Vignettes

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

Asthma

A 64-year-old man presents with painless hematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical exam shows only moderate enlargement of the prostate. Urinalysis is positive for 10 to 15 RBCs and 5 to 10 WBCs per high-power field with no bacteria detected.

Bladder cancer

The mother of a 4-month-old infant reports that he has had 3 to 4 days of constipation. She states that the baby has had difficulty feeding over the past 24 hours and is unable to suck and swallow. She is also worried that he feels limp in her arms and appears to have a very weak cry.

Botulism

A 46-year-old man presents to the ER after being discovered obtunded at home. A history from family reveals complaints of progressive sinus-type headaches during the 2 weeks prior. While in the ER the patient becomes unresponsive and requires intubation. MRI scan with contrast reveals a right parietal ring-enhancing lesion.

Brain abscess

An anxious 30-year-old woman seeks medical attention because of recent worsening headaches and visual disturbances. She is a smoker and has a sibling who was admitted to the hospital for a ruptured cerebral aneurysm. Examination discloses slight ptosis of the left eye. On neurologic exam, her left pupil is dilated, minimally reactive to light, and pointing inferiorly and laterally at rest. CT of the brain shows no subarachnoid blood. Lumbar puncture is normal. Magnetic resonance angiography of the brain discloses a 5-mm aneurysm in the left posterior communicating artery.

Cerebral aneurysm

A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the RUQ that began after eating dinner and radiates through to her back. This pain gradually increased before becoming constant over the last few hours. She has had previous episodes of similar pain for which she has not sought medical advice. Her vital signs are normal. The pertinent findings on physical exam are tenderness to palpation in the right upper quadrant without guarding or rebound.

Cholelithiasis

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

Chronic pyelonephritis

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

Cirrhosis

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

Cirrhosis

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

Cluster headache

A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool, which is associated with a change in his normal bowel habit such that he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well and there was no family history of GI disease. Examination of his abdomen and digital rectal examination are normal.

Colorectal cancer

A 41-year-old alcoholic man has a 6-year history of recurrent attacks of pancreatitis characterized by epigastric pain radiating to the back. The initial attack required hospitalization for severe pain, and clinical chemistry showed a >15-fold elevation in serum amylase and lipase. Subsequent attacks were less severe, managed primarily as an outpatient, and lasted less than 10 days, with long symptom-free intervals. After detoxification 6 months ago he had no further attacks, but has recently developed evidence of diabetes and steatorrhea. CT imaging shows pancreatic calcifications but no cystic or mass lesions

Chronic pancreatitis

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

Chronic pyelonephritis

A 73-year-old woman with previous history of myocardial infarction presents to the ER. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure (JVP) is elevated 3 cm above normal and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest exam. Echocardiogram shows an ejection fraction of 35%.

Congestive heart failure acute exacerbation

A 65-year-old man presents with gradually progressive dyspnea on exertion and a nonproductive cough. He has no history of underlying lung disease and no features that would suggest an alternative etiology for his cough and dyspnea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He is on no medications and has no environmental exposures to organic allergens such as mold. On exam he has fine crackles audible over his lung bases bilaterally but no evidence of volume overload. He has clubbing of his fingers.

Idiopathic pulmonary fibrosis

A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to the hospital for neurologic evaluation.

Febrile seizures

A 42-year-old man presents with a recent history of abdominal pain, distension, and nausea. Urea breath testing for Helicobacter pylori is positive.

Gastritis

A 58-year-old white woman of North European descent presents with a 2-month history of increasing fatigue, difficulty with ambulation, and memory deficits. Family history is notable for autoimmune disease. Laboratory evaluation is remarkable for a macrocytic anemia, a markedly reduced serum vitamin B12, and presence of antiparietal cell antibodies.

Gastritis

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

Gastroesophageal reflux disease

A 16-year-old female high school student presents with complaints of fever, sore throat, and fatigue. She started feeling sick 1 week ago. Her symptoms are gradually getting worse, and she has difficulty swallowing. She has had a fever every day, and she could hardly get out of bed this morning. She does not remember being exposed to anybody with a similar illness recently. On physical examination she is febrile and looks sick. Enlarged cervical lymph nodes, exudative pharyngitis with soft palate petechiae and faint erythematous macular rash on the trunk and arms are found.

Infectious mononucleosis

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

Infective endocarditis

A 34-year-old mother of 3 presents to her family physician with a 3-week history of abdominal cramping pain in both lower quadrants. She has been having frequent small, soft stools accompanied by some mucus but no blood. Her symptoms are improved with bowel movement or passage of flatus. She has had these symptoms almost monthly since she was in college, but they have been worse recently. Past history is negative except for 3 normal pregnancies. Family history is negative for colon cancer. A sister has similar symptoms but has not seen a physician. Personal/social history reveals that she is an accountant working long hours. Her firm is about to merge with another, and she fears her job situation is tenuous. Review of systems is otherwise negative. She has not lost any weight or had any other constitutional symptoms. On physical exam, the only finding is some mild tenderness in the RLQ. No mass is felt.

Irritable bowel syndrome

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

Iron deficiency anemia

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

Iron deficiency anemia

A 40-year-old housewife complains of recurrent constipation. She has had problems since her 20s, but they are worse now. The constipation is accompanied by abdominal bloating and abdominal pain, and the discomfort is only better when she has a bowel movement. On her gynecologist's advice, she has tried more fiber in her diet, including fresh fruits and leafy vegetables, but that has only made the bloating worse. Her past history includes a cholecystectomy and a hysterectomy. Physical exam is entirely normal. Rectal exam reveals normal consistency stool. Stool samples test negative for occult blood

Irritable bowel syndrome

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

Ischemic stroke

A 19-year-old man presents to the emergency department with a witnessed generalized tonic-clonic seizure episode. One month previously he had an upper respiratory tract infection. Over the last 2 weeks he developed headaches, blurred vision, generalized weakness, and progressive difficulty walking. Examination revealed pain on eye movement as well as limb and gait ataxia.

Encephalitis

A 56-year-old man presents to the emergency department with headache, fever, blurred vision, and somnolence followed shortly by unresponsiveness to verbal commands. For the last 2 weeks he had been feeling ill, and had decreased appetite and myalgias. Three days prior to presentation he experienced intermittent confusion, severe headache, and fever. Examination was limited by a generalized tonic-clonic seizure, for which he received lorazepam.

Encephalitis

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

Erectile dysfunction

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

Erectile dysfunction

A 35-year-old man with no past medical history presents to the ER after he noted cola-colored urine. He denies pain or fever associated with the bleed, but has had a sore throat for the past 3 days, which is getting better. He has not had a similar episode previously. Exam reveals a nonblanching purpuric rash over both his legs. There are no other abnormalities.

Glomerulonephritis

A 42-year-old man with a medical history of HIV infection presents to his primary care physician with generalized swelling progressive for the past week. HIV was diagnosed a year ago and he has been noncompliant with the therapy prescribed. He denies orthopnea, abdominal pain, nausea, and blood in his urine. He has nonpitting edema mostly over the lower extremities but extending up to mid-abdomen.

Glomerulonephritis

A 23-year-old man of Iranian origin consults his primary care provider about a skin rash. He has an intensely pruritic rash over his buttocks and back that has appeared spontaneously. He is referred to a dermatologist, who diagnoses dermatitis herpetiformis and prescribes dapsone. Two days later he develops severe nausea and exhaustion, and complains of passing dark urine. His wife notices he has become jaundiced. He attends the ER, where investigations reveal anemia (Hb 7.5 g/dL) and abnormal biochemistry (elevated BUN, deranged liver function, and unconjugated hyperbilirubinemia). An urgent hematology consult is obtained and a diagnosis of drug-induced hemolytic anemia made.

Glucose-6-phosphate-dehydrogenase deficiency

An 18-year-old Greek man presents to the ER with severe nausea, vomiting, and diarrhea. His mother explains that he had been at a lunch party with friends and none of the other guests were ill. The patient had ingested a meal of rice, meat, and freshly cooked beans. He has not had any significant illnesses in the past. Examination reveals a markedly dehydrated young man who is clinically anemic and jaundiced. Investigations show a hemoglobin of 5.1 g/dL, elevated WBC count with a predominant neutrophilia, elevated BUN and creatinine, and deranged liver function. No urine can be obtained. Intravenous fluids are commenced, followed by a transfusion of packed red cells; the patient becomes acutely dyspneic, however, and chest x-ray shows features of pulmonary edema. A nephrologist is consulted. Intravenous diuretic therapy is prescribed, a urinary catheter inserted, and 30 mL of urine obtained that, on testing, shows a high urobilinogen and protein content.

Glucose-6-phosphate-dehydrogenase deficiency

A 24-year-old black woman presents with a history of unprotected vaginal sex with one male partner who told her that he had purulent urethral discharge that was treated as gonorrhea 1 week ago. The woman has had some increased vaginal discharge and pain with intercourse.

Gonorrhea infection

A 35-year-old white man presents with a history of unprotected insertive anal sex with 2 male partners and a 3-day history of urethral irritation, dysuria, and purulent discharge at the meatus

Gonorrhea infection

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

Graves disease

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

Hemorrhagic stroke

A 28-year-old woman presents complaining of rectal pain of 3 days' duration. She states that on the day before the onset of symptoms she had been moving boxes at her home. She describes the pain as sharp and present constantly, but worse with bowel movements or sitting. She denies any fevers or chills or perianal discharge. Physical exam reveals a 2-cm, painful, bluish lesion adjacent to the anal canal.

Hemorrhoids

A 42-year-old man presents to his primary care physician complaining of a 3-month history of lower intestinal bleeding. He describes the bleeding as painless, bright blood appearing on the tissue following a bowel movement. He has had 2 episodes recently where blood was visible in the toilet bowl following defecation. He denies any abdominal pain and any family history of GI malignancy. Physical exam reveals a healthy man with the only finding being bright blood on the examining finger following a digital rectal exam.

Hemorrhoids

A 5-year-old boy is brought in by his mother. He presents with a 4-day history of a rash on his lower extremities, mild abdominal cramping, and diffuse joint pain. His mother reports that he was recently treated for a URI.

Henoch-Schonlein purpura

A 65-year-old woman presents with generalized headache and burning pain in her left temporal area. Eight days after onset of the pain, several facial lesions are noted. On physical examination, she is afebrile. An erythematous tender plaque is present on the left frontal scalp area. Three smaller similar plaques are present on the left temple and cheek.

Herpes zoster infection

A 77-year-old man reports a 5-day history of burning and aching pain on the right side of his chest. This is followed by the development of erythema and a maculopapular rash in this painful area, accompanied by headache and malaise. The rash progressed to develop clusters of clear vesicles for 3 to 5 days, evolving through stages of pustulation, ulceration, and crusting. Common Vignette 2

Herpes zoster infection

A 51-year-old man with moderate obesity (BMI of 34 kg/m^2) is seen in consultation for heartburn and regurgitation. He has a diagnosis of GERD and has been treated with proton-pump inhibitors. His heartburn is less severe with the medication, but he still is bothered by regurgitation. His physical examination is unremarkable. A barium esophagram and upper endoscopy demonstrate a type I (sliding) hiatal hernia, with about one third of the upper stomach in the chest. The patient has free reflux to the level of the cervical esophagus.

Hiatal hernia

A 40-year-old man presents with a 3-week history of fever, headache, dry cough, pleuritic chest pain, and poor appetite. He does not report hemoptysis or dyspnea. His review of systems is otherwise unremarkable. He lives in Ohio and is an archaeologist. He has no sick contacts and cannot recall any specific exposures. His symptoms developed 2 weeks after he had worked on a local excavation project in the Ohio River valley.

Histoplasmosis

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

Oral candidiasis

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

Peptic ulcer disease

A 27-year-old woman presents with amenorrhea. She had been taking the combined oral contraceptive pill for the last 9 years, stopping this 11 months ago. She is otherwise healthy, but on physical exam she has bilateral galactorrhea. Laboratory work-up reveals an elevated prolactin level of 150 micrograms/L (3000 mIU/L). Normal prolactin levels are up to 25 micrograms/L (500 mIU/L). She also had low-normal gonadotropin (LH, FSH) levels. MRI examination of the pituitary sellar region depicts a 6 mm right-sided pituitary mass, with no suprasellar or parasellar extension.

Prolactinoma

A 45-year-old man presents with loss of libido and some erectile dysfunction. He is otherwise healthy. On physical examination he has mild bilateral gynecomastia and normal testes. Laboratory work-up reveals a highly elevated prolactin level of 2300 micrograms/L (46,000 mIU/L). Normal prolactin levels are up to 15 micrograms/L (300 mIU/L). He also has low testosterone, LH, and FSH levels. MRI exam of the pituitary sella depicts a large 32 mm pituitary macroadenoma with suprasellar extension and optic chiasmal compression. Visual field assessment reveals bitemporal hemianopia.

