominal distention indicates possible ascites. With this constellation of symptoms and signs, the working diagnosis is adenocarcinoma of the colon, possibly the cecum, with liver metastases.

Patient will present as → a 6-year-old boy complaining of itchy eyes. The mother states that she has noted that he has been tearing and that both of his eyes have been red for the past 4 days. The patient denies any pain but has had a runny nose for the past week. The mother states that he has not had any sick contacts, and he has been home from school for summer vacation. On exam, there is marked redness, tearing, and eyelid edema of both eyes.

Conjunctivitis

Patient will present as → a 65-year-old male with chronic low back pain complaining of bloating, abdominal pain, straining and pain with bowel movements. He reports less than 3 bowel movements per week that are very hard and difficult to pass. The patient is on 50 mcg of transdermal Fentanyl and takes four 10 mg Norco per day for breakthrough pain.

Constipation

Patient will present as → a 10-year-old boy who was hit in the right eye with a piece of bark that was thrown on the playground. He developed sudden onset of eye pain, photophobia, tearing, and blurring of vision. He claims there is "something stuck in my eye." On physical examination, there is significant conjunctival injection.

Corneal abrasion

Patient will present as → a 34-year-old contact lens wearer with severe pain, redness, and photophobia. Eyes are injected with cloudy discharge unilaterally. A dense corneal infiltrate is visible with fluorescein staining.

Corneal ulcer

55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.

Creutzfeldt-Jakob disease

present as → a 25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having a "nervous stomach," irritable bowel syndrome, and "depression." Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area.

Crohn's

Patient will present as → a 35-year-old female with diastolic hypertension. Physical exam shows a full, plethoric appearing face, increased facial hair, truncal obesity, and purple striae around the abdomen with scattered ecchymoses over the entire body.

Cushing's syndrome

Patient will present as → a 24-year-old male with c/o episodes of depression alternating with times of increased energy, restlessness, and decreased sleep for 2 years.

Cyclothymic disorder

Patient will present as → a 34-year-old woman with a 3-day history of hematuria, dysuria, increased urinary frequency, and nocturia. She has had no fever, chills, or back pain. On examination, she does not look ill. Her temperature is 37.5 ° C. Her abdomen is nontender. There is no CVA tenderness.

Cystitis

Patient will present as → a 45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn't fully emptied after urinating.

Cystocele "sitting on a ball"

Patient will present as → a young patient with weight loss, increased thirst, and urination. The patient has felt tired and nauseous. On examination her weight is below the 5th percentile, she looks thin, and her skin is pale. her blood pressure is 100/70 and her pulse is 104 bpm. Her respirations are deep at a rate of 28 breaths/minute. Her breath smells fruity

DM Type 1

Patient will present as → a 35-year-old Mexican American male complaining of increased thirst, frequent urination, hunger, fatigue, and blurred vision random finger stick blood glucose is 225,

DM Type 2

Patient will present as → a 12-year-old with severe unilateral right eye pain and pressure. On physical exam there is swelling, redness, tearing and drainage from the outermost part of the affected right eye.

Dacryoadenitis

Patient will present as → a 77-year-old female who for the past 4 days, has been crying easily, confused, and rambling incoherently. Her medical history is remarkable for mild dementia and well-controlled hypertension. She has never had anything like this in the past and she has not had any recent changes to her medications. When questioned, she has no difficulty articulating a sentence but difficulty remembering what she was asked. Laboratory testing is significant for leukocytosis.

Delirium altered perception or level of consciousness is present *along with memory impairment*,

Patient will present with → pruritic dry scaly areas on the flexure surfaces of both hands. The skin is thickened and edematous with papules and plaques as well as erosions and some crusts. The patient states he has had similar lesions since he was a child. Patient will present as → a 22-year-old female complaining of a rash around her mouth. She describes a feeling of mild burning or tension but denies pruritus. Examination reveals papulopustules on erythematous bases; the vermillion border is spared. A culture is negative

Dermatitis

A 58-year-old man presents to your office 4 weeks after being hospitalized for MI. He is complaining of chest pain, fever, and multiple joint pain. Laboratory tests do not show an increase in cardiac enzymes. The most likely diagnosis is

Dressler's Syndrome

Patient will present as → a 17-year-old female wth severe widespread red rash involving mainly the trunk and extremities one day after she took oral cephalexin suspension for a sore throat.

Drug Eruptions

65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.

Drug-induced orthostatic hypotension

Patient will present as → a 62-year-old female with complaints of epigastric pain and belching which improves when she eats food but gets worse a few hours after her meal. She said he has noticed a change in the color of her stool. A 26-year old lady presents at the outpatient clinic with 11 month history of recurrent epigastric pain which is worse when she's hungry. It is temporarily relieved by food and antacids. It is also worse at night. It sometimes awakens her. Pain occurs for a few weeks, then goes and occurs again after several weeks. There is history of chronic NSAID ingestion, nausea and anorexia. Which of the following is the most likely diagnosis?

Duodenal ulcer PUD: recurrent epigastric pain which has three notable characteristics: localization to the epigastrium, relationship to food and episodic occurrence (periodicity). Chronic NSAID ingestion can cause PUD.

Patient will present as → a 35-year-old woman with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses come twice a month but other times will skip two months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse and denies any vaginal discharge. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of STIs. On physical examination, her blood pressure is 120/ 80 mm Hg and her body mass index (BMI) is 32. Her pelvic examination is normal.

Dysfunctional Uterine Bleeding

Patient will present as → a 13-year-old with a pruritic vesicular eruption comprised of clear, deep-seated vesicles without erythema erupting on the lateral aspects of fingers, the central palm, and plantar surfaces.

Dyshydrosis

Patient will present as → a 19-year-old nulligravid college female who complains of dull, throbbing, cramping lower abdominal pain during menses for the past three years. She reports nausea and vomiting during menses but denies irregular or heavy periods, pain with intercourse, or abdominal pain outside of menses. Pain tends to peak 24 h after the onset of menses and subsides after 2 to 3 days. A pelvic exam is normal.

Dysmenorrhea

Patient will present as → a 72-year-old with complaints of dry eyes coupled with excessive tearing. On exam the conjunctiva appear red and the left eyelid is turned outward.

Ectropion

Patient will present as → a 65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation and a small, thin appearing heart. PFTs show a decreased FEV1 / FVC ratio.

Emphysema

Patient will present as → a 45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and is shown here. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin. Stroke + Fever A 38-year-old female with history of coarctation of the aorta repair at the age of two presents with fevers for four weeks. The patient states that she has felt fatigued and achy during this time. Maximum temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms. Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border.

Endocarditis

Patient will present as → a 25-year-old male with a dull, achy scrotal pain that has been gradually increasing over the last several days. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/HPF.

Epididymitis

Patient will present as → a 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleed. In the ED a topical vasoconstrictor is tried but also fails to stop the bleeding.

Epistaxis

Patient will present as → a 19-year-old female with a painful rash on her left leg. She has a small bug bite in the same area about three weeks ago. Since then, the area has become red, painful, and hot. On physical exam, you not a shiny, raised, indurated, and tender plaque-like lesions on the left leg. The redness is well-demarcated and hot to the touch. You send her home on penicillin.

Erysipelas acute, well-demarcated, raised superficial bacterial skin infection Symptoms may include redness and pain at the affected site, fevers, and chills

Patient will present as → a 15-year-old complaining of several red lesions on her palms, back of hands, and on her lips of one-week duration. On examination, you note a symmetrical red papular rash with many target lesions. The rash appeared just a few days after herpes facialis.

Erythema Multiforme Skin lesions predominantly involving the extremities (hands, feet, and mucosa). Target-like shape, raised, blanching, and lack of itchiness help characterize this rash.

Patient will present as → a 4-year-old who is brought to the office by his mother. The child has had a low-grade fever, headache, and sore throat for the past week. Four days ago, he suddenly developed a bright red rash on his cheeks, which during the past 2 days has spread to the trunk, arms, and legs. On physical examination, the child has erythema of the cheeks and a maculopapular rash with central clearing on the trunk spreading to the extremities. There are no other significant findings.

Erythema infectiosum Parvovirus B19 - "slapped cheek" rash on face - lacy reticular rash on extremities, spares palms and soles

Patient will present as → a 64-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the general surgery clinic where he was referred for further evaluation of blood in his stool. He reports occasional abdominal pain relieved transiently with meals and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas, but no palmar erythema or hepatosplenomegaly are observed on the exam.

Esophageal varices

Patient will present as → a 54-year-old female with odynophagia (painful swallowing), dysphagia and retrosternal chest pain

Esophagitis

Patient will present as → a 44-year-old Caucasian man with a four-year history of diabetes mellitus presents to your office for a routine check-up. He has no complaints. His medications include metformin, aspirin, and a multivitamin. He works as an insurance salesman and has a sedentary lifestyle. He smokes one pack of cigarettes per day and drinks two cans of beer on weekends. He denies any illicit drug use. His diet includes mostly meat and large amounts of "junk food." On physical exam, his blood pressure is 157/96 mmHg, heart rate is 82 bpm. His BMI is 34.2 kg/m^2. The remainder of his physical exam is unremarkable. Laboratory studies reveal an HbA1c of 7.8%. At his last check-up one month ago, his blood pressure was 151/93 mmHg.

Essential HTN

Patient will present as → a 65-year-old patient with shaking that occurs with simple tasks such as tying his shoelaces, writing, or shaving. According to his wife, the symptoms are aggravated by stress, fatigue, caffeine, and changes in temperature. The patient reports his dad had the same symptoms. On physical examination, there is a 4-10 Hz tremor elicited when both of his arms are outstretched forward. There is no tremor at rest.

Essential Tremor

A young woman in her 20's with a small, rubbery, firm, usually painless, well-circumscribed, completely round, and freely mobile breast mass Patient will present as → a 27-year-old female with a painless mass in the left breast. She discovered this mass three months ago while showering and reports it has been unchanged since that time. Her last menstrual period was 10 days ago. There is no family history of breast cancer. On physical exam, you palpate a 3 cm, firm, non-tender mass in the upper lateral quadrant of the left breast. The mass is smooth, well-circumscribed, and mobile. There are no skin changes, nipple discharge, or axillary lymphadenopathy. Ultrasound of the breast was performed with results seen here.