Prolactinoma

A 60-year-old black man presents to his primary care physician with complaints of difficulty with urination. He describes a weak stream and a sense of incomplete voiding. He describes nocturia (5 episodes per night) and has been taking an alpha-blocker for this with minimal improvement. He says he can last about 60 to 90 minutes without urinating. He denies any suprapubic tenderness, dysuria, or hematuria. He further denies any back pain or gastrointestinal complaints. Rectal exam reveals his prostate to be approximately 60 mL, asymmetrical with a large 2-cm nodule at the right base.

Prostate cancer

A 65-year-old white man presents to his primary care physician in his normal state of health. He describes nocturia (1 episode per night) and a 3-hour daytime voiding interval. He denies any incontinence, hematuria, dysuria, frequency, or urgency. He has no gastrointestinal complaints. Physical examination reveals his prostate to be smooth and symmetrical, with an approximate volume of 40 mL.

Prostate cancer

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

Pulmonary Embolism

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

Meningococcal disease

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

Meningococcal disease

A 10-year-old female Pacific Islander presents with a 2-day history of fever and sore joints. Further questioning reveals that she had a sore throat 3 weeks ago but did not seek any medical help at this time. Her current illness began with fever and a sore and swollen right knee that was very painful. The following day her knee improved but her left elbow became sore and swollen. While in the waiting room her left knee is now also becoming sore and swollen

Rheumatic fever

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

Salmonella infection

A 24-year-old woman with known SCD presents with a 3-day history of cough productive of white sputum, nausea, and poor appetite. She also has chest and hip pain unalleviated by acetaminophen or ibuprofen.

Sickle cell anemia

A 6-month-old boy with no previous medical problems presents with fever and painful swelling of the hands and feet. His parents are concerned because he has been inconsolable for 6 hours. The infant has been refusing bottles and has needed fewer diaper changes over the last 2 days.

Sickle cell anemia

A 77-year-old man presents to his primary care physician with weight loss of 15 pounds and a 3-month history of dysphagia and abdominal pain. The only abnormal finding on physical examination is stools positive for occult blood. He is referred for an upper endoscopy, which shows an exophytic, ulcerated mass in the cardia of the stomach. Biopsy reveals moderately differentiated adenocarcinoma.

Stomach cancer

A 38-year-old white woman presents to the ER with 24 hours of dyspnea and pleuritic chest pain. On further questioning, she reports a 3-year history of Raynaud disease, polyarthralgia, and intermittent migraine. Physical examination reveals hypoxia, tachycardia, and normal blood pressure. Ventilation perfusion scanning confirms a pulmonary thromboembolism.

Systemic lupus erythematosus

A 40-year-old overweight black woman presents with a 1- to 2-week prodrome of fatigue and malaise with diarrhea and vomiting. Examination is normal except for slight confusion and petechiae on her lower extremities. Laboratory studies show a hematocrit of 25% and a platelet count of 10,000 cells/mm^3. Lactate dehydrogenase is elevated. Serum creatinine is 1.1 mg/dL. Peripheral smear shows fragmented RBCs (schistocytes) and an elevated reticulocyte count.

Thrombotic thrombocytopenic purpura

A 40-year-old woman is found to have a 2-cm right-sided thyroid nodule during a routine physical examination. She has no history of head and neck irradiation or family history of thyroid cancer. The nodule is firm and mobile in relation to the underlying tissue. Vital signs and the remainder of the examination are normal.

Thyroid cancer

An overweight 55-year-old woman presents for preventive care. She notes that her mother died of diabetes, but reports no polyuria, polydipsia, or weight loss. BP is 144/92 mmHg, fasting blood sugar 148 mg/dL (on 2 occasions), HbA1c 8.1%, LDL-cholesterol 200 mg/dL, HDL-cholesterol 30 mg/dL, and triglycerides 252 mg/dL.

Type 2 diabetes mellitus

A 27-year-old man with a 3-month history of rectal bleeding and diarrhea is referred for evaluation. Laboratory tests show mild anemia, a slightly elevated sedimentation rate, and the presence of white blood cells in stool. Stool culture is negative. Colonoscopy shows continuous active inflammation with loss of vascular pattern and friability from the anal verge up to 35 cm, with a sharp cut-off. The colonic mucosa above 35 cm appears normal, as does the terminal ileum. Biopsy specimens show active chronic colitis.

Ulcerative colitis

A 15-year-old boy presents with left scrotal swelling/mass detected on a routine school physical exam. The patient states that he is completely asymptomatic. There is no significant medical history and he has not had any previous surgeries. He is on no medications and has no allergies. Physical exam in the supine position reveals asymmetric testicular size (left smaller than right) with no masses. With the patient in the standing position, a grade III left varicocele can clearly be seen and palpated in the left hemiscrotum.

Varicocele

A 30-year-old healthy man presents with primary infertility. He has been unable to establish a pregnancy for the last 12 months with his partner. On physical exam, a grade II left varicocele is easily palpable when the patient is standing and is nonpalpable when supine. The testicles are symmetric and normal in size.

Varicocele

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

influenza infection

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

influenza infection

A 74-year-old man with a known history of benign prostatic enlargement and insulin-requiring type 2 diabetes presents with a 7-day history of worsening right-sided scrotal pain and swelling. Initial symptoms of dysuria and frequency have resolved since his family doctor prescribed a course of antibiotics 4 days ago. Examination reveals a tender, swollen right epididymis with an associated hydrocele.

Acute epididymitis

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

Acromegaly

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

Acromegaly

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

Acute cystitis

A 21-year-old man presents with a 3-day history of worsening left-sided scrotal pain and swelling. He reports noticing a white urethral discharge over the last 24 hours. He is otherwise well, and takes no regular medication. He is heterosexual and has a single female partner, with whom he has unprotected intercourse. Examination reveals a tender, erythematous, swollen left hemiscrotum with a palpably thickened epididymis.

Acute epididymitis

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

Acute pyelonephritis

A 67-year-old man has been receiving amoxicillin treatment for bronchitis for 2 weeks. He develops a macular rash on his neck, torso, and back. The amoxicillin is therefore changed to cephalexin for an additional 7 days. The rash resolves, but he returns complaining of fatigue and a low-grade temperature that has persisted despite the resolution of bronchitis. He has a history of hypertension, hyperlipidemia, a previous myocardial infarction (6 years ago), and symptoms suggestive of gastric reflux. There is no history of renal disease. He has been on a stable regimen of lisinopril, metoprolol, simvastatin, and omeprazole. Physical exam reveals a BP of 140/85 mmHg, pulse 68 bpm regular, temperature 100°F (37.8°C), and respirations of 16/minute. Head, eye, ENT, heart and lung, and abdominal exams are negative. He has no edema and no rash.

Acute interstitial nephritis

A 48-year-old woman with a history of migraine headaches presents to the emergency room with altered mental status over the last several hours. She was found by her husband, earlier in the day, to be acutely disoriented and increasingly somnolent. On physical examination, she has scleral icterus, mild right upper quadrant tenderness, and asterixis. Preliminary laboratory studies are notable for a serum ALT of 6498 units/L, total bilirubin of 5.6 mg/dL, and INR of 6.8. Her husband reports that she has consistently been taking pain medications and started taking additional 500 mg acetaminophen pills several days ago for lower back pain. Further history reveals a medication list with multiple acetaminophen-containing preparations. Other Presentations

Acute liver failure

A 38-year-old man presents to his primary care physician complaining of generalized weakness, epistaxis, mouth ulcers, and weight loss. He has unremarkable past medical history and takes no medications. Physical examination reveals mild pallor and petechial hemorrhages over his lower limbs. He has multiple, widespread small lymph nodes that are palpable and mild splenomegaly.

Acute lymphocytic leukemia

A 4-year-old girl presents with lethargy, dyspnea, fever, and bruising. On examination she has hepatosplenomegaly. CXR shows a mediastinal mass and pleural effusion.

Acute lymphocytic leukemia

A 58-year-old man presents to his primary care physician with increasing tiredness, accompanied by bruising on his legs. He also complains of aching bones. He has no previous illnesses. On examination, he is pyrexial and pale, has bony tenderness over the sternum and tibia, and has petechiae on his legs. There are no palpable lymph nodes. He has crepitations at the left base. The liver and spleen are not palpable.

Acute myelogenous leukemia

A 47-year-old overweight woman is admitted with generalized abdominal pain. She has been unable to eat or drink due to nausea and vomiting. She states the pain started in the right upper quadrant, similar to previous episodes that she had been to the emergency room with over the past few months. An ultrasound obtained on her last visit to the emergency room revealed gallstones with no inflammation of the gallbladder, and she was told that she should see a surgeon. She looks jaundiced and in distress. She has point tenderness under her ribs on the right, which is worsened with deep palpation. No mass is palpable.

Acute pancreatitis

A 53-year-old man presents to the emergency room complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forward or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypneic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic with decreased breath sounds over the base of the left lung.

Acute pancreatitis

40-year-old man presents with a recent history of dysuria and genital and perineal pain. He has felt feverish and ill intermittently but has not previously sought medical attention. Digital rectal examination reveals an enlarged, soft-feeling, and tender prostate.

Acute prostatitis

A 30-year-old man presents with a 3-day history of a progressively diminishing urinary stream, dysuria, and urinary frequency. He denies any possibility of an STD. He is sufficiently ill with malaise and chills to require hospital admission. On examination, he is febrile with a temperature of 101.3°F (38.5°C). Digital rectal examination reveals a tender, boggy, and slightly enlarged prostate.

Acute prostatitis

A 52-year-old man presents complaining of anorexia, malaise, diarrhea, and vomiting over the past week. He reports little fluid or food intake.

Acute tubular necrosis

A 78-year-old woman is hospitalized because of a femur fracture. After being operated on, she presents with fever and an aminoglycoside antibiotic is prescribed. After 5 days the patient's condition deteriorates and a blood test discloses a creatinine level of 8 mg/dL (normal range 0.5 to 1.0 mg/dL).

Acute tubular necrosis

A 21-year-old Vietnamese woman presents to her primary care physician to establish care. She emigrated from Vietnam 12 years ago and has not had regular medical care in either country. She reports having chronic fatigue that interferes with her ability to complete her college studies. She has an unremarkable past medical history and has never been pregnant. She is currently sexually active. She has no siblings and her parents have no remarkable medical issues. On physical exam her liver span is 10 cm and her spleen is palpated 5 cm below the left costal margin. No lymph nodes are palpable.

Alpha-thalassemia

A 26-year-old black woman presents in her thirteenth week of pregnancy with fatigue. She is found to be mildly anemic with a hemoglobin of 11 g/dL and an MCV of 75 fL. She is empirically started on iron sulfate tablets and develops significant constipation. Four weeks later she has had no improvement in her hemoglobin and she is referred to hematology. She has never been pregnant previously. There is no known history of anemia in her family. Her physical exam is unremarkable

Alpha-thalassemia

An 18-year-old man presents to his primary care physician with a nonspecific history of malaise. Mild sensorineural hearing loss had been diagnosed during his early education, although hearing aids were not required. Investigations reveal hematuria, heavy proteinuria, and hypertension. There was a history of macroscopic hematuria in infancy associated with an intercurrent infection and high fever. As the patient's family had moved frequently he was lost to follow-up.

Alport syndrome

A 28-year-old woman presents with a history of severe pain on defecation for the last 3 months. She has noticed a small amount of blood on the stool. The pain is severe and she is worried about the pain she will experience with the next bowel action.

Anal fissure

A 52-year-old woman with a history of rheumatoid arthritis reports gradual worsening of symptoms over the past 2 months with fatigue, malaise, and increased stiffness of the wrists and joints of the hands. Physical examination is significant for warmth, tenderness, and synovial thickening in wrists, MCP, and PIP joints bilaterally. She takes NSAIDs as needed. The hemogram shows a drop in Hb from 12.3 to 9.6 g/dL over the last 3 months and an MCV of 77 fL.

Anemia of chronic disease

A 72-year-old man, previously healthy, presents with fever, chills, cough, and shortness of breath. CXR shows a right-middle-lobe infiltrate. He is diagnosed with pneumonia and admitted for IV antibiotics. Blood cultures eventually grow Streptococcus pneumoniae. By hospital day 3, he is afebrile, but his Hb is 10.5 g/dL, down from 12.4 g/dL on admission, and 13.5 g/dL 1 month ago. He has no evidence of GI blood loss or overt hemolysis. Red cell indices reveal a normocytic normochromic anemia.

Anemia of chronic disease

A 58-year-old man with pancreatic adenocarcinoma, who had a plastic stent placed in his common bile duct 6 weeks ago to relieve obstructive jaundice, presents to the emergency department after 1 week of progressive nausea and occasional vomiting after eating. He has generalized abdominal pain that is worse in the RUQ. He has experienced subjective fever/chills and states that his bowel movements are pale. Laboratory results show a WBC of 14,000/microliter (reference range 4800-10,800/microliter) with 8% (reference range 0-4%) bands and PMNs of 77% (reference range 35-70%). AST is 214 units/L (reference range 8-34 units/L), ALT is 181 units/L (reference range 7-35 units/L), alkaline phosphatase is 543 units/L (reference range 25-100 units/L), total bilirubin is 10.7 mg/dL (reference range 0.2-1.3 mg/dL), and amylase is 110 units/L (reference range 53-123 units/L).

Ascending cholangitis

A 65-year-old woman presents to the emergency department with a 2-day history of progressive RUQ pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have started to become loose but with no diarrhea, bright red blood, or black tarry stools. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics nor does she use nonsteroidal anti-inflammatory drugs (NSAIDs) or drink alcohol. On examination, she is febrile at 102.9°F (39.4°C); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturations. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Fecal occult blood test is negative. Laboratory results show a WBC of 18,000/microliter (reference range 4800-10,800/microliter) with 17% (reference range 0% to 4%) bands and PMNs of 82% (reference range 35% to 70%). AST is 207 units/L (reference range 8-34 units/L), ALT is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 6.3 mg/dL (reference range 0.2-1.3 mg/dL), and amylase is 82 units/L (reference range 53-123 units/L).

Ascending cholangitis

A 34-year-old man presents with the acute onset of blurry vision, nausea, and vomiting. He notes weakness in his arms and trunk. He recently returned from Alaska. Of note, he recalls eating home-preserved fish while visiting a family friend.

Botulism

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

Bacterial meningitis

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

Bacterial meningitis

A 55-year-old obese man presents with frequent heartburn. He describes a postprandial, retrosternal burning sensation following fatty and spicy meals. This symptom also frequently wakes him from sleep, with occasional coughing and a sour taste in his throat. He has tried many OTC antacids, which only relieve symptoms in the short term. He has suffered from this symptom for over 10 years. He denies dysphagia, odnophagia, or weight loss, but reports frequent hoarseness in the mornings. His past medical history is significant only for HTN. His family history is unremarkable. He did smoke cigarettes, but quit 5 years ago

Barrett esophagus

A 40-year-old woman awakens with left-sided facial fullness and a subjective feeling of facial and tongue "numbness" without objective hypoesthesia. She also notes left-sided dysgeusia. Later that day she develops left-sided otalgia, hyperacusis, postauricular pain, and facial discomfort. Left-sided facial palsy ensues, with associated oral incompetence, facial weakness, and asymmetry progressing to complete flaccid paralysis by the next morning. On physical exam, the resting appearance of the left face demonstrates brow ptosis, a widened palpebral fissure, effacement of the left nasolabial fold, and inferior malposition of the left oral commissure. There is complete absence of brow movement, incomplete eye closure with full effort, and loss of smile, snarl, and lip pucker on the affected side. The remainder of the history and physical exam are unremarkable.

Bell palsy

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

Benign prostatic hyperplasia

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

Benign prostatic hyperplasia

An 8-month-old boy of Mediterranean origin presents with pallor and abdominal distension, both of which are progressive. The perinatal history was uneventful, and the boy is noted to be pale, with poor feeding, decreased activity, and failure to thrive. Hepatosplenomegaly and mild bony abnormalities of the skull are noted (frontal and parietal bossing).

Beta thalassemia

A 46-year-old woman presents with fatigue and is found to have iron deficiency with anemia. She has experienced intermittent episodes of mild diarrhea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms. Examination reveals 2 oral aphthous ulcers and pallor. Abdominal examination is normal and results of fecal testing for occult blood are negative.

Celiac disease

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

Central hypothyroidism

A 45-year-old woman was having dinner when she felt the sudden onset of a severe headache, unlike anything she had ever experienced. She vomited many times before her husband brought her to seek medical attention. On presentation she requires stimulation to maintain alertness and has mild nuchal rigidity. Her BP is elevated but examination is otherwise normal. CT of the brain reveals subarachnoid blood in the anterior interhemispheric fissure. Angiography reveals a 7-mm aneurysm in the anterior communicating artery

Cerebral aneurysm

A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant RUQ pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhea. Three months ago she developed intermittent, sharp RUQ pains. On physical exam she has a temperature of 100.4°F (38ºC), moderate RUQ tenderness on palpation, but no evidence of jaundice.

Cholecystitis

A 3-year-old boy is brought to the health post in a rural Zimbabwean village by his distraught mother. The child started to have diarrhea 20 hours ago, and the volume has increased rapidly, so that now there is almost a continuous passage of thin yellow stools into the bed. Initially the child was taking fluids, but he is now drowsy and unresponsive. On examination, the radial pulse is impalpable, blood pressure is unrecordable, and the eyes are sunken. The capillary return is 5 seconds and skin turgor poor. The mother notes that the child has not urinated for 12 hours. The mother also reports that several members of her family and others in the village are also ill with a similar illness and that 3 children have already died.

Cholera

A 37-year-old Indian woman is referred urgently to the local emergency department, having collapsed in the toilet during a flight she had taken from India, where she had been visiting relatives in a rural village. Other passengers state that she returned to the toilet 3 to 4 times per hour initially and then locked herself in there for the remainder of the flight. On arrival she is talking but is mildly confused, with a pulse of 130 bpm and BP of 90/50 mmHg. Her mucous membranes are dry and skin turgor is poor. She is almost continually passing thin, pale, cloudy yellow stools without blood or mucus.

Cholera

A 60-year-old man presents with swollen lymph nodes in the cervical and inguinal region that have been present for 2 months and are gradually increasing in size. The lymphadenopathy is painless and has not responded to a course of antibiotics prescribed by the primary care physician. The patient denies any recent history of infection, fever, or chills.

Chronic lymphocytic leukemia

A 62-year-old man presents at the primary care physician's office for an annual physical. He denies any complaints such as fever or chills, weight loss, or fatigue. Of note, his blood tests show an elevated WBC count. The WBCs are predominantly lymphocytes, with a differential of 80% lymphocytes and an absolute lymphocyte count of 75,000/microliter.

Chronic lymphocytic leukemia

A 50-year-old man presents to his primary care physician for a routine physical. He is asymptomatic at the time of the visit and the physical exam is normal. Routine baseline bloods showed elevated WBC and platelet counts.

Chronic myelogenous leukemia

A 54-year-old man presents to his primary care physician with a 2-month history of fever, malaise, and weight loss. He also reports frequent epistaxis, abdominal fullness, and early satiety. On exam, he is found to have splenomegaly

Chronic myelogenous leukemia

A 54-year-old man had blood taken from his left antecubital fossa. At the time of needle insertion he complained of a burning and stinging pain radiating into his hand and shoulder. Almost immediately his left arm and hand became swollen and turned blue. Within days the pain spread to the left side of his face and head, later spreading to his left leg, left foot, and groin. Nine years later he remains in constant pain and is severely disabled. He barely uses his left upper extremity and keeps it close to his torso. On examination, allodynia and hyperalgesia are present over the left side, most severe in the upper extremity, axilla, and neck. Pin, touch, vibratory, and proprioceptive sensations are decreased on the left side. There is dystonic posturing of the arm with contractures at the fingers, wrist, elbow, and shoulder. There is left-sided bluish discoloration below the mid-arm, shiny and swollen skin of the hand and fingers, and excessively thin nails.

Complex regional pain syndrome

A 65-year-old woman suffered a fracture of her left wrist (scaphoid and distal radius) with a fall. Two months after application of the cast she developed a burning pain over the radial aspect of her wrist and shooting pains into her palm, which increased with movements of the wrist. On removal of the cast she complained of excessive sensitivity to non-noxious stimuli (allodynia) and noxious stimuli (hyperalgesia) over the volar and lateral wrist, with mild swelling and erythema over an area of 6 to 7 cm^2.

Complex regional pain syndrome

A 15-year-old girl was playing lacrosse and was struck in the head with the ball. She remembers everything up to and including the event, but her memory for events after being concussed is suspect for the details of the rest of the day. She further reports feeling dizzy and nauseated, as well as feeling both emotional (both laughing and crying for no reason) and extremely irritable. She continued to play after being struck and had worsening symptoms. After the game she went to the ER, where she had a CT scan, the results of which were normal.

Concussion

An 18-year-old man hit the previous day while playing football presents with overall good orienting, but reports feeling "slow" with a severe headache and limited memory for the events occurring immediately before and after the impact. He also describes feeling worse now than he did immediately after the impact. He has no visible head injury and did not lose consciousness, but does report sensitivity to light and sound.

Concussion

A 34-year-old woman presents with complaints of weight gain and irregular menses for the last several years. She has gained 20 kg over the past 3 years and feels that most of the weight gain is in her abdomen and face. She notes bruising without significant trauma, difficulty rising from a chair, and proximal muscle wasting. She was diagnosed with type 2 diabetes and hypertension 1 year ago.

Cushing syndrome

A 54-year-old man presents for evaluation of an incidentally discovered adrenal nodule. He underwent a CT scan of the abdomen for evaluation of abdominal pain, which was negative except for a 2 cm well-circumscribed, low-density (2 Hounsfield units) nodule in the right adrenal gland. He reports weight gain of 15 kg over the past 4 years. He has difficult-to-control type 2 diabetes and hypertension. He has had 2 episodes of renal colic in the last 5 years.

Cushing syndrome

A 30-year-old woman presents for assessment of thrombophilia, as her sister was recently diagnosed with a deep venous thrombosis (DVT) associated with pregnancy. She is a smoker and recently started a combined oral birth control pill.

Hypercoagulable state

A 54-year-old man presents with pain and swelling of his left leg. He has a 30 pack-year smoking history. On examination his left leg is grossly swollen to the thigh. D-dimer (marker of fibrinolysis) is elevated. Chest x-ray suggests a right hilar mass.

Hypercoagulable state

A 16-year-old girl presents with primary amenorrhea, galactorrhea, and mild headaches. Ophthalmologic examination reveals loss of vision in the right eye (20/40).

Craniopharyngioma

A 2-year-old girl presents with a 2- to 3-week history of nausea, vomiting, and an enlarging head. Physical exam reveals megacephaly and poor visual regard (acuity 20/200).

Craniopharyngioma

A 54-year-old HIV-positive man with a CD4 count of 100 cells/microliter presents with a 1-week history of feeling ill with fever, malaise, headache, and increasingly bizarre behavior. His CXR is unremarkable. The bronchoalveolar lavage is positive for cryptococcal organisms, and serum cryptococcal polysaccharide antigen (sCRAG) is positive. A mass lesion is detected on CT and MRI of the head and CNS involvement is confirmed by a positive lumbar puncture for the organism on India ink staining. The opening pressure on LP is 25 cm H2O.

Cryptococcosis

An asymptomatic 33-year-old male lifelong nonsmoker undergoes a CXR following minor chest trauma. The CXR reveals a pleurally based right lower lobe lesion. Fine-needle aspiration biopsy of the lesion grows Cryptococcus neoformans var. grubii. The sCRAG is negative.

Cryptococcosis

A 35-year-old man with uncontrolled HIV infection and AIDS complains of a 2-week history of visual floaters and blurring of vision involving both eyes. His HIV RNA load is >750,000 copies/mL and his CD4 cell count is 2 cells/microliter. Physical examination reveals a severely cachectic man with enlarged cervical, axillary, and inguinal lymph nodes. Ophthalmologic examination reveals creamy-colored areas with overlying retinal hemorrhages, consistent with a diagnosis of chorioretinitis

Cytomegalovirus infection

A 45-year-old CMV-seronegative (CMV R-) man presents with 1 week of fever, malaise, and diarrhea. Five months prior to this clinical illness, he received a kidney transplant from a CMV-seropositive (CMV D+) donor. He has a history of long-standing diabetes mellitus that was complicated by end-stage renal failure. He received valganciclovir prophylaxis for the first 3 months after kidney transplantation. Laboratory examination shows leukopenia, thrombocytopenia, and elevated serum levels of creatinine, ALT, and AST. Colonoscopic examination shows severe hyperemia and mucosal ulcerations involving the entire length of the colon

Cytomegalovirus infection

A 63-year-old man, recently returned from a trip to Haiti, presents to the emergency room complaining of persistent sore throat and difficulty swallowing. A rapid test for group A streptococcal antigens and a test for heterophile agglutinins are negative, and he receives oral amoxicillin and clavulanate potassium. On the fourth day of illness, the patient returns to the emergency room with chills, sweating, restlessness, difficulty swallowing and breathing, nausea, and vomiting. On examination, he is afebrile and has stridor and a swollen neck. Expiratory wheeze and diminished breath sounds in the left lung base are noted. Arterial pO2 is 88% on room air.

Diphtheria

Cutaneous diphtheria is another common presentation of corynebacteria infection, and can be caused by toxigenic or nontoxigenic strains. It is characterized by a nonprogressive, superficial skin infection with a scaling rash or nonhealing ulcers covered by gray-brown membranes. [3] Pain, tenderness, erythema, and exudate are typical features. Most lesions begin as lacerations, burns, or bites with secondary infection by corynebacteria and so tend to be found on exposed areas of skin on the head, neck, or limbs. [3] Rarely, systemic and respiratory manifestations have been reported in cutaneous diphtheria. [4] Involvement of mucocutaneous membranes (for example, ocular, external auditory, or genital) can also occur, with or without respiratory involvement. Nontoxigenic strains have also been reported to cause pyogenic arthritis.