Fibroadenoma; not changed w/menstrual cycle

Patient will present as → a 42-year-old woman with breast masses that changes in size, especially during her menstrual cycles. These masses are usually painful and pain radiates into the axillae. She reports that her breasts often feel full and heavy. Occasionally she has a small amount of greenish-brown nipple discharge. Ultrasound exam shows cystic masses within the breasts.

Fibrocystic disease

Patient will present as → a 35-year-old woman who comes to your office with a 1-year history of "aching and hurting all over." She also complains of a chronic headache, difficulty sleeping, and generalized fatigue. When questioned carefully, she describes "muscle areas tender to touch." Although the pain is worse in the back, there really is no place free of pain. She also describes headaches, generalized abdomen pains, and some constipation.

Fibromyalgia

Patient will present as → a 50-year-old female brought to the emergency department by ambulance. The patient had an appointment with the local housing authority when she began acting abnormally. She stopped responding to questions and stared blankly off into space, not responding to verbal stimuli. Other than odd lip-smacking behavior, she was motionless. Several minutes later, she became responsive but seemed confused. The patient has a past medical history of opioid use disorder and homelessness. She is not currently taking any medications. Her temperature is 98.9°F (37.2°C), blood pressure is 124/78 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals cranial nerves II-XII as grossly intact with 5/5 strength in the upper and lower extremities and a stable gait. The patient seems confused when answering questions and has trouble remembering the episode.

Focal seizures (complex partial) Altered consciousness, automatisms (ie. Lip-smacking) Present with a postictal state (confusion and loss of memory) which differentiate them from absence seizures

Patient will present as → a 43-year-old alcoholic man who arrives at the hospital with alcohol withdrawal. He confabulates and trembles uncontrollably. He is started on supportive therapy for now. Bloodwork comes back with macrocytic megaloblastic anemia, an increased homocysteine, normal methylmalonic acid and decreased folate. He is immediately started on folic acid supplementation.

Folate Def

Patient will present as → a 35-year-old woman comes to your office complaining of "pimples in my armpit." She said that it first appeared five days ago and they are itchy and mildly painful. She denies fever, nausea, vomiting, and recent travel - she has never had any prior lesions like this in the past. She admits to going to a party where she used a hot tub two weeks ago. Temperature is 98.1°F (36.7°C), blood pressure is 132/75 mm-Hg, pulse is 76/min, and respirations are 14/min. Both axillae have short, 2-mm hairs, and lack lymphadenopathy. You note multiple papules and pustules in the right axillae. The lesions are mildly tender to palpation.

Folliculitis

Patient will present with → a 21-year-old male presents with a cough and mild shortness of breath for three days. The cough is occasionally productive of yellowish mucus. He reports a low-grade fever with this episode but says that he has otherwise been healthy. He has spent the last month working in bat caves. He denies tobacco or alcohol use.

Fungal pneumonia

Patient will present as → a 20-year-old healthy male was treated 4 days ago for an MRSA skin infection with sulfamethoxazole-trimethoprim (Bactrim). The infection is improving but he is increasingly weak and his sclera have turned yellow. Today his hemoglobin is 11 g/ dL (13.5 to 18 g/ dL) and his MCV is 85 (80 to 100 fL); the corrected reticulocyte count is elevated, he has an increased indirect bilirubin and decreased haptoglobin. The peripheral smear demonstrates bite cells and Heinz bodies.

G6PD Def

Patient will present as → a 55-year-old male with complaints of heartburn, belching, and epigastric pain which is aggravated by drinking coffee, eating fatty foods, and lying down. He says it gets better when he takes antacids.

GERD; intermittent, burning, substernal chest pain that does not typically radiate. Additional, but less common symptoms, include chronic nonproductive cough, change in voice quality, halitosis, sore throat and atypical chest pain. GERD occurs when gastric contents are able to reflux into the esophagus which is most commonly caused by low tone of the lower esophageal sphincter. Symptoms associated with GERD can be exacerbated by many factors including caffeine, fatty foods, tomato-based foods, alcohol, and smoking

Patient will present as→ a 54-year-old male presents with a slowly enlarging mass on the dorsum of his left wrist which has been present for 3 years. He denies any significant symptoms. Physical exam shows a 1 cm palpable mass that transilluminates.

Ganglion

Patient will present as → a 68-year-old man, who presents to your clinic with complaints of fatigue, loss of appetite, and abdominal pain/fullness. He reports a 15-pound weight loss over the last three months. Vital signs are within normal limits. On exam, you discover a firm, enlarged painless lymph node above the patient's left clavicle. Upon further questioning, the patient reports the node has been present for the past 2 months. His stool is Guaiac positive.

Gastric cancer

Patient will present with → abdominal discomfort that is worse with meals and gets better an hour or so later after eating.

Gastric ulcer

Patient will present as → a 37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day.

Gastritis

Patient will present as → a 22-year-old man is brought to the emergency department by his wife. While he was raking leaves in the backyard, he suddenly lost consciousness, became rigid, and fell to the ground. His respirations temporarily ceased. This lasted for approximately 45 seconds and was followed by a period of jerking of all four limbs lasting 2 or 3 minutes. The patient then remained unconscious for 3 or 4 minutes.

Generalized seizures (tonic clonic)

Patient will present as → a 19-year-old sexually active woman presents to your office with complaints of yellow vaginal discharge and intermittent postcoital vaginal bleeding for 1 week. She otherwise feels well. On examination, there is purulent discharge visible in the endocervical canal. After you collect vaginal fluid for a wet prep and cervical samples for gonorrhea and chlamydia cultures, you note bleeding at the cervical os. On bimanual examination, the patient complains of tenderness on cervical palpation but denies uterine or adnexal tenderness. Wet prep reveals vaginal pH 4; negative whiff; 20 white blood cells (WBCs) per high-power field; and no clue cells, trichomonads, or pseudohyphae.

Gonorrhea

Patient will present as → a 65-year-old man with pain in his right knee. He says he fell and "banged it up fairly bad" approximately 6 months ago but that it had since recovered spontaneously and provided no further trouble until now. He further said the pain does not get worse during the day, and if anything, it hurts more on awakening. His past history showed no hypertension, and he never had any other joint pain of significance. On examination, his temperature is 37.5 °C and his blood pressure is 125/70 mm Hg. He has an inflamed, tender, swollen right knee. No other joints are affected. No other abnormalities are found on physical examination. A plain radiographic examination of the right knee reveals streaking of the surrounding soft tissue with calcium deposits (chondrocalcinosis). You remove accumulated synovial fluid for polarized light microscopic analysis and also obtain a serum sample.

Gout

Patient will present as → a 32 year-old male with dyspnea and a nonproductive cough. His is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated A 47 year-old HIV positive female presents with a complaint of a nonproductive cough. She is febrile, tachypneic and tachycardic. Lung exam reveals bilateral rales. Chest x-ray shows diffuse interstitial infiltrates

HIV-related pneumonia

Patient will present as → a 57-year-old female with complaints of a severe headache, vomiting, neck stiffness, and chest pain that has developed over the last several hours. Physical examination is significant for papilledema, but no focal neurologic defects are noted. The patient is afebrile and vital signs are the following: pulse is 88/min, blood pressure is 200/140 mmHg, respirations are 20/min, and SpO2 is 97% on room air. A head CT is obtained and is shown here. Urinalysis reveals gross hematuria and proteinuria. A 55-year-old male with history of hypertension and diabetes mellitus presents to the emergency department. The patient's wife states that the patient developed progressive irritability and confusion today after complaining of a headache. Physical examination reveals a BP of 230/130 mmHg and papilledema

HTN Emergency

Patient will present as → a 2-year-old who is brought to the office by his mother. The child has had a low-grade fever, rash, and loss of appetite for the past two days. On physical exam, there are multiple 2-3-mm grey vesicular lesions on the bilateral palms and soles and several vesicles and ulcers on the oral mucosa. The physician assistant informs her parents that this disease typically resolves spontaneously and to keep the patient hydrated.

Hand, foot and mouth dz Children < 10 years old caused by coxsackievirus type A virus producing sores in the mouth and a rash on the hands, feet, mouth, and buttocks

Patient will present as → a 59-year-old male with complaints of fatigue, shortness of breath with physical exertion, and a sense of abdominal fullness. His wife accompanies him to his appointment and expresses concerns about his skin color, commenting that he has an "orange hue" to his skin. On physical exam the patient is noticeably jaundice with palpable splenomegaly. A peripheral smear comes back with spherocytes as well a smudge cells. His direct Coombs test is positive with anti-C3 and anti-IgG antibodies.

Hemolytic Anemia Autoimmune Hemolytic anemia (+ Direct Coombs Test) - ↑ Retic, ↑ LDH, ↓ Haptoglobin, and ↑ Bilirubin (indirect) Hereditary Spherocytosis (+) osmotic fragility test. ↑ Retic, ↑ LDH, ↓ Haptoglobin, and ↑ Bilirubin (indirect) and the presence of spherocytes G6PD deficiency after infection or medication (oxidative stress) in an African American male (x-linked) + Heinz Bodies and Bite Cells on a smear (damaged hemoglobin - G6PD protects RBC membrane) Sickle Cell Anemia (Very ↑ Retic count + Pain in African American male, Hemoglobin electrophoresis: Hemoglobin S, Blood smear: Sickled RBCs, Howell-Jolly bodies, target cells) Thalassemia Very ↓ MCV (microcytic and hypochromic) with a normal TIBC and Ferritin, elevated iron and family history of blood cell disorder

3-year-old boy whose mom is concerned about his prolonged nosebleeds. Ever since he was about 2 years old, he has had multiple episodes of nosebleeds that stopped only after hours. On physical exam, his right elbow is slightly swollen and tender to palpation. There is a family history of unexplained bleeding in the patient's maternal uncle. Lab results reveal increased PTT that corrects after mixing studies. Lateral radiograph of the knee shows swelling of the soft tissues from blood accumulation in the knee.