Diphtheria

A 32-year-old obese, but otherwise healthy, man presents to the emergency department with onset of acute right-lower abdominal pain of 2-hour duration. There is no history of any previous significant illness, except loud snoring, possible sleep apnea, and being overweight.

Diverticular disease

A 55-year-old man presents with severe dysphagia to solids and worsening dysphagia to liquids. His social history is significant for 40 pack-year cigarette smoking and a 6-pack of beer per day. He has lost over 10% of his body weight and currently is nourished only by milkshake supplements. He complains of some mild odynophagia and is constantly coughing up mucus secretions.

Esophageal cancer

An otherwise healthy 45-year-old male executive complains of heartburn. He has tried over-the-counter medications with no relief. He was tried on a course of proton pump inhibitors for 6 weeks, but still has heartburn. He has no weight loss or dysphagia

Esophageal cancer

A 55-year-old male presents with several episodes of hematemesis in the past 24 hours. He has a history of alcoholic cirrhosis and is being treated for ascites with diuretics and for encephalopathy with lactulose. Currently he is confused and unable to give a complete history. His vital signs include a pulse of 85 bpm and BP of 84/62 mmHg. He is noted to have jaundice, splenomegaly, and multiple spider angiomas.

Esophageal varices

A 68-year-old woman presents with a complaint of "shaking hands." She reports a 10-year history of bilateral hand tremor that has slowly progressed and is worse in her right hand. It mainly bothers her when she is using her hands for various tasks. She has great difficulty drinking from cups and eating peas and other foods, and uses either a straw or both hands to eat and drink. She also finds writing and signing checks problematic. She has come to rely increasingly on her spouse for assistance with activities of daily living, and has retired from work as a secretary. She has stopped eating out in restaurants because of the social embarrassment. She denies any slowness of movement, rigidity, or cramping. Her father has a long history of tremor, but otherwise she has no personal or family history of neurologic diseases. When the patient has a glass of red wine, she notes that her tremor abates. Other Presentations

Essential tremor

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

Extrapulmonary tuberculosis

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

Extrapulmonary tuberculosis

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

Folate deficiency

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

Fungal meningitis

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

Fungal meningitis

A 19-year-old man presents with some burning with urination. He denies any penile discharge. He does not use condoms and had recent unprotected vaginal intercourse with a new female sexual partner about 7 days ago. He denies any prior sexually transmitted infections. On examination, there is no apparent discharge on initial inspection. There is a slight whitish discharge after applying pressure along the penile shaft. No other physical abnormalities are noted.

Genital tract chlamydia infection

A 22-year-old woman presents with postcoital bleeding, but denies any other symptoms. She is currently in a monogamous relationship with a male sexual partner. She is concerned that her partner may have had other sexual contacts. She currently uses oral contraception and does not use condoms. Her last sexual contact with her boyfriend was 8 days ago. On examination, her external genitalia are normal. Speculum examination reveals a mucopurulent discharge from the cervical os. The cervix is friable when scraped with a Dacron swab. Manual pelvic examination reveals no cervical motion tenderness. She has no other abnormalities on physical examination.

Genital tract chlamydia infection

A 72-year-old white woman presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders. Review of systems is positive for low-grade fever, fatigue, and weight loss. On physical examination, there is tenderness of the scalp over the temporal areas and thickening of the temporal arteries. Fundoscopic examination reveals pallor of the right optic disk. Bilateral shoulder range of motion is limited and painful. There is no synovitis or tenderness of the peripheral joints. There are no carotid or subclavian bruits, and the blood pressure is normal and equal in both arms. The remainder of the examination is unremarkable.

Giant cell arteritis

A 20-year-old woman with no significant past medical history presents with lower back pain and bilateral foot and hand tingling. Her symptoms rapidly progress over 4 days to include lower extremity weakness to the point that she is unable to mobilize her lower extremities. She reports coryzal symptoms 2 weeks ago. On examination, she has 0/5 power in her lower extremity with areflexia, but despite the paresthesias she does not have sensory deficits. Her aminotransferases are elevated, and LP reveals mildly elevated protein with no cells and normal glucose. She weighs 70 kg and her admission vital capacity is 1300 mL, maximum inspiratory pressure is -30 cmH2O, and maximum expiratory pressure is 35 cmH2O.

Guillain-Barre syndrome

A 26-year-old female bank clerk is 24 weeks pregnant and is offered an HIV rapid test as part of her antenatal care. Her test is positive and confirmed on a second rapid test. She is referred for general HIV care. At the HIV clinic she explains that she has been very well with only pregnancy-related nausea and mild fatigue. This is her first pregnancy. On examination, she looks well, with mild generalized lymphadenopathy only. She has been married for 2 years and had only 1 sexual partner in the last 4 years. An HIV test at 20 years of age was negative. A CD4 count is performed and she is staged as WHO stage 1. She receives counseling regarding risks to her unborn child and information about prevention of mother-to-child transmission. She has not yet disclosed her status to her partner and needs assistance with this, as well as further information about positive living and initiation of antiretroviral therapy.

HIV infection

A 32-year-old male taxi driver was found to be HIV-infected during a recent hospitalization for a pneumonic illness. Compatible CXR findings and confirmatory sputum culture were positive for Mycobacterium tuberculosis, resulting in a diagnosis of pulmonary TB. In consideration of this diagnosis, the patient had agreed to HIV testing in the hospital. HIV serology was positive by rapid HIV testing and this was confirmed on a second blood specimen. The patient was informed of the diagnosis and referred for outpatient care. In the outpatient clinic, a history obtained from the patient confirmed some months of deteriorating health. He had lost approximately 10 kg in weight and had experienced fevers, night sweats, loss of appetite, and intermittent bouts of diarrhea. In addition, 4 weeks prior to admission he had developed a productive cough and pleuritic chest pain. He had also noted a scaly skin condition at the hair line. His medical history is nonsignificant, but he nursed his mother with TB approximately 6 years ago. His current medication includes antituberculous therapy and pyridoxine. He has recently completed 1 week of topical mycostatin for oral candidiasis. On examination he is thin, with evidence of oral thrush and mild seborrheic dermatitis. He has mild bronchial breathing in his right upper chest, with mild tracheal deviation to the right. His neurologic, cardiovascular, and abdominal examinations are normal. A CD4 count performed while the patient was still in the hospital was 186 cells/microliter. He was clinically staged, based on history and findings, as WHO stage 3. A baseline viral load, CBCs, and LFTs are ordered prior to initiation of antiretroviral therapy. The patient discloses that he is married and has 3 children ages 6 years, 4 years, and 13 months. They are all well. Implications for testing the family for HIV are discussed with the patient.

HIV infection

A 50-year-old man presents to the emergency room with a history of black, tarry stools but denies hematemesis or abdominal pain. His family has noticed progressive confusion. History is significant for cirrhosis and alcoholism. His heart rate is 112 bpm and BP is 105/66 mmHg. He is jaundiced and lethargic, is oriented to person and place but not date, and has moderate ascites. Neurologic exam reveals asterixis, and stool is guaiac-positive (positive for occult blood).

Hepatic encephalopathy

A 34-year-old man presents 2 weeks after returning from a month-long trip to India. He denies attending pretravel vaccination clinic and did not take prophylaxis of any sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain, nausea with emesis, and dark urine. He admits to dietary indiscretion and consumed salad at a roadside vendor 3 weeks before onset of symptoms. On examination there is icterus. His ALT is 5660 units/L, and total bilirubin 9 mg/dL. Serum IgM anti-hepatitis A virus (HAV) antibodies are detected.

Hepatitis A

A 40-year-old asymptomatic Chinese-American man presents for routine visit with elevated alanine aminotransferase (ALT) level (55 international units [IU]/mL). His mother died of hepatocellular carcinoma and he has a middle-aged sister with "hepatitis B infection." He has a normal physical examination and has no stigmata of chronic liver disease.

Hepatitis B

A 60-year-old man presents with several months of gradually worsening abdominal swelling, intermittent hematemesis, and dark stool. He denies chest pain or difficulty breathing. Past medical and family history are not contributory. Past surgical history is significant for back surgery requiring blood transfusion in 1990. Social history is significant for occasional alcohol use. BP is 110/80 mmHg. Physical examination is significant for spider angiomata on the upper chest, gynecomastia, caput medusae, and a fluid wave of the abdomen. The rest of the examination is normal.

Hepatitis C

A 55-year-old black man with a history of intravenous drug use, heavy alcohol drinking, and chronic hepatitis C virus (HCV) with cirrhosis of the liver is referred to a liver specialist with an elevated serum alpha fetoprotein of 200 ng/mL and a 2 cm liver mass in the screening ultrasound of the abdomen. Physical examination reveals palmar erythema, bilateral leg edema, and ascites.

Hepatoma

A 60-year-old Asian man with a longstanding history of chronic hepatitis B virus (HBV) complicated by cirrhosis presents to his primary care physician with abdominal distension, yellow eyes, RUQ abdominal pain, decreased appetite, weight loss, and change in his sleep pattern for several weeks. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, a palpable mass in RUQ, and asterixis.

Hepatoma

A 24-year-old woman presents with a 3-day history of painful sores in the genital area, dysuria, fever, and headache. She is sexually active with men and has a new partner within the past month. She does not use condoms. Physical examination reveals a temperature of 100.9°F, stable vital signs, slight nuchal rigidity (implying aseptic meningitis), bilateral tender inguinal lymphadenopathy, and multiple tender 1- to 2-cm erythematous ulcerations without labial crusts. The cervix is edematous with pustules and clear discharge. Cervical motion tenderness is also present.

Herpes simplex virus infection

A 25-year-old man presents for STD screen. He is sexually active with men, has had 4 partners in the past year, and uses condoms "most of the time." He was HIV-negative 6 months ago and denies a history of urethral discharge, dysuria, or genital ulcers. He does have occasional genital itching and mild sores on the penile shaft. Genitourinary examination reveals a circumcised male with no inguinal lymphadenopathy, no lesions on the penile shaft or perianal area, and no urethral discharge

Herpes simplex virus infection

A 25-year-old male presents to his primary care provider with a slowly enlarging, nonpainful right neck mass. He denies recent upper respiratory tract infections, fevers, night sweats or unintentional weight loss. He is otherwise healthy. Social history and family history are unremarkable. On examination he is afebrile with normal vital signs. Pertinent findings include a 3-cm, firm, round, nontender, mobile mass in the mid-right neck. There is no other peripheral lymphadenopathy. The liver and spleen are not enlarged.

Hodgkin lymphoma

A 42-year-old school teacher presents with difficulty managing her classroom. She has become increasingly irritable with students and fails to complete assigned tasks on time. Her sister and husband report that she has become restless, pays less attention to her appearance and social obligations, and at times is anxious and upset. She has stumbled unexpectedly. Her symptoms resemble those of her mother when she was diagnosed with Huntington disease. On examination, her speech is somewhat uneven and she is inappropriately flippant. Subtracting serial 7s from 100, while seated with her eyes closed, brings out random "piano-playing" movements of the digits along with other movements of the limbs, torso, and face. Subtraction errors occur with this task. She is unable to keep her tongue fully protruded for 10 seconds. Finger tapping is slower than the examiner's, and tapping tempo is uneven. Tandem walking is impaired.

Huntington disease

A 12-month-old boy presents to his primary care physician with a right scrotal mass. The mass is smaller in the morning than in the evening and increases significantly in size during crying. It gets smaller again when he is lying down. He has no GI or urinary symptoms. Physical exam demonstrates normal findings on the left side of the scrotum and a nontender soft swelling on the right side. The mass is transilluminated when a light is shone on the scrotum, suggesting it is fluid-filled. The right testicle is palpable after gentle pressure reduces the swelling.

Hydrocele

A 45-year-old woman has a total thyroidectomy for papillary carcinoma. Ten hours after the operation she complains of perioral and digital paresthesias. Her condition rapidly deteriorates with a sense of constriction in her throat and difficulty on inspiration.

Hypoparathyroidism

A 52-year-old woman is operated on for long-term primary hyperparathyroidism diagnosed by serum calcium of 12.6 mg/dL (3.15 mmol/L) and PTH of 270 picograms/mL. Her intraoperative PTH after resection of a 2-gram adenoma was 12 picograms/mL. Twelve hours after her procedure, she complains of paresthesias and anxiety. Her serum calcium is 6.8 mg/dL (1.7 mmol/L).

Hypoparathyroidism

A 50-year-old woman presents approximately 3 weeks after an upper respiratory illness with petechiae, easy bruising, and gum bleeding. She has no personal or family history of a bleeding disorder and takes no medications. Physical exam is normal except for petechiae and bruising. Specifically, she has no lymphadenopathy or hepatosplenomegaly. CBC reveals thrombocytopenia with a platelet count of 12 x 10^3/microliter but other cell lines are within normal limits. Peripheral smear shows thrombocytopenia but no other abnormalities.