Hemophilia

Patient will present as → a 35-year-old male with bright yellow discoloration of his skin. He states that this started yesterday and has been getting progressively worse. Upon obtaining further history you learn that this patient has recently lost 10 pounds over the past month and has had urine that he believes is darker. The patient is currently sexually active with women and does not use protection. On physical exam, you note the patient has prominent scleral icterus.

Hep B Transmission from needles, sex, mom to child, close contact Flu-like symptoms + jaundice

Patient will present as → a 55-year-old man who is referred to your clinic after abnormal blood workup noted at a Red Cross blood donation site. The man reports having donated blood 30 years ago without any serologic abnormalities. The patient appears healthy and denies any history of blood transfusion or IV drug use. On further questioning, the man reports having been stuck by a needle while working as a phlebotomist 20 years ago which he never reported. Lab results reveal positive anti-HCV antibodies. Subsequent HCV genotyping and HCV RNA levels for this patient reveals genotype 1 and RNA levels of 100,000,000 IU/mL.

Hep C Acute symptoms look like the flu with RUQ pain similar to hepatitis A

Patient will present as → a 38-year-old female who has just returned from a 2-week trip to Mexico. She complains of nausea, vomiting, loss of appetite, and right upper quadrant abdominal pain. She has been sick for the past 3 days. She complains of passing dark-colored urine for the past 2 days. She has had no exposure to blood products, has no history of intravenous drug use, and has no significant risk factors for sexually transmitted disease. On examination, she looks acutely ill. Her pulse is 100 beats/minute, blood pressure 110/70 mm Hg, respirations 18, and temperature 101°F. Her sclerae are icteric, and her liver edge is tender. 28 year old just returned from Thailand. Four days later he develops fever, fatigue and right upper quadrant pain. Four days later he develops jaundice.

Hepatitis A Fecal-oral transmission Look for recent travel to Asia Hepatomegaly + jaundice Fatigue malaise, nausea, vomiting, anorexia, fever and right upper quadrant pain

Patient will present as → a 42-year-old man with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining

Hiatal hernia

Patient will present as → a 27-year-old obese, African American female with tender inflammatory nodules and abscesses in her axillae and anogenital area. The lesions have waxed and waned over the past few years but have become more painful and bothersome in the past month. Some of the larger lesions are foul smelling and are draining a purulent material.

Hidradenitis suppurativa

Patient will present as → a 21-year-old male with fever, chills, and night sweats for 1-month. Exam reveals painless enlarged posterior cervical and supraclavicular lymph nodes bilaterally. CBC, HIV, and RPR are normal. Excisional biopsy of lymph node demonstrates Reed-Sternberg cells (owl-eye appearance)

Hodgkin's lymphoma

Patient will present as → a 15-year-old male with pain, redness, and swelling of the upper eyelid for the last 3 days. There are no visual changes or photophobia. Examination reveals a tender, erythematous, and outward-pointing edema of the right eyelid.

Hordeolum=HOT (stye)

Patient will present as → a 55-year-old obese Caucasian gentleman who arrives at your clinic for a routine check-up after having some blood work done during a routing workplace health screening. He is found to have a total cholesterol level of 430 mg/dL. He complains of calf pain while walking to the convenience store, which only resolves with rest. He states that he has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well demarcated yellow deposits around his eyes.

Hyperlipidemia

Patient will present as → a 34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite.

Hyperthyroidism Graves - Diffuse goiter with a bruit, exophthalmos, pretibial myxedema Thyroid storm - Fever, tachycardia, delirium

Patient will present as → a 17-year-old female brought in by her parents to check her cholesterol due to family history of hypertriglyceridemia. Her dad and paternal aunt have history of pancreatitis. Family history is negative for premature arteriosclerotic cardiovascular disease. Her cholesterol panel is as following: Total cholesterol 188 mg/dL (<200), triglyceride 851 mg/dL (<150), HDL 15 mg/dL (>50), LDL 102 mg/dL (<130).

Hypertriglyceridemia

Patient will present as → a 14-year-old who sustained a blunt trauma to his right eye after being struck by a baseball. He complains of blurry vision. On physical exam, you note unequal pupils, injected conjunctiva/sclera, and blood in the anterior chamber of the right eye.

Hyphema

Patient will present as → a 28-year-old woman with increased fatigue and a 10-lb weight gain over the last 2 months. She states that she "feels cold" all the time, has decreased energy, and is experiencing worsening constipation. Patient has a tender thyroid, increased TSH, elevated antimicrosomal antibodies, and increased antithyroglobulin antibodies.

Hypothyroidism

Patient will present as → a 40-year-old woman comes to your office with a several-year history of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. On physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize.

IBS

Patient will present as → a 42-year-old male complaining of easy bruising and gingival bleeding. He reports his symptoms began one day prior to presentation and has never occurred before. Medical history is significant for a recent diagnosis of hepatitis C infection. On physical exam, there is mild bleeding of the gums. There are petechiae throughout the chest, arms, and legs. There is no evidence of splenomegaly on abdominal exam. A complete blood count is significant for a platelet count of 24,000/μL (normal 150,000 - 400,000/μL) and peripheral blood smear demonstrates enlarged platelets. He has a + Direct Coombs Test. He is started on corticosteroids.

ITP Associated with HIV, HCV, SLE, CLL CBC normal except low platelets. (+ Direct Coombs Test) Autoimmune reaction to platelets usually after a viral illness (ITP is insidious and chronic)

Patient will present as → a 5-year-old girl with crusting facial lesions present for 3 days. The mother reports that prior to the development of the facial lesions her daughter was scratching at insect bites. Examination reveals a red facial rash with a golden "honey-colored crust" and pruritus.

Impetigo

Patient will present as → an 11-year-old boy who is brought to the clinic for diarrhea and vomiting. He has no fever but complains of intermittent, cramping, and abdominal pain. They just returned from a family picnic, where about two hours ago the child ate potato salad. The mother reports other family members had become ill after the meal as well.

Infectious diarrhea

Patient will present as → a 5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgia, especially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes.

Influenza

Patient will present as → a 15-year-old male who was brought in to the ED for respiratory failure following sniffing and inhalation of petroleum for an extended time. This patient has been admitted to the ED many times, last time for abusing bath salts. He comes from a foster home and is largely unsupervised.

Inhalant-related disorders A young child from low socioeconomic background arrives in the ED with a headache, loss of appetite, rhinorrhea, injected sclera, dizziness, photophobia, or a cough

Difficulty initiating or maintaining sleep at least 3 times per week for 3 months

Insomnia disorder

Patient will present a → a 30-year-old obese white female presents with fatigue and generalized weakness for several weeks. Physical exam reveals pale nail beds, spoon nails, mucosal pallor and an atrophic tongue. Upon further questioning, the patient reveals a "craving for ice and inanimate objects." Laboratory data shows a microcytic, hypochromic appearance to the RBCs, an elevated TIBC, low serum iron of 16 µg/dl, and a low plasma ferritin of 12 µg/dl.

Iron Def

Patient will present as → a 61-year-old male who is concerned about unintentional weight loss, night sweats, and fevers. He complains of a rash on his face that bothers him cosmetically. The rash does not hurt or itch. On physical exam, there are multiple well-demarcated red/purple, infiltrative, firm nodules, and plaques on his head, neck, and mouth. The patient has a history of risky behaviors, including IV drug use and unprotected intercourse with multiple partners. His CD4 count comes back at 100/mm3.

Kaposi's Sarcoma Kaposi sarcoma causes lesions to grow in the skin, lymph nodes, internal organs, and mucous membranes lining the mouth, nose, and throat. It is associated with human herpesvirus 8 and is an AIDS-defining cancer Purple, red, or brown skin blotches are a common sign. Tumors also may develop in other areas of the body

Patient will present as → a 23-year-old male is brought into the ED by his friends at 1 a.m. They are afraid that he is going to hurt himself. They say that he has "been freaking out" and seeing things that are not there. At one point, he tried to ride a bike off the roof of a house. On exam, you see a young man who appears to be in a panic. His gait is abnormal, he has diffuse tremors and his pupils are dilated.

LSD Patient wants to hurt himself. They say that he has "been freaking out" and seeing things that are not there.

60-year old caucasian male with shortness of breath and fatigue on exertion. On physical exam, you note an S3 heart sound, crackles on pulmonary auscultation, and a displaced left apical impulse. He undergoes an echocardiogram and is found to have a dilated left ventricle and an ejection fraction of 35%.

LV CHF

Patient will present as → a 23-year-old female PA student with hearing loss and tinnitus that began yesterday. She describes a sensation of the room "spinning" around her. She feels extremely nauseous and vomited already one time this morning. On physical exam, a horizontal nystagmus is observed. You excuse her from her histology exam later that afternoon. A 26-year-old woman comes to your office with a 6-day history of severe dizziness associated with ataxia and right-sided hearing loss. She had an upper respiratory tract infection 1 week ago. At that time, her right ear felt plugged. On examination, there is fluid behind the right eardrum. There is horizontal nystagmus present, with the slow component to the right and the quick component to the left. Ataxia is present. What is the most likely diagnosis in this patient? 55 yo F c/o dizziness that started this morning and of "not hearing well." She feels nauseated and has vomited once in the past day. She had a URI two days ago.

Labyrinthitis Acute onset, vertigo, hearing loss, and tinnitus of several days to a week. Often preceded by a viral respiratory illness There is an absence of neurologic deficits.

Patient will present as → a 27-year-old mezzo-soprano who states that she developed acute hoarseness 2 days ago. Prior to that, she had a cold, the symptoms of which are improving. There is no history of smoking or other tobacco use. She is very worried as she has an upcoming performance 3 days from now.

Laryngitis

Patient will present as → a 9-year-old girl who is brought in by her mom who noticed the child scratching her head at school pickup. She reports that this itchiness has gone on for around 1 week now. Her mom reports angrily that the school just notified them that several children had lice. Physical exam reveals several ovoid, grayish-white eggs < 1 cm away from the base of the hair shaft at the back of the head and behind the ears. She is given topical permethrin and counseled that she can still go to school.

Lice

Patient will present as → a 30-year-old male being seen for a non-painful mass on the upper back which has grown slowly over the past year. He denies previous trauma, drainage from the area or history of dermatologic diseases. Examination reveals a four centimeter firm, but highly mobile subcutaneous mass with no overlying skin discoloration or punctum with drainage

Lipomas/epithelial inclusion cysts Lipomas are benign fatty tumors, generally slow-growing, and usually harmless. Lipomas are just under the skin and move easily when pressure is applied. They commonly occur in the neck, shoulders, back, abdomen, arms, and thighs The term epidermal inclusion cyst refers specifically to an epidermoid cyst that is the result of the implantation of epidermal elements in the dermis Most of the cysts appear as solitary, soft, well defined, mucin-filled lesions and are painless Characteristically, they have a smooth surface and a small opening to the surface of the skin, known as a punctum

Patient will present as → a 65-year-old woman with a 40 pack-year history of smoking presents with a 7kg weight loss over the last 3 months and recent onset of streaks of blood in the sputum. PE reveals a thin, afebrile woman with clubbing of the fingers, an increased anteroposterior diameter, scattered and coarse rhonchi and wheezes over both lung fields, and distant heart sounds.

Lung cancer

Patient will present as → a 38-year-old New Jersey resident who went for a jog in the woods and found a tick while showering. His wife successfully removed it using a pair of tweezers. Now 7-10 days after the bite he has developed a strange red rash with clearing between the center and periphery. He brought the tick in a canning jar.

Lyme disease

Patient will present as → a 23-year-old female is brought into the ED by her friends as they are concerned about her behavior. She seems more energetic than usual and this has gone on well past the end of the rave. On exam, you see a young female in neon clothing, consumed with the colors of her outfit, and very affectionate towards you.

MDMA (Ecstasy)

Patient will present as → a 21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department.

MW Tear

Patient will present as → a 62-year-old male who arrives for his follow-up visit for chronic central visual loss. He describes a phenomenon of wavy or distorted vision that has deteriorated rather quickly. The patient is frustrated because he 'just can't drive anymore" and he "is having difficulty seeing words when he reads." When looking at a specific region of the Amsler grid, he reports a dark "spot" in the center, with bent lines. On the funduscopic exam, you note areas of retinal depigmentation along with the presence of yellow retinal deposits.

Macular degen (dry)

Patient will present as →a 33-year-old woman complaining of fatigue and decreased interest in "the things that used to make me happy." She is sleeping less and eating less, and she says that she is forcing herself to eat "because I know I have to eat something." She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she used to have.

Major depressive disorder

Patient will present as → a 67-year-old man of Irish descent who presents to your dermatology clinic for the first time. When asked why he was referred to the clinic, the patient reports that his wife has been nagging him to have his skin checked for years. On exam, you notice an asymmetric, elevated, blue-tinged lesion with irregular, scalloped borders on his shoulder. When discussing the risk factors for skin malignancy, the patient proudly asserts that he was a lifeguard in Australia for 15 years from his late teens to his early 30s.

Melanoma

Patient will present as → a 35-year-old female who complains of worsening hyperpigmentation to her face, particularly her cheeks. Physical examination of the face reveals diffuse light-to-dark brown macules to bilateral upper cheeks. The patients has no significant past medical history and her only medication is Ortho Tri-Cyclen which she takes for birth control.

Melasma Hyperpigmentation of sun-exposed areas of face (cheeks, forehead, nose, and chin); Appear as dark, irregular, well-demarcated macules/patches, Also known as chloasma = "mask of pregnancy"

Patient will present as → a 31-year-old man with right flank pain radiating into the scrotum, gross hematuria, right-sided hydronephrosis, and normal abdominal x-ray

Nephrolithiasis Colicky flank pain radiating to the groin, hematuria, CVA tenderness, and nausea and vomiting

Patient will present as → a 32-year-old male with complaints of recurrent, episodic vertigo lasting up to 8 hours per episode for the past 3 months. The attacks generally last less than half an hour and are associated with decreased low-frequency hearing in the left ear along with nonpulsatile tinnitus in the ipsilateral ear. You obtain an audiogram which shows a low-frequency hearing loss in the left ear only. 35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week

Meniere Disease

Patient presents as → a 34-year-old man who is brought by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights. His temperature is 103.1° F, blood pressure is 134/82 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs.

Meningitis

Patient will present as → a 52-year-old female with no menses for 12 months she also complains of hot flushes and dyspareunia

Menopause

Patient will present a → a 25-year-old female comes to your office with a 3-year history of recurrent headaches that have gotten worse during the past year. These headaches occur approximately twice per week. She is concerned that she may be having some kind of stroke because before the headache, nausea, and severe vomiting begin, she experiences a "type of odd visual feeling or sight—flashing lights, almost like a pattern in front of my eyes." With respect to the headache, it usually lasts 24 to 36 hours. It is throbbing in nature and often "switches from one side to the other" with each attack. She needs to be in a dark room and finds noise bothersome when she has these headaches.

Migraine

Patient will present as → a 6-year-old boy who is brought to the emergency department by his mother due to swelling around his eyes and legs. The mother reports that the patient recently recovered from an upper respiratory tract infection. Physical exam is significant for periorbital and lower extremity edema. Laboratory testing is significant for hypoalbuminemia and normal complement levels. Urinalysis demonstrates 4+ protein and fatty casts with a "maltese cross" sign.

Nephrotic Syndrome

Patient will present as → a 14-year-old boy with 3-days of sore throat, fever, and generalized malaise. On exam, he has a temperature of 102.2 F (39.0 C), BP 96/50, and a diffuse exudate on both tonsils. He also is noted to have palpable splenomegaly, swollen painful lymph nodes, and mild hepatomegaly. Labs show leukocytosis of 12,000/mm3 with 50% neutrophils, 12% monocytes, and 38% lymphocytes. The rapid pharyngeal streptococcal screen is negative. A 21-year old female comes to you with complaint of low grade fever, sore throat, malaise, anorexia, and body rash. Physical examination reveals cervical lymphadenopathy, generalized maculopapular rash, enlarged tonsils, exudative pharyngitis and soft palatal petechiae. Monospot test shows positivity for Heterophile antibody.

Mono

patient will present as → a 64-year-old man comes to the emergency department because of chest discomfort for the past 5 hours. When the patient is asked where the pain is located, he places a clenched fist to indicate a squeezing over his substernal region. The pain radiates to the neck, left shoulder, and left arm. His temperature is 36.8°C (98°F), pulse is 55/min, respirations are 17/min, and blood pressure is 117/78 mm Hg. The examination shows a diaphoretic male. ECG shows inverted U-waves in leads V5 and V6. The cardiac biomarker test shows an elevated concentration of troponin.

NSTEMI

Patient will present as → a 6-year old female who is being seen for a routine well-child exam is noted to have multiple teardrop-shaped growths partially obstructing the nasal passages. The child has a history of chronic sinusitis and recurring ear infections. As an astute PA, you order a sweat chloride test.

Nasal polyps

Patient will present as → a 26-year-old man who presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on methadone but is non-adherent. His blood pressure is 155/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts.

Nephritic Syndrome

Patient will present as → a 65-year-old woman with left knee pain. The pain has been present in both knees for approximately 5 years and has been steadily getting worse. She describes stiffness, sticking and grinding of the right knee. Over the last 2 weeks, she has been taking ibuprofen almost every day, requiring an increasing frequency of doses for adequate pain control. On physical exam, there is swelling of the right knee and tenderness to palpation. There is palpable crepitus. A weight-bearing radiograph of the left knee is shown in here.

OA

a 47-year-old African American male presents for an ophthalmic examination. Medical history is significant for hypertension and type II diabetes mellitus. On slit-lamp examination, there is cupping of the optic disc, with a cup-to-disc ratio > 0.6. Tonometry reveals intraocular pressure of 45 mmHg (normal is 8-21 mmHg). Peripheral field vision loss is noted on visual field exam.

Open angle glaucoma

Patient will present as → a 30-year-old male brought to the ED by his friends who state that he has been unresponsive to verbal cues. They reported that he had been abusing heroin and "he overdid it this time." On physical exam, he has several needle marks along the antecubital fossa, a respiratory rate of 4/min and small, pinpoint pupils.

Opioid-related disorders Patient with restlessness, mydriasis and excessive lacrimation as well as several needle puncture sites in his left antecubital fossa that are in various stages of healing.

Patient will present as → a 31-year-old male complaining of unilateral scrotal swelling with pain radiating to the ipsilateral groin. Examination reveals a tender swollen testicle, scrotal edema with erythema and shininess of the overlying skin.

Orchitis

55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension.

Orthostatic hypotension due to dehydration

Patient will present with → a 61-year-old white postmenopausal woman who comes to your office for a routine health examination. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, she weighs 115 pounds and she is not currently taking calcium supplements.

Osteoporosis

Patient will present as → a 25-year-old female patient with complaints of sudden onset of a pounding heartbeat, which is regular and "too rapid to count." She reports that the episodes begin and terminate abruptly and are associated with shortness of breath and chest discomfort. On exam the patient appears anxious, her heart rate is 170 bpm. EKG demonstrates a shortened PR interval, widened QRS, and delta waves.

Paroxysmal supraventricular tachycardia (WPW here)

Patient will present as → a 4-year-old girl who is brought to the clinic by her mother who states that the child has been complaining of progressively worsening ear pain and itchiness over the past week. Examination reveals left tragal tenderness and an edematous and closed canal. Weber lateralizes to the left. A 24 year-old patient presents after a recent vacation. He complains of left ear pain. Physical examination reveals an inflamed external auditory canal and the tympanic membrane can not be visualized.

Otitis Externa

Patient will present as → a 3-year-old previously healthy male is brought to your office by her mother. The mother reports the child has been crying and pulling at her right ear over the past 2 days and reports the patient has been febrile the past 24 hours. The patient's past medical history is unremarkable, although the mother reports the patient had a "common cold" a week ago which resolved without intervention. His temperature is 101.6 F, blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min. The otoscopic exam is seen here.

Otitis Media

Patient will present as → a 24-year-old who was brought into the ED and has attempted to assault a nurse several times. He is extremely aggressive and becomes enraged when sudden movements or loud sounds are made. The patient is escorted to a dimly lit, quiet exam room where he becomes much calmer. On physical exam, the patient is agitated and has nystagmus. His blood pressure in the ED is 180/100 mmHg.