Idiopathic thrombocytopenic purpura

An 18-year-old man presents in July with a 1-week history of nonpruritic, erythematous rash with low-grade fever and arthralgias. On examination, the patient has multiple skin lesions, about 4 cm to 10 cm in diameter, with central clearing. The patient had significant outdoor exposure, but there was no recollection of a tick or insect bite.

Lyme disease

A 53-year-old woman initially presents to her primary care physician with a 12-month history of postprandial epigastric discomfort associated with minimal weight loss. She does not report any fevers, chills, or sweats, and exam reveals no lymphadenopathy or splenomegaly. When simple measures fail to improve her symptoms, the physician treats her for gastroesophageal reflux disease and commences acid-suppression therapy. Despite this, her discomfort continues and she is eventually referred for gastrointestinal endoscopy, which identifies a large mass in the antrum of the stomach.

MALT lymphoma

A 48-year-old man presents to the ER after several episodes of vomiting blood following periods of forceful retching and vomiting. He had been binge drinking alcohol over the preceding 2 days

Mallory-Weiss tear

A 64-year-old man presents to the ER after 4 episodes of vomiting over the past 2 days. He describes the appearance of the vomit as resembling coffee grounds. Black, tarry stool was seen during rectal exam; however, no other physical findings were seen.

Mallory-Weiss tear

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

Migraine headache

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

Migraine headache

A 45-year-old woman presents to the emergency department with nausea, vomiting, and confusion. She had history of low back pain of 6 months' duration and increasing sciatic pain in the last 2 weeks. On physical exam, the patient was pale and dehydrated with bone tenderness in the lumbar region. Neurologic exam revealed an up-going plantar reflex on the left with intact power in all muscle groups and at all joints. An MRI revealed an L5 compression fracture. This was associated with hypercalcemia and renal insufficiency.

Multiple myeloma

A 60-year-old previously healthy man presents with 2 to 3 months of back pain. Over the last 3 weeks, he has developed a cough and increasing fatigue. On examination he had evidence of pneumonia and was noted on radiography to have osteolytic lesions. Laboratory data revealed anemia associated with the presence of a monoclonal protein.

Multiple myeloma

A 28-year-old white woman who was raised in the northern US and has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in 1 eye, with pain on movement of that eye. She also notes difficulty with color discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and on further history recalls that she had a 3-week history of unilateral hemibody paresthesias during finals week in college 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.

Multiple sclerosis

A 31-year-old woman with strong FHx of autoimmune disease is 6 months postpartum and develops ascending numbness and weakness in both feet, slightly asymmetrically, over a period of 2 weeks. She gradually develops difficulty walking to the point where she presents to an ER and is also found to have a UTI

Multiple sclerosis

A 25-year-old woman presents with recurrent slurring of speech that worsens when she continues to talk. She has trouble swallowing, which deteriorates when she continues to eat, and has double vision that gets worse when sewing, reading, or watching TV. She reports that her head is heavy and hard to hold up. Her symptoms have progressively deteriorated over the past 6 months. She has intermittent weakness in her legs and arms. She is fearful of falling due to her legs giving out and she has trouble combing her hair or putting on deodorant. She reports a feeling of generalized fatigue and is occasionally short of breath.

Myasthenia gravis

A 76-year-old man reports double vision for the past 2 months. Within the past 2 weeks he has developed bilateral ptosis (drooping eyelids). His ptosis is so severe at times that he holds his eyes open to read. He is unable to drive due to the ptosis and the diplopia (double vision). His symptoms are generally better in the morning and progress throughout the day.

Myasthenia gravis

A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down toward his groin. The patient is writhing in pain, which is unrelieved by position. He also complains of nausea and vomiting.

Nephrolithiasis

A 55-year-old male farmer presents with worsening shortness of breath, night sweats, fevers, bilateral axillary lymphadenopathy, and a 7.7 kg (12%) total body weight loss over 3 months. Recently, he has not been able to work because of fatigue. Physical exam revealed a 3.5 cm left axillary mass; enlarged cervical, axillary, and inguinal lymph nodes; splenomegaly; and no hepatomegaly.

Non-Hodgkin lymphoma

A 56-year-old woman presents with painless right neck lump that has been slowly enlarging for the last 2 years. She denies fevers, night sweats, or weight loss. Physical exam reveals bilateral cervical and axillary adenopathy and a palpable spleen.

Non-Hodgkin lymphoma

A 28-year-old woman presents with headaches for the past 9 months that have worsened recently. Review of systems is otherwise negative except for some irregularity in her menstruation over the past year. On physical examination she has no stigmata for Cushing syndrome or acromegaly. Her visual fields by confrontation are normal and she has had no galactorrhea. Common Vignette 2

Nonfunctional pituitary adenoma

A 52-year-old man presents with some difficulty driving at night and reports not seeing cars coming from the sides. He also describes progressive loss of libido and inability to obtain and maintain an erection, which started about 2 years ago. He reports bumping into things. He has gained about 5 kg (11 lb) in weight over the past 2 to 3 years. He has fatigue and is unable to do the same jobs that he used to do a year ago. The examination reveals moderate obesity (BMI 35) with some loss of muscle bulk over the proximal arm and leg muscle groups. Other positive findings include the presence of small bilateral gynecomastia, soft testicles (12 mL), and abnormal visual fields to confrontation, with bitemporal hemianopia.

Nonfunctional pituitary adenoma

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

Oral candidiasis

A 55-year-old man complains of persistently aching legs. He is initially diagnosed with fibromyalgia. However, his blood tests reveal an elevated serum alkaline phosphatase. Subsequent x-ray of the tibia/fibia shows defects in the cortical and cancellous bone, with some degree of tibial bowing, leading to a revised diagnosis of Paget disease.

Paget disease of bone

A late middle-aged woman presents with chronic right hip and anterior thigh pain, with increased localized temperature. Lately, she has needed a cane for walking. During the last 6 months her relatives have noticed a progressive hearing loss on her left side, as well as some facial changes - mostly enlargement of her mandible.

Paget disease of bone

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

Painless lymphocytic thyroiditis

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

Painless lymphocytic thyroiditis

A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain MRI are normal.

Parkinson disease

A 12-month-old female infant presents with spasmodic cough, cyanosis around her lips and fingers during coughing, and posttussive vomiting. Her parents report that she has had a cold for approximately 3 weeks, and her appetite has decreased. The infant's mother reports that she herself has been coughing for 6 weeks. The infant's immunization records are incomplete

Pertussis

A 40-year-old high school teacher presents with cold symptoms lasting 3 weeks. She has low-grade fever, fatigue, and paroxysms of coughing. Her cold symptoms were initially mild but gradually increased in severity, resulting in her presentation to the emergency room. OTC cold medications have not provided relief.

Pertussis

A 33-year-old female presents to her doctor complaining of a several-month history of episodic palpitations and diaphoresis. She states that her husband noticed that she becomes pale during these episodes. She has been experiencing progressive episodic headaches, which are not relieved by acetaminophen. In the past, she has been told that she had a high calcium level. She has a history of kidney stones. Her FHx is unremarkable; specifically, there is no history for tumors, endocrinopathies, or HTN. Physical exam reveals a BP of 220/120 mmHg and hypertensive retinal changes.

Pheochromocytoma

A 34-year-old man with a history of sex with men presents with 3 weeks of worsening dyspnea associated with fevers and a nonproductive cough. He is tachycardic and tachypneic, and has a temperature of 100.5°F (38.1°C). His pulse oximetry is 86% on room air. He appears thin and in moderate respiratory distress. His lung examination is unremarkable.

Pneumocystis jirovecii pneumonia

A 45-year-old woman with a history of Wegener granulomatosis, treated for 6 months with cyclophosphamide and prednisone, presents with 1 week of cough, shortness of breath, and fevers. She is tachypneic and has a pulse oximetry of 80% on room air. She is in a moderate amount of respiratory distress and has some diffuse rales in her lungs.

Pneumocystis jirovecii pneumonia

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

Primary hypothyroidism

A 30-year-old woman with a family history (i.e., father, aunt, and grandfather) of PKD comes to the renal clinic for evaluation. She denies any history of flank pain, pyelonephritis, or hematuria, but reports having had 2 UTIs over the last year. She is contemplating having a family in the near future. She was recently screened for this disease with an abdominal ultrasound. This showed several small echogenic foci and small cystic changes in the liver. Several bilateral kidney cysts were seen (with the largest measuring 3.2 cm), and an adjacent renal calculus. She denies any history of migraines or headaches. There is no family history of aneurysms or cerebrovascular events. She had an ambulatory BP monitor study performed prior to her evaluation revealing normal BP. Her exam is completely normal.

Polycystic kidney disease

A 43-year-old man with a history of mild ulcerative colitis is noted to have an elevated serum alkaline phosphatase, slightly elevated aminotransferases, and normal bilirubin on routine laboratory testing. He complains of fatigue and upper abdominal pain. He denies pruritus or fevers. Physical examination is unremarkable.

Primary sclerosing cholangitis

A 40-year-old man discovered that he had PKD about 15 years ago when he had renal colic. He was found to have bilateral stones at the time and was treated with lithotripsy. A stone was analyzed. He thinks it was a uric acid stone but is not sure. He has had no further renal colic or passage of stones since that time. About 10 years ago, he developed hypertension that has been treated since with adequate control, by his account. He denies having had any UTIs. He had repair of a left inguinal hernia when he was a teenager. Recently, he had a bout of gross painless hematuria lasting 3 days and went to the emergency department for evaluation. A CT was performed, which showed no change in his polycystic kidneys compared with findings on a CT scan 1 year prior. Over the last several years, he has experienced increasing abdominal girth and has developed early satiety and dyspnea on exertion. He denies any mechanical low back pain.

Polycystic kidney disease

At a routine exam, a 65-year-old female patient is discovered to have hypercalcemia. Follow-up laboratory tests show synchronously elevated serum calcium and intact PTH, with low phosphorus and mildly elevated alkaline phosphatase. 25-hydroxyvitamin D is in the low normal range. Past medical history is significant for HTN and CAD. Review of symptoms includes complaints of fatigue, feeling achy, and vague depression and mental fatigue. The patient has a history of nephrolithiasis and newly detected osteopenia. Family history is negative for renal stones or calcium disorders.

Primary hyperparathyroidism

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

Pulmonary tuberculosis

A 52-year-old man, recently arrived from India, presents after 3 days of restlessness and intermittent abdominal pain. Exam shows only diaphoresis and mild distress. He is admitted for possible bowel obstruction. Over 12 hours, he develops cardiac arrhythmia, fever, and increased diaphoresis. He is unable to ingest liquids. The following day he exhibits strange behavior and leg numbness. Later he develops hallucinations, aggressive behavior, hypersalivation, and cardiac arrest. The patient is resuscitated and admitted to the ICU. He has tachycardia, muscular rigidity, and body tremor. An MRI of the brain is unremarkable. A detailed history reveals that the patient had sustained bites from a puppy in India to the right hand and leg 3 months ago and has never received a rabies immunization. At this point rabies is suspected. The patient becomes comatose and dies 2 days later after another cardiac arrest.

Rabies

An 11-year-old boy presents to the ER with fever, sore throat, and vomiting. The only known animal contacts are house pets. There is no history of travel abroad, but the patient attended a summer camp in Alabama 2 months earlier. The patient has never received rabies immunization. Laboratory tests and CXR are unremarkable and he is sent home. He returns the same day with additional symptoms of insomnia, urinary urgency, paresthesias of the scalp and right arm, dysphagia, disorientation, and ataxia. He deteriorates rapidly, with slurred speech, hallucinations, and agitation requiring sedation and intubation. Tests for West Nile virus, HSV, and enterovirus are negative. The patient progresses to coma over several days, and develops autonomic instability. He dies on the 14th day.

Rabies

A 32-year-old woman with no prior medical history is seen for worsening headache and is found to have a BP of 180/110 mmHg. Her BP responds inadequately to thiazide diuretics and calcium-channel blockers. An MRA of the renal arteries reveals a beaded appearance indicative of fibromuscular dysplasia.

Renal artery stenosis

A 68-year-old man with known coronary artery disease and PVD presents with recurrent episodes of flash pulmonary edema, worsening kidney function, and progressively difficult-to-control HTN. An angiogram of the aorta and renal arteries shows a sclerotic aorta with plaque extending into the proximal third of both renal arteries

Renal artery stenosis

A 56-year-old obese woman presents to the ER with a history suggestive of biliary colic, including epigastric discomfort after a heavy meal. Her past medical history includes cholelithiasis, hypertension (treated with an angiotensin-converting enzyme [ACE] inhibitor), and dyslipidemia (treated with a statin). She is an ex-smoker, drinks alcohol socially, and has no significant family history. On palpation of her abdomen, she has RUQ pain, but there are no other relevant findings on exam. An abdominal ultrasound is performed, which demonstrates the presence of gallbladder stones without obstruction, and an incidental 5-cm, left-sided renal mass.

Renal cell carcinoma

A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity edema, and 4 days of gross hematuria with clots. On exam, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting edema to the mid-shins bilaterally, which is worse on the right.