PCP Patient is extremely aggressive and becomes enraged when sudden movements or loud sounds are made.

Patient will present as → a 27-year-old female who comes to the emergency department with a 2-day history of lower abdominal pain, fever, chills, and malaise. The patient also complains of nausea and multiple episodes of vomiting in the past 24 hours. On physical examination, there is bilateral adnexal tenderness, mucopurulent cervical discharge, and cervical motion tenderness.

PID

Patient will present as → a one-week-old infant with a wide-scale symmetrical papular eruption over his trunk. Lesions align along skin folds. He had a mild upper respiratory infection last week prior to presenting to the clinic.

PItyriasis Rosea characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash. Pityriasis rosea is easier to identify when the general eruption appears with smaller secondary lesions that follow Langer's lines (cleavage lines) in a Christmas tree-like pattern. Herald patch: Large oval plaque with central clearing and scaly border. 1st sign Pruritic erythematous plaque with central scale in Christmas tree pattern on the trunk

The patient has experienced a traumatic event that causes an acute stress reaction. Once the symptoms persist past 1 month it is now considered post-traumatic stress disorder (PTSD)

PTSD

chronic eczematous itchy, scaling rash on the nipples and areola

Paget's disease of nipple

Patient will present as → a 26-year-old first-year PA student with a medical history significant for GERD comes to your office because of frequent episodes of palpitations. The palpitations are sudden in onset and are accompanied by sweating and a sense that she is going to "pass out." The episodes typically last no more than 10 minutes, and although the patient feels as if she may pass out, she never has. The episodes first appeared when she started PA school and have increased in frequency to the point where she is afraid to attend lectures out of fear of having an "attack."

Panic disorder

Patient will present as → a 32-year-old female with a painful index finger. She obtains regular manicures, changing colors every 2 weeks. She recently had one a week ago and started feeling pain near the nail on her left index finger. Physical exam reveals redness, warmth, and pain along the nail margin of the index finger. When applying pressure to the nail plate, some pus drains from the nail. She is prescribed frequent warm soaks with chlorhexidine and oral antibiotics.

Paronychia

Patient will present as → an 11-year-old boy with malaise and swelling of his face. He has no significant past medical history, but it is documented in his chart that his mother declined the recommended standard immunizations for children because of personal beliefs. Vital signs are stable with the exception of a mild fever. In addition to the facial swelling, physical exam is also notable for swelling around the testes. There are no rashes.

Parotitis

Patient will present as → a 22-year-old college basketball player with chronic anterior pain of her right knee. The patient has had over 6 months of physical therapy without improvement. It initially only bothered her during training, but she is now no longer able to compete and has pain with daily activities. Physical exam reveals swelling of the anterior knee and tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at distal pole of the patella in full flexion. Her MRI is shown here.

Patellar tendinitis

Patient will present as → a 48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis with dyspnea, cough and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. The patient reports significant relief of his chest pain with sitting up or leaning forward. A basic metabolic panel is remarkable for a BUN > 60 mg/dL. On cardiac auscultation, you hear a pericardial friction rub that is heard best when the patient is upright and leaning forward. The EKG (seen here) demonstrates diffuse, ST-segment elevations in the precordial leads.

Pericarditis

Patient will present as → a 63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8. A 76-year-old male with a 5 year history of atrial fibrillation presents to the Emergency Department with an inability to move his left leg. The patient notes that he first noted that his leg "felt funny" about two hours ago, and that it appeared to be more pale than normal. Since the leg started feeling funny, his ability to move it has decreased, to the point where he can no longer move it. He recently ran out of his warfarin, and hasn't taken any in two weeks. On physical exam his vital signs are within normal limits. His neurological exam reveals a pale, painful left leg with absent femoral and dorsalis pedis pulses. He has no other strength deficits and pulses in his right leg and right arm are intact.

Peripheral Artery Disease

Patient will present as → a 19-year-old male who you are seeing for follow-up from the urgent care where he was seen 2 days earlier with a sore throat. The patient is febrile (102°F), has a muffled (hot potato) voice, and extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation.

Peritonsillar abscess

Patient will present as → a 15-year-old male with pain, discomfort and swelling above the anus and near his tailbone that comes and goes. He reports that the pain worsens when he sits or bends forward. Medical history is significant for metabolic syndrome. He is a high school student who spends hours playing on his Xbox. On physical exam, there is a tender and fluctuant mass that is erythematous. There is also purulent discharge from a sinus tract.

Pilonidal Disease

Patient will present as → a 4-year-old is brought to the office by his mother because the daycare teachers noticed he is unusually restless at school. The mother also noticed that he has not been sleeping well lately and has started wetting the bed at night. The child is alert and cooperative but scratches his buttocks while you are interviewing. Cellophane tape applied to the perianal area reveals football-shaped ova under the microscope. 4-year-old girl complains of vaginal and anal itching, especially at night when she is going to bed.

Pinworms

Patient will present as → a 32-year-old woman, G2P1, at 35 weeks' gestation with a complaint of painless vaginal bleeding that began two hours ago and has delivered a substantial amount of blood with clots. She has had no evident pain or cramping. Upon physical examination, the fetal heart rate is noted to be normal. Her last pregnancy was delivered by emergency cesarean at 37 weeks due to a breech presentation during labor.

Placenta previa Painless vaginal bleeding! Usually occurs after 28 weeks of gestation (third trimester bleeding)

Patient presents as → a 39-year-old woman presents with complaints of pain in her left foot of 4 weeks' duration. The patient works as a cashier in a department store, which requires her to be on her feet for long periods. She notes that the pain is most severe on the bottom of her foot and is worse upon arising in the morning and then it subsides with ambulation. On examination, there is no pain with medial and lateral compression of the calcaneus. Active and passive foot and ankle range of motion is pain-free and equal bilaterally. Resisted foot and ankle range of motion is 5/5 and pain-free. The patient has a benign medical history and no other complaints.

Plantar fascitis

Patient will present as → a 19-year-old male transported to the ED following a car crash. Upon arrival, he is alert and anxious and appears to be in respiratory distress. A quick assessment reveals that she sustained trauma to his face, neck, and chest. His left hemithorax appears to be expanding more than the right. He is receiving oxygen via nonrebreathing mask. His vital signs are: respiratory rate 36 and labored. SpO2 is 85%. On physical exam, you notice decreased tactile fremitus, deviated trachea, hyperresonance, and diminished breath sounds.

Pneumothorax

Patient will present as → a 62-year-old female presents to the emergency room with complaints of severe, whole-body itching. She states that she first noticed her symptoms while in the bathtub at home. She has never had symptoms like this before. However, over the previous several months she has had episodes of severe joint swelling and pain in her hands as well as redness, burning pain, and swelling of her hands and feet. Her past medical history is significant for type II diabetes mellitus, hypertension, and osteoporosis for which she takes metformin, enalapril, and alendronate, respectively. In addition, she was found to have a deep vein thrombosis of her right leg five months prior to presentation. The patient's temperature is 98.6°F (37.0°C), the pulse is 80/min, blood pressure is 135/85 mmHg, and respirations are 13/min. Physical exam is notable for a woman in discomfort with excoriations over the skin on her forearms. The patient's laboratory tests demonstrate elevated RBC count, hemoglobin, and hematocrit of 54%, leukocytosis with a WBC count of 19,000 cells/mm^3 with normal differential, and thrombocytosis with a platelet count of 900,000/mm^3.

Polycythemia

Patient will present as → a 24-year-old college student complaining of a feeling as though his heart is momentarily stopping followed by a feeling of his heart in his throat. He appears anxious and reports a weight loss of about 7 lbs over the past 3 months. On auscultation of his heart, you notice an occasional skipped beat, followed by a brief pause and then a regular rhythm. His laboratories reveal a TSH of 0.001 and on his EKG you notice a wide, bizarre QRS complex, greater than 0.12 sec and no identifiable p wave.

Premature beats (PVC here)

Patient will present as → a 40-year-old carpet installer who spends his working day on his knees, fitting carpets. In the past few months, he had been aware of a dull ache over his right knee, which had seemed to be aggravated by pressure and on flexion of the knee. He had been wearing kneepads, using a soft mat and trying to avoid kneeling on that knee. However, he was alarmed to wake one morning with a large, tender, fluctuant swelling over the kneecap.

Prepatellar Bursitis (Housemaid's Knee)

Patient will present as → an 80-year-old bed-bound woman with a temperature of 104°F who you are called to see in the nursing home. The patient is disoriented and confused. On physical examination, the patient's blood pressure is 110/ 80 mm Hg, and her pulse is 72 beats/ minute and regular. There is an 8 × 5-cm pressure ulcer over her sacrum. Also, there is a purulent, foul-smelling discharge coming from the ulcer.

Pressure ulcers

Patient will present as → a 25-year-old male presents complaining of fatigue, weight loss, and recurrent nausea and vomiting. On physical exam, he appears weak and has skin that appears abnormally tan. Her blood pressure is 90/70. A basic metabolic panel reveals hyponatremia and hyperkalemia

Primary Adrenal Insufficiency (Addison's Disease)

Patient will present as → a male patient with a history significant for ulcerative colitis who has been stable and free of problems for over 7 years. He describes worsening symptoms of fatigue, pruritus, anorexia, and indigestion over the past 6 months. His wife reports that his skin and eyes appear yellow although she adamantly denies alcohol consumption. Labs reveal an elevated alkaline phosphatase, mild elevations in AST and ALT. ERCP fails to show common bile duct obstruction.

Primary Sclerosing Cholangitis (itching + jaundice)

Patient will present as → a 63-year-old man with a history of benign prostatic hyperplasia reports 3-days of fever, chills, and pain with urination. He was recently catheterized during admission to the hospital. Physical exam reveals a tender and enlarged prostate on digital rectal exam. Urinalysis reveals pyuria and hematuria.

Prostatitis

Patient will present as → a 75-year-old female with patches of chronic, inflammatory, well-demarcated, erythematous, silvery scaly plaques which involves the scalp and extensor surfaces.

Psoriasis Psoriasis is an immune-mediated disease that causes raised, red, scaly patches to appear on the skin Typically affects the extensor surfaces of the elbows, knees or scalp, though it can appear on any location. The classic clinical appearance is a well-demarcated, erythematous plaque with silvery scaling. Patients may also present with no rash and only joint symptoms - pain in both hands and nail changes such as pitting and onycholysis Auspitz sign (bleeds when the scale is picked), Koebner's phenomenon (minor trauma causes new lesion)Psoriasis Vulgaris: most common. Noted on extensor surfacesGuttate Psoriasis: children, after URI. small lesionsInverse Psoriasis: intertriginous areas.Pustular Psoriasis: contains pustules

Patient will present as → a 65-year-old male Hispanic farmworker who is brought to you by his concerned wife. She reports he has had this "thing" on his left eye for years and refuses to seek care. He denies pain or discharge from the affected eye. Physical exam reveals an elevated, superficial, fleshy, triangular-shaped fibrovascular mass in the inner corner/nasal side of the left eye.

Pterygium

Patient will present as → a 68-year-old woman who underwent hip replacement surgery two weeks ago. The postoperative period was complicated by pneumonia, and the patient has been bed-ridden ever since. A nurse calls you to the patient's room due to vital sign abnormalities and complaints of chest pain. The patient's HR is 105 bpm, BP is 90/60 mmHg, RR is 35 rpm, and T is 100.2F. You note jugular venous distension and profound dyspnea. Upon auscultation you notice tachypnea and crackles heard here: Decr filling of right upper lobe, CT chest A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis? (tachypnea is MC sx of acute)

Pulmonary embolism

Patient will present as → a 32-year-old female presents with fever, chills, nausea and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts.

Pyelonephritis Irritative voiding + fever + flank Pain + nausea and vomiting + CVA tenderness

Patient will present as → a 36-year-old woman who comes to your office with a 6-month history of malaise, paresthesia in both hands, and vague pain in both hands and wrists. She also has felt extremely fatigued. She tells you that the pains in her joints are much worse in the morning and improves throughout the day. She is also beginning to notice pain and swelling in both knees. The patient has a normal family history, with no significant diseases noted. She is taking no drugs and has no allergies. On examination, vital signs are normal. There is a sensation of bogginess and slight swelling in both wrists and multiple metacarpophalangeal joints. Both knees also feel somewhat swollen and boggy. There are no other joint abnormalities, and the rest of the physical examination is normal. Rheumatoid Factor and Anti-citrullinated peptide antibodies are positive.

RA

64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes with increasing shortness of breath and ankle swelling over the past month. On physical examination, you note jugular venous distention, increased hepatojugular reflex, and hepatomegaly. His lungs are clear to auscultation. A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test's mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis? A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis?

RV CHF

Patient will present as → a 23-year-old male with redness of the eye as well as discharge. He reports that he experiences pain with urination and stiffness and pain of the knee and ankle. With further questioning, he reports a history of gonorrhea infection that was diagnosed and treated approximately 5 weeks ago. He is otherwise healthy. On physical exam, there is conjunctivitis, asymmetric oligoarthritis, and discharge from the urethral meatus.

Reactive arthritis

Patient will present as → a 50-year-old female with pelvic pressure reports and a sensation of a mass present in the vagina. She reports chronic constipation and a sensation that the rectum is not completely emptied following a bowel movement. Occasionally, she experiences episodes of fecal incontinence.

Rectocele

Patient will present as → a 65-year-old man complaining of a sudden unilateral vision loss which he describes as "a curtain or dark cloud lowering over my eye." This was preceded by small moving flashing lights, and floaters. The fundoscopic exam reveals a detached superior retina. A 59 year-old male complains of "flashing lights behind my eye" followed by sudden loss of vision, stating that it was "like a curtain across my eye." He denies trauma. He takes Glucophage for his diabetes mellitus and atenolol for his hypertension. He has no other complaints. On funduscopic exam, the retina appears to be out of focus. Which of the following is the most likely diagnosis?

Retinal Detachment=FLASHING LIGHTS Serous retinal detachment is characterized by a dome shaped retina and subretinal fluid that shifts position with posture changes. Serous retinal detachment results from subretinal fluid accumulation which can occur in exudative age-related macular degeneration.

Patient will present as → a 74-year-old man presents with sudden vision loss in his right eye. He described the onset as if a curtain came down over his eye. He has a medical history of hypertension and coronary artery disease and new onset atrial fibrillation. On physical exam, a carotid bruit is auscultated. A retinal exam is performed.

Retinal vascular occlusion (amaurosis fugax); see cherry spot & pale retina Retinal hemorrhages in all quadrants=retinal vein occlusion (blood & thunder fundus)

Patient will present as → a 64-year-old diabetic patient who is being seen for a routine health screening. On fundocopic exam, you see cotton wool spots, hard exudates, blot and dot hemorrhages, neovascularization, flame hemorrhages, A/V nicking

Retinopathy HTN retinopathy: Chronic hypertension accelerates the development of atherosclerosis. The retinal arterioles become more tortuous and narrow and develop abnormal light reflexes (silver-wiring and copper-wiring). There is increased venous compression at the retinal arteriovenous crossings (arterio-venous nicking), an important factor predisposing to branch retinal vein occlusion.

Patient will present as → a 30-year-old woman presents with 2 weeks of arthralgias, migrating from distal to proximal joints. It began with increased warmth and erythema in her right ankle and left knee. She has a low-grade fever and reports a history of sore throat and swollen glands about 1 month ago. On physical exam she has red skin lesions on the trunk and proximal extremities, and also small, non-tender lumps located over the joints. Antistreptolysin O titer is positive.

Rheumatic fever

Patient will present as → a 13-year-old boy with clear fluid discharge from his nose for 2 days duration. This has also been associated with sneezing. On nasal exam, the mucosa and turbinates appear edematous and slightly bluish, he has swollen dark circles under his eyes, and a transverse nasal crease.

Rhinitis

Patient will present as → a 46-year-old white woman presents with facial flushing that she notes is worse when she has her morning coffee and when she is stressed at work. Physical examination reveals the presence of localized facial erythema, telangiectasias as well as several scattered papules and pustules on her cheeks.

Rosacea women aged 30-50, facial erythema, telangiectasias, papules, may cause rhinophyma. Triggers include heat, alcohol, spicy foods, treat with topical metronidazole

High fever 3-5 days then rose pink maculopapular blanchable rash on trunk/back and face Herpesvirus 6 or 7, only childhood exanthem that starts on the trunk and spreads to the face

Roseola (sixth disease)

"3-day rash" pink light-red spotted maculopapular rash first appears on the face, spreads caudally to the trunk and extremities and becomes generalized within 24 hours (lasts 3 days) Cephalocaudal spread of maculopapular rash, lymphadenopathy (posterior cervical, posterior auricular) Although the distribution of the rubella rash is similar to that of rubeola, the spread is much more rapid, and the rash does not darken or coalesce

Rubella (German measles) "3-day rash" pink light-red spotted maculopapular rash first appears on the face, spreads caudally to the trunk and extremities and becomes generalized within 24 hours (lasts 3 days) Cephalocaudal spread of maculopapular rash, lymphadenopathy (posterior cervical, posterior auricular) Although the distribution of the rubella rash is similar to that of rubeola, the spread is much more rapid, and the rash does not darken or coalesce -no Koplik spots & light pink, only 3 days

Patient will present as → a 6-year-old child who is brought to the emergency room for a complaint of high fevers and a rash. His mother reports that she thought he had "just a cold" approximately one week ago—he had a mild fever, runny nose, conjunctivitis, and cough. Then he developed a rash that started on his face and gradually spread downward. The child has no significant past medical history, however, he was adopted from Russia at age 5, and his medical history prior to adoption is unknown. On examination, the child appears lethargic and has a temperature of 104.3. There is a mild injection of his conjunctiva and a generalized macular rash. White macules are noted on his buccal mucosa.

Rubeola The 4 C's - cough, coryza, conjunctivitis and cephalocaudal spread Morbilliform - maculopapular, brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days Koplik spots (small red spots on buccal mucosa with blue-white pale center) precedes rash by 24-48 hours.

Patient will present as → a 44-year-old female with intermittent joint pain. The joint pain began about 13 months ago affecting primarily the joints in her hands, wrists, and feet. She expresses concern regarding worsening fatigue, muscle aches, and feelings of depression. The physical exam reveals a tender, edematous bilateral wrists; painless oral ulcers; and erythematous maculopapular lesions on her face.

SLE

patient will present as → a 60-year-old man is brought to the emergency department because of crushing substernal chest pain for the past 45 minutes. He received 325 mg of aspirin en route. Nitroglycerin does not relieve his pain. He has a history of diabetes and hypertension. Medications include carvedilol and sildenafil. His temperature is 36.8°C (98°F), pulse is 99/min, respirations are 18/min, and blood pressure is 192/88 mm Hg. He appears diaphoretic. ECG shows ST-segment elevation (poss Q waves) in leads V1, V2, and V3.

STEMI

Patient will present as → a 43-year-old Caucasian male who spent the past month on a business trip in the Caribbean. Two weeks following his return, he began experiencing diarrhea, pain in his abdomen, and a headache. He presents to the hospital and is noted to be febrile with discrete, blanching, rose-colored spots on his back, chest, and abdomen. Alternative presentation → a 21-year-old bodybuilder presents with complaints of diarrhea, cramps, and low-grade fever for 24 hours. He has been training for a competition, eating large amounts of protein, including shakes made with raw eggs. He reports three thick green "pea soup" stools with blood in the commode today. He denies nausea or vomiting and tolerates liquids and solids. Examination reveals a well-muscled man in no apparent distress; lungs and heart unremarkable; abdomen, with mildly hyperactive bowel sounds and no tenderness or organomegaly; no evidence of hemorrhoids or anal fissure, no masses, and no stool present for hemoccult.

Salmonellosis

Patient will present as → an 11-year-old male complaining of intensely itchy, painful, red streaks between his fingers and in the groin area. The patient reports that the itchiness seems to be worse at night. His best friend who he had a sleepover with this past weekend is also having similar symptoms.