Renal cell carcinoma

An 8-year-old boy presents to an emergency room in the southeastern US in June with a 5-day history of fever, headache, vomiting, myalgia, and abdominal pain and a 2-day history of a rash, which was first noted over the wrists and ankles. image He frequently spends time outdoors and had just returned from a camping trip 1 week before these symptoms began. On physical examination the patient has a temperature of 105°F (40.5°C) and appears uncomfortable. He is sleepy but arousable. Mild conjunctival hyperemia is present. The abdomen is minimally tender and the spleen tip is palpable. A maculopapular rash covers most of his arms and legs, including the palms and soles, and several discrete petechiae are also present over the extremities.

Rocky Mountain spotted fever

A 50-year-old obese woman with longstanding, poorly controlled diabetes presents with lethargy and fatigue. Screening labs report that she has a creatinine level of 2.5 mg/dL and a BUN level of 40 mg/dL. Additional labs are ordered, which reveal a calcium level of 7.4 mg/dL and a phosphorus level of 5.9 mg/dL. The parathyroid hormone level is 400 picograms/mL.

Secondary hyperparathyroidism

An 85-year-old female nursing-home patient is being seen for postmenopausal skeletal disease that has become a concern after she fell and broke her wrist. Her bone densitometry reveals osteoporosis (T-score: -3.5). Lab tests return with a calcium level of 8.8 mg/dL and a parathyroid hormone level of 120 picograms/mL. These results prompt vitamin D testing that returns a 25-hydroxyvitamin D level of 14 nanograms/mL.

Secondary hyperparathyroidism

A 12-year-old boy presents with a 1-week history of sudden-onset watery diarrhea while visiting relatives in Dhaka, Bangladesh. On his return to the US, he developed abdominal cramps, fever, and bloody diarrhea. He is febrile, with a temperature of 101.2°F (38.5°C). The mucous membranes are dry, and there is reduced skin turgor; his pulse is 100 beats/minute, and BP is 110/70 mmHg with a 10 mmHg postural drop.

Shigella infection

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

Subacute granulomatous thyroiditis

A 27-year-old man notes a painless penile ulcer. He has recently started a new relationship. He is otherwise asymptomatic, as is his partner. On exam, the ulcer is indurated and the inguinal lymph nodes are rubbery and moderately enlarged.

Syphilis

A 30-year-old man presents with difficulty hearing conversations while in a crowded room. Following referral for audiometry, bilateral high-frequency hearing loss is diagnosed. On further questioning he reports a past history of an anal fissure about 10 weeks previously that healed spontaneously. He also describes a mild transient skin rash 2 weeks before his auditory symptoms appeared. He says that he has been feeling unusually tired.

Syphilis

A 52-year-old woman with a history of Crohn disease developed fevers while receiving total parenteral nutrition for 2 weeks. She recently underwent a small bowel resection followed by prolonged IV antibiotics for intra-abdominal abscess and fistulae. Exam reveals a temperature of 101°F (38.5°C), normal heart sounds without murmur, central venous catheter site without erythema or drainage, and no rash.

Systemic candidiasis

A 78-year-old man, who has insulin-dependent diabetes, presents with a neurogenic bladder, and is admitted with hypotension (BP 80/40), pulse 120 bpm, temperature of 102°F (39°C), and confusion. Urine exam reveals pyuria, and numerous budding yeast are visualized on urine microscopy.

Systemic candidiasis

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

Tension-type headache

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

Tension-type headache

A 13-year-old boy developed sudden-onset unilateral scrotal pain that woke him from sleep. He presents with left scrotal pain, nausea and vomiting, and left lower abdominal pain. On exam, he has a tender, enlarged, high-riding left testicle with a transverse lie. There is an absent cremasteric reflex on the left.

Testicular torsion

A 63-year-old man sustained a cut on his hand while gardening. His immunization history is significant for not having received a complete tetanus immunization schedule. He presents with signs of generalized tetanus with trismus ("lock jaw"), image which results in a grimace described as "risus sardonicus" (sardonic smile). Intermittent tonic contraction of his skeletal muscles causes intensely painful spasms, which last for minutes, during which he retains consciousness. The spasms are triggered by external (noise, light, drafts, physical contact) or internal stimuli, and as a result he is at the risk of sustaining fractures or developing rhabdomyolysis. The tetanic spasms also produce opisthotonus, image board-like abdominal wall rigidity, dysphagia, and apneic periods due to contraction of the thoracic muscles and/or glottal or pharyngeal muscles. During a generalized spasm the patient arches his back, extends his legs, flexes his arms in abduction, and clenches his fists. Apnea results during some of the spasms. Autonomic overactivity initially manifests as irritability, restlessness, sweating, and tachycardia. Several days later this may present as hyperpyrexia, cardiac arrhythmias, labile hypertension, or hypotension.

Tetanus infection

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

Toxic thyroid adenoma

A 25-year-old woman in her third trimester of pregnancy is found to have positive serology for anti-Toxoplasma IgG. No previous serologic profiles are available. She reports no recent illnesses, and has no significant medical history. She reports taking care of several cats at home, and frequently changes their litter. Her physician then checks for anti-Toxoplasma IgM, which is positive. Sonogram of the fetus shows no abnormalities

Toxoplasmosis

A 45-year-old man with AIDS (CD4+ T lymphocyte count 55 cells/microliter) and poor medical follow-up presents with fever, confusion, right hemiplegia, and slurred speech. He is taking no medications. A CT scan with IV contrast of the head reveals multiple ring-enhancing lesions with surrounding vasogenic edema. Ophthalmologic exam reveals retinitis. CSF bacterial antigen panel is negative and serum has detectable anti-Toxoplasma IgG.

Toxoplasmosis

A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. On arrival in the ER 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.

Transient ischemic attack

A 12-year-old white girl is brought to the emergency room by her parents due to 12 hours of rapidly worsening nausea, vomiting, abdominal pain, and lethargy. Over the last week she has felt excessively thirsty and has been urinating a lot. Physical examination reveals a lean, dehydrated girl with deep rapid respirations, tachycardia, and no response to verbal commands.

Type 1 diabetes mellitus

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

Viral meningitis

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

Viral meningitis

A 68-year-old man presents for a routine physical exam and follow-up for his HTN, hyperlipidemia, and hypothyroidism. He complains of mild fatigue but is otherwise healthy. Laboratory evaluation is remarkable for a hematocrit of 34, with an MCV of 110 fL. On further query, he denies alcohol use or any other symptoms.

Vitamin B12 deficiency

A 6-year-old female without significant past medical history presents for evaluation of frequent unusual episodes for the past 3 months. The unusual episodes consist of sudden activity arrest with staring and minimal eyelid flutter for 10 to 20 seconds occurring 5 to 10 times per day. The patient is unresponsive to voice or tactile stimulation during the episodes. She is able to immediately resume activities without any recollection of the event once the episode finishes. Her teachers have noted that she stares off in class repeatedly and does not seem to be remembering instructions and classroom material. The diagnosis of attention-deficit/hyperactivity disorder had been suggested. One such unusual episode is induced in front of medical staff with hyperventilation.

Absence seizures

A 48-year-old man has a 4-month history of increasing fatigue and anorexia. He has lost 12.2 lb (5.5 kg) and noticed increased skin pigmentation. He has been otherwise healthy. His mother has Hashimoto thyroiditis and one of his sisters has type 1 diabetes. His BP is 110/85 mmHg (supine) and 92/60 mmHg (sitting). His face shows signs of wasting and his skin has diffuse hyperpigmentation, which is more pronounced in the oral mucosa, palmar creases, and knuckles.

Acute Adrenal Insufficiency (Addisons)

A 54-year-old woman with hypothyroidism complains of persistent fatigue, despite adequate thyroxine replacement. She has noticed increasing lack of energy for the past 3 months and additional symptoms of anorexia and dizziness. She also has significant loss of axillary and pubic hair. Her BP is 105/80 mmHg (supine) and 85/70 mmHg (sitting). The only abnormal finding on physical examination is a mild increase in thyroid size, with the thyroid having rubbery consistency.

Acute Adrenal Insufficiency (Addisons)

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

Acute COPD exacerbation

A 60-year-old man develops shortness of breath while he is in the hospital recovering from a recent myocardial infarction. He is unable to lie flat without significant discomfort, has marked labored breathing, and has a respiratory rate of 36 breaths per minute. Auscultation of the chest reveals diffuse rales. During exam, breathing becomes more rapid and shallow and the patient slowly loses consciousness.

Acute Respiratory Failure

A 67-year-old man with known COPD presents with fever and cough. He complains of worsening shortness of breath and the inability to get enough oxygen. His mental status waxes and wanes and he is cyanotic around the lips and cheeks. During exam, ventilatory efforts rapidly deteriorate.

Acute Respiratory Failure

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

Acute asthma exacerbation

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

Acute bronchitis

A 50-year-old woman, who has no eye symptoms, is found during routine ophthalmic examination to have elevated intraocular pressure of 42 mmHg in both eyes. Funduscopy shows that the optic nerve head appears normal, with no evidence of glaucomatous neuropathy. Gonioscopy shows that the anterior chamber angles are closed for almost the full circumference.

Angle-closure (acute) glaucoma

A 64-year-old woman presents to the ER with severe pain around her right eye of 4-hour duration, accompanied by blurred vision in that eye. She is also nauseated. Examination shows a red right eye with edematous cornea and a wide pupil that is unresponsive to light. Intraocular pressure is extremely elevated (60 mmHg), only in the right eye. The anterior chamber angle is closed in both eyes

Angle-closure (acute) glaucoma

A 55-year-old woman presents for evaluation of a chronic cough, productive of thick, yellow sputum that sometimes becomes blood-tinged. She has experienced recurrent episodes of fever associated with pleuritic chest pain. She states that she is embarrassed by the persistent, intractable nature of her cough and has been prescribed multiple courses of antibiotics. Over the last 5 years, she has developed shortness of breath with exertion. Her past medical history is significant for pneumonia as a child and sinus polyps during adulthood for which she has had surgery.

Bronchiectasis

A 72-year-old woman presents with polyarticular joint pain. She has longstanding mild joint pain, but over the last 10 years notes increasing discomfort in her wrists, shoulders, knees, and ankles. She has had several recent episodes of severe pain in 1 or 2 joints, associated with swelling and warmth of the affected areas. These episodes often last 3 to 4 weeks. Her exam shows severe bony changes consistent with osteoarthritis in many joints, and slight swelling, warmth, and tenderness without erythema in the second and third MCP joints, left shoulder, and right wrist.

Calcium pyrophosphate deposition (pseudogout)

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

COPD

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

COPD

An 80-year-old man presents with a swollen red wrist, fever, and chills. He recalls falling out of his wheelchair several days ago but seemed well until 24 hours before admission, when he developed pain in his right wrist. His daughter noted fever and some confusion and brought him to the hospital. On exam, he appears ill and has fever to 102ºF (39ºC). There is swelling, tenderness, and redness around the right wrist with edema over the dorsum of the hand.

Calcium pyrophosphate deposition (pseudogout)

A 70-year-old woman with a history of hypertension, hyperlipidemia, 40 pack-years of cigarette smoking, and remote percutaneous transluminal coronary angioplasty is witnessed falling to the ground while shoveling her sidewalk. She has not complained of any preceding symptoms. The emergency medical personnel who respond to the scene find her unconscious, pale, and without a pulse. After the pads from an automated external defibrillator are attached, the patient is noted to be in ventricular fibrillation.

Cardiac arrest

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

Cardiac tamponade

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

Cardiac tamponade

A 60-year-old man presents to the emergency room (ER). He reports being progressively short of breath. He has a history of uncontrolled hypertension, noninsulin-dependent diabetes mellitus, and has been a heavy smoker for more than 40 years. He underwent a successful primary angioplasty for a large acute anterior MI 2 months ago. His blood pressure is 75/40 mmHg, his heart rate 110 bpm, and his respiratory rate 30. He has elevated neck veins and a prominent S3. His ECG shows sinus tachycardia, and a transthoracic echocardiogram (TTE) performed in the ER reveals impaired systolic function, with an ejection fraction of 20%.

Chronic congestive heart failure

A 67-year-old woman presents to her primary care physician complaining of increasing shortness of breath, especially when trying to sleep. She has a history of hypertension and hyperlipidemia, and is being treated with a beta-blocker and statin therapy. She does not smoke and drinks alcohol in moderation. On examination, her blood pressure is 148/83 mmHg and heart rate is 126 bpm. There is an audible S4 and the jugular venous pressure (JVP) is elevated 3 cm above normal

Chronic congestive heart failure

A 70-year-old woman complains of increasing exertional dyspnea for the last 2 days and now has dyspnea at rest. She has a history of hypertension for the last 5 years and a 35 pack-year smoking history, but no other established illnesses. Current medications are hydrochlorothiazide daily for the last 3 years. She has been prescribed lisinopril but failed to fill the prescription. On examination her BP is 190/90 mmHg, heart rate 104 bpm. There is an audible S4 and the jugular venous pressure (JVP) is elevated 2 cm above normal. Lung examination reveals fine bibasal crepitations. There is no ankle edema. Echocardiogram shows an ejection fraction of 60%.