Scabies Pruritic papules. S-shaped or linear burrows on the skin. Often located in web spaces of hands, wrists, waist with severe itching (worse at night)

Patient will present as → a 67-year-old male concerned about skin cancer. He notes that over the past several years, several greasy moles have cropped up on his back. His wife had died of melanoma and he is scared that these moles are melanomas. On exam you note several small flesh colored, grey brown and black papules/plaques with a velvety warty texture and a greasy, "stuck on" appearance.

Seborrheic keratosis barnacles of old age

Patient will present as → a 23-year-old prison inmate was brought in from the detention clinic with a 3-day history of crampy abdominal pain and diarrhea. Patient reports the stools were small volume and bloody. On examination his abdomen is tender, he has decreased skin turgor, and the temperature was found to be 101.5°F (38.6°C). Stool microscopy reveals numerous RBCs and WBCs and a stool culture was ordered.

Shigellosis

Patient will present as → a 39-year-old female complaining of episodic left-sided jaw pain and swelling. The symptoms are typically aggravated by eating or by the anticipation of eating. Over the last 2-days, the patient has been experiencing worsening pain, redness, and fever. On physical exam, the left salivary gland is exquisitely tender. High-resolution noncontrast computed tomography (CT) scanning reveals a left-sided salivary gland stone.

Sialadenitis

Patient will present as → a 45- year-old male admitted to the hospital because of several months of sudden onset of recurrent weakness accompanied by flushing of the face and dizzy spells. The patient also had recurrent spells of chest pain localized to the sternal area. The symptoms last for 10-15 seconds and sometimes 30 seconds to a minute and go away without treatment. During his stay in the ICU, the patient had similar symptoms several times and the monitor showed long periods of asystole with no ventricular activity. This was associated with blood pressure drops and the patient felt dizzy. The echocardiogram is within normal limits.

Sick Sinus

Patient will present as → an 18-year-old student radiographer presents with a five-month history of blackouts which had latterly been occurring three or four times a day. They invariably occurred when she was standing, and from her description, there was no reason to think that the blackouts were other than vasovagal attacks, but their frequent occurrence was inconvenient. There were no other symptoms and no previous medical complaints. The pulse rate was 60 beats per minute and irregular; blood pressure was 100/60 mmHg with no postural drop. A three-minute electrocardiogram recorded during spontaneous respiration showed respiratory sinus arrhythmia with an amplitude of 20-1%, well outside the normal range.

Sinus arrhythmia

Patient will present as → a 34-year-old previously healthy male with complaints of facial pressure and rhinorrhea for the past 3 weeks. The patient reports that several weeks prior, he had a "common cold" which resolved. However, he has since developed worsening facial pressure, especially over his cheeks and forehead. He reports over 1 week of green-tinged rhinorrhea. His temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. Nasal exam reveals edematous turbinates and purulent discharge. The patient has facial tenderness with palpation over the involved sinus. A 20 year-old woman presents with a 3-day history of sneezing, watery nasal discharge, and a nonproductive cough. Her throat was sore for the first 2 days, and she now complains of fatigue and difficulty breathing because of her "stuffy nose."

Sinusitis Looking for symptoms that worsen over 5-7 days or do not improve in > 10 days Symptoms: fever, facial pain, a headache that can radiate to the upper teeth, purulent rhinorrhea, congestion, and loss of smell Physical exam: Classically, facial tenderness with palpation over the involved sinus Acute sinusitis < 4 weeks duration Sudden onset Most commonly caused by S. pneumoniae, H. influenzae, Moraxella catarrhalis Usually precipitated by an acute viral respiratory tract infection which is thought to lead to reduced clearance of mucus Chronic sinusitis > 12 consecutive weeks Associated bacteria include S. aureus, anaerobes, and gram-negative organisms Other risks include systemic disease, anatomic anomalies, trauma, noxious chemicals such as pollutants or smoke, and medications

Patient will present as → a 48-year-old man is brought to his physician by his wife, who is concerned about his daytime sleepiness. Last week, he fell asleep while stopped at a red light. She says that he snores loudly and sometimes stops breathing for a few seconds while sleeping. His past medical history is significant for hypertension. He has a 20-pack-year history of smoking. His temperature is 37 C (98.6 F), heart rate is 86/min, blood pressure is 156/95 mm Hg, respiratory rate is 12/min. On physical exam, he is obese, but chest auscultation and extremity exam are within normal limits.

Sleep Apnea and Obesity Hypoventilation Syndrome

Patient case presentation → a lab technician calls to tell you that a 22-year-old man you have sent for a blood draw is very anxious. He says he is terrified of having his blood drawn and almost faints at the sight of the needle.

Specific phobia

A 25-year-old female, G2 P1001, presents to your office at 11-weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, blood is noted at the dilated cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8-9 weeks gestation. No other abnormalities are found.

Spontaneous abortion

Patient will present as → a 50-year-old woman with a history of hyperlipidemia and diabetes type 2 complaining of "chest pain attacks." She says that these attacks tend to occur while walking up five flights of stairs to get to her apartment, they last for 15-20 minutes and are relieved by rest. She describes the pain as sharp and substernal. A baseline EKG is unremarkable. Suspecting the diagnosis, you perform an exercise stress EKG and observe transient ST depressions in the anterolateral leads after significant exertion.

Stable angina

Patient will present as → a 38-year-old man with a history of a gastric bypass for morbid obesity comes to your office with a hemoglobin level of 10 g/ dL. His MCV is 88 mm3. His ferritin level is 35 mcg/ L, and his red cell distribution width is high. His reticulocyte count is high. Further questioning reveals mild anorexia, diarrhea, glossitis, and distal paresthesia. On exam you notice she has a swollen red tongue.

Vitamin B12 def

Patient will present as → a 60-year-old woman with a severe drug-induced reaction on both lower limbs with few lesions elsewhere in addition to mucosal involvement of the mouth of two days duration. The insulting drug was sulfonamide and the onset of the rash was within 48 hours of taking the drug. The rash comprised of bilateral symmetrical bullae on a background of erythematous macules and patches in addition to erosions and peeling.

Stevens Johnson Syndrome SJS is 3-10% of the body Begins with a prodrome of flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Layers of skin peel away in sheets (+) Nikolsky's sign (pushing blister causes further separation from dermis) Stevens-Johnson syndrome (SJS) is a milder form of toxic epidermal necrolysis (TEN) with LESS THAN 10% of body surface area detachment

Patient will present as → a 69-year-old woman who is brought in to the emergency department by ambulance after her husband noticed that she began slurring her speech and had developed facial asymmetry during dinner approximately 30 minutes ago. Her past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. She is noted to have distinct right facial paralysis. Non-contrast head CT is performed, which is negative for blood.

Stroke (can wrinkle eyebrows unlike bell's palsy)

55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.

Subdural hematoma

Patient will present as → a 17-year-old female who attempts suicide by swallowing several tablets of acetaminophen.

Suicide

Patient will present as → a 78-year-old man with a 3-month history of weight loss, fever, fatigue, night sweats, and cough. He is a former smoker. A recent HIV test was negative. A CT scan of the chest reveals a 3 cm lesion in the upper lobe of the left lung and calcification around the left lung hilus. A sputum smear was positive for acid-fast organisms.

TB

Patient will present as → a 9-month-old female with nasal congestion and cough is brought to your clinic by her mother who reports that the child is very fussy, has been tugging at her right ear, and refuses to eat. On physical exam, you note copious green/yellow nasal discharge and right-sided otorrhea. Otoscopic exam reveals a significant amount of clear/white discharge obstructing your view. With careful examination, you are able to observe a ruptured right tympanic membrane.

TM Perforation

Patient will present as → a 34-year-old woman who arrives at the ED with acute-onset fatigue, fever, palpitations, and blurry vision. On chart review, it is revealed that she was recently diagnosed with AIDS and was on multiple antiretroviral medications. On physical exam, her skin is mildly jaundiced. She has multiple purpura over her extremities. A complete blood count is significant for a platelet count of 37,000/μL (normal 150,000 - 400,000/μL) and mild anemia. Her peripheral smear reveals schistocytes. She has a negative Coombs test. Alternative presentation (TTP-HUS) → a child with renal failure + Escherichia coli O157:H7 infections and diarrhea.

TTP

Patient will present as → a 22-year-old male who develops a firm, painless, non-tender testicular mass with elevated serum β-HCG

Testicular cancer

Patient will present as → a 10-year-old boy with chief complaint of paleness refer to your office. On physical exam he has splenomegaly (3 cm BCM) and lab data show these results: Hb: 8.5 (normal 12-17.5), MCV 79 (normal 80-100), MCH 22.5 (normal 25-34), WBC: 50,000, Plt: 650,000 (normal 150,000 - 400,000)

Thalassemia A quick way to differentiate the two anemias is to examine the RBC count. In iron deficiency, the number will be low. In thalassemia, the number will be normal to high

Patient will present as → a 7-year-old female with large patches of depigmentation affecting the neck, upper back and the chest of three years duration. The whitish patches are sharply demarcated with some residual brownish areas within. Some hairs in the involved areas have become white as well. Wood's light examination reveals a "milk-white" fluorescence over the lesion. The patient is started on topical corticosteroids and a referral is provided to the dermatologist.

Vitiligo

30-year-old woman with a recurrent history of nosebleeds and heavy menses. She recently read that taking a baby aspirin was good for the heart. However, ever since she started taking aspirin, she has been experiencing more and more nosebleeds. Her father and paternal uncle similarly have histories of prolonged nosebleeds. Labs show increased PTT, normal PT, and increased bleeding time.