Congestive heart failure acute exacerbation

A 16-year-old girl presents to emergency care with perianal pain and discharge. She reports a 2-year history of intermittent bloody diarrhea with nocturnal symptoms. On examination, she is apyrexial with normal vital signs. Her abdomen is soft and slightly tender on palpation in the left lower quadrant. Rectal examination is difficult to perform due to pain, but an area of erythematous swelling is visible close to the anal margin, discharging watery pus from its apex. Several anal tags are also present.

Crohn disease

A 25-year-old white man presents to his primary care physician with cramping abdominal pain for 2 days. He reports having loose stools and losing 15 lb (6.8 kg) over a 3-month duration. He also reports increased fatigue. On physical exam, his temperature is 99.6°F (37.6°C). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the right lower quadrant, without guarding or rigidity. Rectal exam is normal and the stool is guaiac positive. The rest of the examination is unremarkable.

Crohn disease

A 20-year-old man is brought to the emergency department with abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the day before. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67 mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per minute, temperature 98.8°F (37.1°C). On mental status examination, he is drowsy. Physical examination reveals Kussmaul breathing (deep and rapid respiration due to ketoacidosis) with acetone odor and mild generalized abdominal tenderness without guarding and rebound tenderness. Initial laboratory data are: blood glucose 450 mg/dL, arterial pH 7.24, pCO2 25 mmHg, bicarbonate 12 mEq/L, WBC count 18,500/microliter, sodium 128 mEq/L, potassium 5.2 mEq/L, chloride 97 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, serum ketones strongly positive.

Diabetic Ketoacidosis

A 57-year-old woman with history of hypertension and hypercholesterolemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant GI problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for GI disorders.

Diverticular disease

A 64-year-old black man presents for a routine visit to establish care. He denies past medical problems, but has been told that his BP was a little high. He has no complaints, takes no medications, tries to adhere to a healthy diet, and rarely exercises. He reports that over the previous 5 years he has gained 6.8 kg (15 lb). Review of systems is otherwise noncontributory. Physical exam is notable for obesity and BP 172/86 mmHg. The remainder of the exam is unremarkable.

Essential hypertension

A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with acetaminophen and ibuprofen at home. The child then began to have frequent jerking movements of all limbs. The rectal temperature was 103.1°F (39.5°C). The parents called 911, and an acetaminophen suppository was administered during transport to the emergency department. The jerking stopped after approximately 5 minutes. Afterward, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurologic status. Common Vignette 2

Febrile seizures

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

Fibromyalgia

A 70-year-old man presents with a generalized tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond, mumbles words that do not make sense, and stares. After several minutes, he is usually responsive. His past medical history includes hypertension and hypercholesterolemia. He had a stroke during the preceding year. Although he recovered significantly, he still walks with a limp on the left side.

Focal seizures

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upward through her chest. She is usually unaware for a few minutes, but others have told her that she smacks her lips, picks at her clothing, and is unable to speak during these episodes. After the event, she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her past medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.

Focal seizures

A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterward. Further review of the history reveals that the patient has been experiencing "jerks" in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These "jerks" do not seem to present a problem during the rest of the day.

Generalized seizures in adults

A 55-year-old woman recently diagnosed with a brain tumor in the left hemisphere has a witnessed seizure event. The seizure is initially recognized when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic extension of the right arm and flexion of the left arm. This is quickly followed by tonic extension of the left arm as well, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.

Generalized seizures in adults

A 10-year-old girl presents after having had a generalized tonic-clonic seizure while at school the previous day. It lasted approximately 2 minutes and she was incontinent of urine during the episode. Afterward she complained of headache and feeling tired. She had been well prior to this episode and there is no family history of epilepsy. General physical exam including neurologic assessment on the day after the seizure were both normal. An ECG was done, which was normal and showed a normal QTc interval

Generalized seizures in children

A 15-year-old boy presents with a history of having had 2 seizures. He is healthy and has no relevant past medical history. There is no family history of epilepsy. Both episodes happened early in the morning and were self-limited. Jerking of the whole body and all 4 limbs lasted <5 minutes, and he was sleepy for several hours after the episodes. His general exams, including blood pressure, a random blood sugar, and an ECG, were normal.

Generalized seizures in children

A 72-year-old white woman presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders. Review of systems is positive for low-grade fever, fatigue, and weight loss. On physical examination, there is tenderness of the scalp over the temporal areas and thickening of the temporal arteries. Fundoscopic examination reveals pallor of the right optic disk. Bilateral shoulder range of motion is limited and painful. There is no synovitis or tenderness of the peripheral joints. There are no carotid or subclavian bruits, and the blood pressure is normal and equal in both arms. The remainder of the examination is unremarkable

Giant cell arteritis

A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had ("even covering my foot with the bed sheet hurts"). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot.

Gout

An 85-year-old man presents with several days of swelling and severe pain in both hands limiting his ability to use his walker. He has a history of gout but has not experienced these symptoms before. On examination, he has a temperature of 100.1°F (37.8°C). There is diffuse warmth, mild erythema, and pitting edema over the dorsum of both hands. There is tenderness and limited hand grip bilaterally. There are multiple nodules around several of the proximal interphalangeal and distal interphalangeal joints, and effusion and tenderness in his left olecranon bursa with palpable nodules.

Gout

A previously healthy 61-year-old woman presents with a 3-month history of sinusitis and nasal drainage. She has noted only marginal, temporary improvement despite multiple courses of antibiotics. The nasal drainage is purulent and frequently hemorrhagic. She also has a 2-week history of migratory joint pain, mainly affecting wrists, knees, and ankles. She does not describe joint swelling. She reports having less energy and has lost 10 pounds in weight over the past 2 months. She has no respiratory, urinary, neurologic or other symptoms. Bleeding and inflammation of the nasal mucosa is noted, along with tenderness to percussion over both maxillary sinuses. The remainder of the physical examination is unremarkable. In-office urinalysis reveals 3+ microscopic hematuria and 2+ proteinuria

Granulomatosis with polyangiitis (Wegener)

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

Graves

A 43-year-old pilot presents for a stress test required by his employer. He states that there is a strong history of premature cardiac disease in his family and 2 of his older brothers are currently being treated for high cholesterol. System review is negative except for some mild SOB with exercise. Examination demonstrates moderate abdominal obesity with a BMI of 31 kg/m^2 and waist circumference of 40 inches (102 cm). The remainder of the exam is normal.

Hypercholesterolemia

A 50-year-old black man with a history of untreated hypertension presents to the emergency room with substernal chest pressure. His symptoms started 1 day prior. The pain was initially intermittent in nature but has become constant and radiates to his jaw and left shoulder. He also complains of dizziness and some SOB. Apart from a history of hypertension diagnosed 1 year ago, the patient denies any past medical history. He is not taking any antihypertensive medications. The patient denies smoking, or alcohol or drug use. Family history is unremarkable. His BP is 230/130 mmHg with otherwise normal vital signs and no other significant findings. ECG shows diffuse T-wave inversion and ST depression in lateral leads. Laboratory testing is significant for elevated troponin, signaling MI

Hypertensive emergency

A 45-year-old woman presents with sweating, nausea, and headache. She does not have any significant prior medical illnesses. The symptoms typically occur when she has skipped a meal or not had anything to eat for several hours, although they have rarely occurred within a couple hours of a meal as well. She does not snack between meals and reports that her weight has been stable. She has never lost consciousness, but has become very confused and distractible. If she does not eat soon after, she begins to feel nauseated and sweaty. She has found that the symptoms quickly resolve after eating.

Hypoglycemia

A 56-year-old obese man with poorly controlled type 2 diabetes mellitus presents with symptoms of nausea, vomiting, and worsening abdominal pain after a dinner of steak, French fries, and wine. On examination he has diffuse abdominal tenderness, which is most marked in the LUQ. Eruptive xanthomas are noted on his back and forearms. image His triglyceride level is 2500 mg/dL and his blood glucose is 364 mg/dL. Serum lipase levels are elevated and abdominal ultrasound shows evidence of pancreatitis.

Hypertriglyceridemia

A 63-year-old woman with diabetes presents with an episode of retrosternal chest pain and diaphoresis that occurred while walking up stairs earlier that day. Her examination is unremarkable except for BP 156/96 mmHg and abdominal obesity. A recent lipid profile showed triglycerides 335 mg/dL, total cholesterol 243 mg/dL, LDL cholesterol 142 mg/dL, and HDL cholesterol 34 mg/dL. Her electrocardiogram shows no acute changes.

Hypertriglyceridemia

A 21-year-old active college student with no past medical history has sudden loss of consciousness, 1 hour into a game of basketball. CPR is administered by bystanders. On arrival of emergency medical professional, he has regained consciousness. The family history is significant for a murmur in his father and grandmother only. Physical examination reveals a systolic ejection murmur that increases in intensity when going from a supine to a standing position and disappears with squatting.

Hypertrophic cardiomyopathy

A 60-year-old woman has progressive dyspnea on exertion over the last 2 months. She is otherwise well with no risk factors for ischemic heart disease. Family history is significant for a cousin who died suddenly in his youth, and is otherwise unremarkable. Physical examination reveals a prominent jugular a-wave and a double apical impulse. There are no murmurs audible. An S4 is present. The remainder of the examination is normal.

Hypertrophic cardiomyopathy

A 52-year-old woman with a history of chronic obesity (BMI = 38 kg/m^2) presents with a 2-week history of increasing shortness of breath and lower-extremity swelling. In addition, the patient reports increasing daytime sleepiness and morning headaches. Vital signs are significant for a pulse oximetry reading of 86% on room air. Physical exam reveals a small, crowded oropharynx; an enlarged neck circumference (48 cm); an increased P2 on cardiac auscultation; an enlarged abdomen; and 3+ lower-extremity edema. Basic laboratory investigations are remarkable for an elevated serum bicarbonate of 32 mEq/L. An arterial blood gas is obtained revealing a pH of 7.28, PaCO2 of 68 mmHg, PaO2 of 56 mmHg, and SaO2 of 85%.

Hypoventilation syndrome

A 42-year-old woman presents with progressive muscular weakness and recurrent facial edema. The edema started 3 months ago and worsened to the point that she was unable to open her mouth or eyes. Concomitant to her facial rash, she experiences intermittent difficulty swallowing. Her weakness results in an inability to rise from a chair or ascend stairs. Skin examination demonstrates blue-purple discoloration on the upper eyelids with edema. Her muscle strength is 3/5 on bilateral hip flexion and 3/5 on bilateral shoulder abduction. The rest of the neurologic exam is normal.

Idiopathic inflammatory myopathies (polymyositis)

A 57-year-old man presents with a 5-year history of slowly progressive leg weakness. Recently he has had multiple falls and experiences difficulties with fine tasks using his hands. Neurologic exam shows atrophy of iliopsoas, quadriceps, and finger flexors bilaterally. Manual muscle strength test finds predominant weakness in finger/wrist flexors compared with finger/wrist extensors. Additionally, it demonstrates neck flexion 3/5, neck extension 4/5, arm abduction 4/5, forearm flexion 4/5, hip extension 3/5, hip flexion 2/5, knee extension 2/5, knee flexion 2/5, ankle dorsiflexion 4/5, and ankle plantar flexion 5/5. The rest of the neurologic exam is unremarkable except for reduced patellar reflexes.

Idiopathic inflammatory myopathies (polymyositis)

A 36-year-old woman presents with a 6-month history of gradually progressive dyspnea on exertion and fatigue. On physical exam, her vital signs are normal and she appears not to be in any distress. Her lungs are clear to auscultation. Her cardiac exam shows a prominent jugular V wave, an accentuated pulmonic component to the second heart sound (P2), and a high-pitched holosystolic murmur best heard at the left sternal border.

Idiopathic pulmonary arterial hypertension

A 72-year-old man with a history of cigarette smoking presents with mild shortness of breath. He is treated initially with inhaled bronchodilators for a presumed diagnosis of chronic obstructive lung disease but has no symptomatic improvement. PFTs are performed and show restriction rather than obstruction, and impaired diffusing capacity for carbon monoxide. A follow-up CXR shows prominent bibasilar interstitial markings.

Idiopathic pulmonary fibrosis

A 7-month-old boy presents with brief episodes of head drops and flexion of the body, followed by tonic extension of arms and legs. These movements last 1 to 2 seconds and occur in several clusters per day, with 15 to 30 spasms per cluster. The head drops are mostly seen on awakening or just before falling asleep. He was born at 41 weeks' gestation with a birth weight of 4050 grams and Apgar scores of 7 at 1 minute and 8 at 5 minutes. He had achieved normal developmental milestones but has regressed since the onset of seizures.