Von Willebrand disease

Patient will present as → a 68-year-old female who arrives at the emergency department after a syncopal episode at work. Physical exam reveals an obese, unresponsive female with bilateral nonpalpable radial, carotid, and distal pedal pulses. Vital signs are as follows: T 99.4 F and BP 88/47. An emergent EKG is obtained

Vtach Stable: amiodarone-->lido-->procainamide Unstable (CP, dyspnea, hypoTN, AMS): -monomorphic: sync DC cardioversion 100J -polymorphic: immediate defib

60-year-old male complains of fatigue, blood tests demonstrate severe anemia, decreased neutrophil count, and small, abnormal B lymphocytes in the bone marrow (>30%) with levels at 90,000 per cubic millimeter. Has painless cervical lymphadenopathy and hepatosplenomegaly.

chronic lymphocytic leukemia (CLL)

Verruca vulgaris (common warts): skin-colored papillomatous papules Verruca plana (flat warts): Hands, face, arms, legs Verrucae plantaris (plantar warts): bottom of the foot. Rough surface. Dark spot (thrombosed capillaries) Condyloma acuminatum (venereal warts): flesh-colored, cauliflower appearance genital warts caused by HPV types 6 and 11 Epidermodysplasia verruciformis: a rare, lifelong hereditary disorder characterized by chronic infection with HPV

Warts=HPV

a 60-year-old Asian American woman presents with sudden ocular pain. She reports she was visiting the planetarium when the pain started and when she walked outside she saw halos around the street lights. The pain was so bad that she began to vomit. She reports her vision is decreased. Physical examination reveals conjunctival injection, a cloudy cornea, and pupils A 64 year-old woman complains of headache and left eye pain for about a day. She says it started yesterday as a dull ache and now is throbbing. She also complains of nausea and vomiting, which she attributes to the popcorn she ate at the movie theater yesterday afternoon. On exam, the left pupil is mid-dilated and nonreactive. The cornea is hazy. A ciliary flush is noted.

acute angle closure glaucoma

a 3-7 y/o child with lymphadenopathy, bone pain, bleeding, and fever. Bone marrow demonstrates > 20% lymphoblasts

acute lymphocytic leukemia (ALL)

present as → a 32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had an intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points.

UC

Patient will present as → a 45-year-old male with a one week history of hacking non-productive cough, low grade fever, malaise and myalgias. The chest x-ray reveals bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest.

Viral pneumonia

Tinea Barbae: papules pustules, around hair follicles Tinea Pedis: Athlete's Foot: pruritic scaly eruptions between toes. Trichophyton rubrum is the most common dermatophyte causing athlete's foot Mgmt: Topical antifungals Tinea Cruris: "Jock Itch" diffusely red rash in the groin or on the scrotum Tinea capitis: Most common fungal infection in the pediatric population. Occurs mainly in prepubescent children (between ages 3 and 7 years). Asymptomatic carriers are common and contribute to spread Tinea corporis: (ringworm): usually seen in younger children or in young adolescents with close physical contact with others (i.e. wrestlers) Tinea versicolor: is caused by Malassezia furfur, a yeast found on the skin of humans. Lesions consist of hypo or hyperpigmented macules that do not tan; case example of tinea versicolor: A 20-year-old male with no significant past medical history presents complaining of patchy tanning. He states that he has been out in the sun without a shirt several times. Areas on his chest and back just don't tan, and he is becoming self-conscious

Tinea infections

Patient will present as→ a 70-year-old female who states that her children and grandchildren have asked her to seek medical attention as she seems to be losing her hearing. She also describes an occasional ringing, buzzing, and hissing sound. She is in generally good health and her only medications are a multivitamin along with calcium and vitamin D. You examine her ears and find the external auditory canals to be free of cerumen and the tympanic membranes to be normal in appearance.

Tinnitus

Patient will present as → a 45-year-old male who reports that he has felt more anxious and irritable lately. He states that he has been very stressed out at work lately and thinks that his symptoms are attributable to the stress. He smokes 1 pack per day, but lately has found himself smoking up to 4 packs per day to ease his stress. Upon further counseling, he says he is interested in quitting and wants your help.

Tobacco related disorders

Patient will present as → a 60-year-old woman with a severe drug-induced reaction with extensive skin involvement covering > 30% of her body surface area. The insulting drug was anticonvulsant medication and the onset of the rash was within 10 days of taking the drug. The rash comprised of bilateral symmetrical bullae on a background of erythematous macules and patches in addition to erosion and peeling. On examination, her skin peels away in sheets when pressure applied and rubbed.

Toxic epidermal necrolysis TEN is > 30% of body Very similar to Steven-Johnson syndrome - The difference is the age of the individuals (in toxic epidermal necrolysis older patients vs. SJS younger patient) and percentage of the body affected (in TEN > 30% of body surface area affected vs. SJS < 10% of body surface area affected)

Patient will present as → a 73-year-old male with a history of hyperlipidemia, tobacco use, and diabetes arrives at the ER with slurred speech. He was eating dinner with his daughter earlier that night when the symptoms began. She notes that he had a similar episode one year ago that resolved within an hour, as well as an episode of right arm weakness two months ago that resolved within 2 hours. His current symptoms resolve in the ED. His vital signs are as follows: T 99.6 F, BP: 146/96, HR: 76 and O2: 98% on room air. Physical exam reveals bilateral carotid bruits. A CT scan of his head is shown here.

Transient Ischemic Attack (mini stroke b/c just temporary)

Patient will present as → a 58-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia presents to an emergency department for evaluation of chest pain. He reports somewhat suddenly experiencing dull left-sided chest discomfort while at rest at home that was not relieved with taking nitroglycerin. His vital signs are T 37.1, HR 94 beats per minute, BP 133/87, and O2 saturation 97% on room air. His ECG shows no ST-segment changes; serum troponin is not elevated. His chest pain subsequently resolves and he is admitted to the cardiac service for further management. A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains inactive the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis?

Unstable angina

Patient will present as → a 22-year-old heterosexual male who recently started having unprotected intercourse with his new girlfriend. He now reports a painful itching and burning sensation with urination and discomfort in the urethra. He says that sometimes in the morning it appears that the walls of the meatus are stuck together with evidence of dried secretions. On exam, there is no purulent discharge. The meatus does appear red. His girlfriend does not have any symptoms.

Urethritis

Patient will present as → a well-appearing 9-month-old male with a rash that comes and goes. According to the mother, citrus was recently added to the patient's diet. On physical exam, you observe a widespread rash composed of blanchable, edematous, pink, papules and wheels on the face, trunk, and lower extremities. The patient is started on PRN oral antihistamines for pruritis and the mother is encouraged to eliminate citrus from his diet. The rash resolves within 72 hours.

Urticaria blanchable, pruritic, raised, red, or skin-colored papules, wheels or plaques on the skin's surface (+) Darier's sign: localized urticaria appearing where the skin is rubbed (histamine release) Angioedema: painless, deeper form of urticaria affecting the lips, tongue, eyelids hand and genital

Patient will present with → symptoms that depend upon the cause of the inflammation, but all types will usually cause vaginal itching or burning and pain with sexual intercourse. Bacterial infections cause a foul-smelling vaginal discharge that is grayish in color. PH > 4.5 Fungal infections cause white curd-like discharge. PH < 4.5 Vaginal trichomoniasis infection can cause a green-yellow vaginal discharge and strawberry cervix. Menopause-induced vaginitis will cause itching and irritation of the vagina and painful intercourse. There may be pain present during urination, as well.

Vaginitis

81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. Mental status has clearly worsened after each stroke.

Vascular ("multi-infarct") dementia *Associated with arteriolosclerotic small vessel disease Multi-infarct, usually correlated with a cerebrovascular event and/or cerebrovascular disease Stepwise deterioration with periods of clinical plateaus

55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.

Vestibular neuronitis *Vertigo without position change but no hearing loss or tinnitus (inflammation of vestibular portion of CN VIII). Often associated with viral illness

Patient will present as → a 72-year-old male who develops coarse ventricular fibrillation while being monitored following an uneventful colonoscopy. He is immediately defibrillated using a bi-phasic defibrillator at 120 joules. The countershock is successful and he is converted to a sinus tachycardia. He has resumed spontaneous breathing. You are taking the history of a patient who is scheduled to have an internal cardiac defibrillator placed when the patient becomes unresponsive without a pulse. The nurse attaches a cardiac monitor and a chaotic rhythm with no discernible pattern is seen. What is the most likely diagnosis?

Vfib -Treat with unsynchronized cardioversion & start CPR Give 3 sequential shocks (120, 150, 180); assess rhythm If VF persists --> do CPR and intubate Administer 2 doses amiodarone 2-4 min. Administer 1 mg IV bolus epi every 3-5 minutes (will increase myo and dec cerebral blood flow and dec defib threshold) Implantable cardioverter-defibrillator may be necessary

older male (>60y) with severe back or abdominal (flank) pain who presents with syncope and hypotension with a tender pulsatile abdominal mass.

abdominal aortic aneurysm

an 18-year-old surfer complaining of an intensely pruritic, serpiginous-type rash that has formed on the sole of his foot. The rash appears to be spreading and is forming bullae at the affected site.

hookworm

a 43-year-old who has recently noticed bright red blood on the toilet paper when he wipes. He denies any fatigue, decreased exercise tolerance, abdominal pain, or maroon-colored or black, tarry stools. He has no family history of colon cancer. He has never had a colonoscopy. On physical exam, his temperature is 98.6 F, heart rate 70/min, and blood pressure 120/75 mmHg. He does not have conjunctival pallor. There are no abnormalities on cardiac, pulmonary, and abdominal exams. significant pain, but no bleeding.

internal hemorrhoids vs external

Patient will present as → a 16-year-old female with an acute eruption of violaceous, pruritic, polygonal, shiny, flat-topped papules involving the flexor surfaces.

lichen planus The 5 P's: pruritic, purplish, polygonal, plain-topped papules

Patient will present as → a 34-year-old male with a very itchy skin lesion on the front of the ankle of his left foot. The itching is paroxysmal and severe. On examination, there is a well-defined, thickened and hyperpigmented large plaque spreading across the front of left ankle

lichen simplex chronicus thick, leathery, brownish skin A long-term manifestation of scratching atopic dermatitis

Patient will present as → a 6-year-old male is brought to the clinic by his mother complaining of a rash. On physical exam, you observe dozens of discrete 5-15 mm, pink, flesh-colored, waxy, dome-shaped, umbilicated pearly papules with central umbilication on the lower abdomen and genital area.

molluscum contagiosum (poxvirus)

a 32-year-old sportsman who recently attended a wild-game feed banquet consumed summer sausage made from bear meat. He complains of abdominal discomfort, diarrhea, and muscle tenderness.

roundworm

Patient will present as → a 68-year-old female with a syncopal episode that lasted less than 1 minute. She states she felt nauseous prior to losing consciousness. She has no significant past medical history. Resting blood pressure is 132/84 mm Hg. ECG is normal.

syncope