Infantile spasms

A previously healthy 1-year-old female was admitted to a children's hospital with a 7-day history of spiking fever up to 103°F (39.5°C). Three days after the onset of fever she developed left-sided neck swelling and diaper rash, and became progressively fussy and irritable. She was seen at an emergency room, diagnosed with cervical adenitis, and sent home on oral antibiotics. The mother noted continued irritability, high fever, and decreased oral intake. On subsequent admission she was extremely irritable, with a temperature of 102°F (38.9°C), heart rate of 140 beats per minute, respiratory rate of 40 breaths per minute, and blood pressure 110/54 mmHg. There were no signs of nuchal rigidity. Both palpebral and bulbar conjunctivae were deep red and injected, lips were dry and crusted, the oropharynx hyperemic with some areas of ulcerated mucosa, and the tongue papillae were enlarged and red (strawberry appearance). Examination of the neck revealed a mildly tender left unilateral mass, measuring 4 cm. The skin showed a generalized polymorphous, erythematous, macular, blanching rash, in addition to severely red and desquamated perineal region. Her extremities, especially palms and soles, were swollen, red, and mildly tender.

Kawasaki disease

A 69-year-old man develops worsening substernal chest pressure after shoveling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for HTN and he has been told by his doctor that he has borderline diabetes. On examination in the emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and BP is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads. Three doses of sublingual nitroglycerin provide little relief.

MI (NSTEMI)

A 70-year-old woman is 2 days postoperative for knee replacement surgery. Her past medical history includes type 2 diabetes and a 40-pack-a-year history of smoking. She reports feeling suddenly ill with dizziness, nausea, and vomiting. She denies any chest pain. On exam she is hypotensive and diaphoretic. ECG shows convex ST-segment elevation in leads II, III, and aVF with reciprocal ST segment depression and T-wave inversion in leads I and aVL.

MI (STEMI)

A middle-aged man with a medical history of hypertension, diabetes, dyslipidemia, smoking, and family history of premature CAD presents with retrosternal crushing chest pain (10/10 in intensity), radiating down the left arm and left side of the neck. He feels nauseated and lightheaded and is short of breath. Examination reveals a hypotensive, diaphoretic man in considerable discomfort with diffuse bilateral rales on chest auscultation. ECG reveals convex ST-segment elevation in leads V1 to V6.

MI (STEMI)

A 43-year-old man with no significant medical history presents with 3 days of progressive fatigue, dyspnea on exertion and while lying in the supine position, and lower extremity swelling. He reports having a flu-like illness consisting of fevers, myalgias, fatigue, and respiratory symptoms 2 weeks prior that resolved spontaneously. On examination the patient has an elevated jugular venous pressure, bilateral pulmonary rales, and a heart rate of 104 bpm with an audible left ventricular S3 gallop. He is mildly dyspneic at rest but becomes markedly dyspneic with minimal exertion

Myocarditis

A 49-year-old man originally from Argentina with a 3-year history of CHF presents to the emergency room with syncope while at work. He reports speaking with a coworker then suddenly awaking on the floor of the office. The patient's wife states that the patient has had 2 similar episodes in the past. The patient is euvolemic with nondistended neck veins and a normal lung exam. Cardiac exam reveals a laterally displaced apex, and regular rate and rhythm without murmur or gallop but frequent ectopy.

Myocarditis

A 76-year-old retired foundry worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack/year smoking history, but quit at age 50. There is no family history of lung disease. He does not take any respiratory medication on a regular basis. He has noticed he wheezes when he has an URI, and his doctor once prescribed him an inhaler. He is also bothered by joint swelling and stiffness. Lung auscultation is normal. (This case is a common clinical presentation of silicosis or coal workers' pneumoconiosis.)

Pneumoconioses

A 50-year-old male diabetic smoker presents complaining of leg pain with exertion for 6 months. He notices that he has bilateral calf cramping with walking. He states that it is worse on his right calf than his left and that it goes away when he stops walking. He has noticed that he is able to walk less and less before the onset of symptoms.

Peripheral vascular disease

A 75-year-old woman with hypertension and hyperlipidemia presents with abnormal ankle brachial index on a routine screening. She is able to walk without any discomfort and is active.

Peripheral vascular disease

A 35-year-old man who works machining beryllium-copper alloy for the electronics industry is concerned about the possibility of adverse health effects from beryllium, which is a component of the metal he is machining. He has heard about a blood test that can be used for diagnosing beryllium disease. He is not sure if he has had some increased shortness of breath with exercise. He has never smoked cigarettes. He has no personal or family history of allergies or asthma. Lung auscultation is normal. (This case is a common clinical presentation of chronic beryllium disease.)

Pneumoconioses

An otherwise healthy 30-year-old man presents with a several-day history of progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The pain is worse on lying down and improved with sitting forward. There is radiation to the neck and shoulders and specifically to the trapezius muscle ridges. The pain is constant and unrelated to exertion. On physical exam, a pericardial friction rub is heard at end-expiration with the patient leaning forward

Pericarditis

A 20-year-old man presents to the emergency room with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he may have strained a chest wall muscle but, because the pain and dyspnea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular exam is normal.

Pneumothorax

A 65-year-old patient with COPD presents to the emergency room with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the color or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.

Pneumothorax

A 44-year-old woman presents with a 3-month history of abdominal pain, fever, and weight loss. The abdominal pain is cramping in nature and occurs 30 minutes after eating. Abdominal exam is unremarkable. She has widespread purpuric lesions on her lower limbs. image Blood tests reveal elevated inflammatory markers (ESR 93 mm/hour, CRP >160 mg/L) and elevated aminotransferases (ALT 300 U/L). ANCA is negative. Hepatitis B e-antigen and hepatitis B surface antigen are positive, with elevated hepatitis B DNA. A liver ultrasound exam is normal. A full-thickness skin biopsy of the purpuric lesions is reported as showing segmental necrotizing vasculitis of medium vessels with fibrinoid necrosis. A mesenteric angiogram demonstrates multiple aneurysms involving the superior and inferior mesenteric arteries.

Polyarteritis nodosa

A 55-year-old man presents with tingling of the left hand and loss of sensation in both lower limbs. He gives a 6-week history of a 5-kg weight loss and fevers. Exam shows mononeuritis multiplex affecting both the common peroneal nerves and the left radial nerve. Investigation reveals a normocytic, normochromic anemia (hemoglobin 9.3 g/dL), neutrophilia (WBC count 11,500/mm^3), an elevated creatinine (2.48 mg/dL), and elevated inflammatory markers (ESR 89 mm/hour, CRP >160 mg/L) but normal urinary sediment. Tests are negative for antineutrophil cytoplasmic antibodies (ANCA), with no evidence of hepatitis B infection. His blood pressure is 193/103 mmHg. Sural nerve biopsy demonstrates a transmural vascular inflammatory infiltrate with a mixture of macrophages, lymphocytes, and neutrophils plus evidence of focal and segmental necrotizing vasculitis with fibrinoid necrosis. Multiple aneurysms are seen on renal angiography.

Polyarteritis nodosa

A 58-year-old woman presents with a 2-week history of fatigue, anorexia, fevers, and bilateral pain and stiffness in the shoulder and hip girdles. These symptoms are worse at night. Upon awakening in the morning, she feels as if she has a bad flu. She reports difficulty getting out of bed in the morning due to stiffness. Her wrists and finger joints are also painful and swollen

Polymyalgia rheumatica

A 21-year-old male college student presents with a 4-week history of a painful, hot, and swollen left knee, low back pain with bilateral buttock pain, and left heel pain. He denies trauma and states the symptoms began acutely. He denies any fever or any other significant arthralgias. Further review of symptoms indicates the patient was treated for a chlamydia infection after he developed dysuria approximately 8 weeks ago (he was treated with a single dose of 1-g azithromycin). He admits to unprotected sexual intercourse with a new partner 2 days before the onset of his dysuria. In addition to pain and swelling, the patient reports that he has developed morning stiffness in the left knee and low back that last more than 1 hour. He continues to have episodes of dysuria. The findings of physical examination are significant for a large effusion of the left knee with warmth. Range of motion is slightly diminished. There is tenderness to palpation of the left heel at the site of the Achilles' insertion. Laboratory findings are significant for an ESR of 35 mm/hour, and both a CBC and uric acid level are within normal limits. He is HLA-B27 positive, rheumatoid factor negative, and ANA negative. The synovial fluid analysis is negative for crystals, with a total nucleated cell count of 22,000 cells/microliter (65% neutrophils). A urethral swab was positive by PCR for Chlamydia trachomatis 9 weeks ago at initial presentation of dysuria. There was no evidence of gram-negative diplococci on Gram stain.

Reactive arthritis

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

Rheumatoid arthritis

A 72-year-old man presents with progressive malaise, weakness, and confusion. He suffers from hypertension but this is well controlled with a thiazide diuretic and an ACE inhibitor. He has diabetes, treated with metformin, but no other medical problems, and he is able to perform all activities of daily living independently. The patient's wife reports general deterioration over the last 2 days. The patient appears severely ill, weak and obtunded, unable to speak. His skin is mottled and dry with cool peripheries, and he is mildly cyanotic. Respiratory rate is 24 breaths/minute, pulse rate 94 beats/minute, BP 87/64 mmHg, and temperature 95.9°F (35.5°C). Auscultation yields coarse crackles over both lung bases.

Shock

A 29-year-old woman presents with shortness of breath, cough, and painful red skin lesions on the anterior surface of the lower part of both legs. CXR reveals bilateral hilar lymphadenopathy with pulmonary infiltrates.

Sarcoidosis

A 35-year-old woman presents with skin lesions around her nose, which are indurated plaques with discoloration. She also reports a red, moderately painful right eye with blurred vision and photophobia

Sarcoidosis

A 45-year-old man presents to the emergency department with upper abdominal pain and a history of peptic ulcer disease. He reports vomiting blood at home. He is otherwise well, takes no medications, and abstains from use of alcohol. While in the emergency department he vomits bright red blood into a bedside basin and becomes light-headed. BP is 86/40 mmHg, pulse 120 bpm, and respiratory rate 24 per minute. His skin is cool to touch, and he is pale and mottled in skin coloration.

Shock

A 45-year-old woman presents with fatigue and a history of positive antinuclear antibodies. She has had recurrent sensation of sand/gravel in eyes and dry mouth every day for more than 3 months.

Sjogren syndrome

A 50-year-old man presents to clinic with a complaint of central chest discomfort after walking for more than 5 minutes or climbing more than 1 flight of stairs for the past 2 weeks. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years. On examination, his blood pressure is 144/92 mmHg with a heart rate of 82 bpm. The remainder of his exam is normal.

Stable ischemic heart disease

A 60-year-old man with a history of a myocardial infarction presents to clinic for follow-up. He was started on aspirin, beta-blocker, and statin therapy after his heart attack. In the past 2 weeks the patient has noted return of chest pressure when he walks rapidly. The chest pressure resolves with sublingual nitroglycerin or a decrease in his activity level. He is a former smoker and has modified his diet and activity to achieve his goal body weight. He is normotensive on exam with a heart rate of 72 bpm. The remainder of his exam is normal.

Stable ischemic heart disease

A 15-year-old girl wakes up disoriented and confused. She remains still in bed, looking continuously around the room as if daydreaming. When asked about her strange behavior, she does not appear to understand and replies with unintelligible words. For the last 3 years, she has been having subtle early morning body jerks and has been told by her teachers that she frequently spaces out in class.

Status epilepticus

A 45-year-old homeless man is found unconscious in the street. He appears stiff, with continuously shaking extremities, foaming at the mouth, and urinary incontinence. On arrival to the emergency department, he has stopped shaking but is still unconscious. Stiffening and shaking resume a few minutes later. Two empty medication bottles are found in his pocket, labeled phenytoin and valproic acid.

Status epilepticus

A 16-year-old black female presents to her primary care physician with symptoms of fatigue, musculoskeletal pain, and a facial rash. On examination she is noted to be thin with malar skin changes. No other abnormality is found.

Systemic lupus erythematosus

A 35-year-old woman presents complaining of puffy hands and feet for the past 3 months. She noted the onset of Raynaud phenomenon 6 months ago. Examination confirms the presence of puffy hands and feet, with subtle skin thickening of the fingers and dorsum of the hands. Serology tests reveal a positive ANA with both speckled and nucleolar patterns at a titer of >1:1280. Anti-topoisomerase (antiScl 70) antibody is strongly positive. Pulmonary function tests are normal (although this does not preclude the possibility of the development of fibrosis at a later date). The patient is diagnosed with diffuse cutaneous systemic sclerosis.

Systemic sclerosis, scleroderma

A 38-year-old woman presents with Raynaud phenomenon for the past 5 years. She also has a history of digital ulcers and GERD. Physical exam reveals telangiectasias on the hands. She has sclerodactyly. Digital pits are present with no active ulcers. image Serology tests reveal a high-titer ANA by indirect immunofluorescence, at a titer of >1:640 in a centromere pattern. The patient is diagnosed with limited cutaneous systemic sclerosis.

Systemic sclerosis, scleroderma

A 36-year-old woman with a history of chronic sinusitis presents with nasal deformity. She has had nonspecific muscle and joint aches for 2 years, diagnosed as fibromyalgia. For a few years she has regularly noted dark crusts from her nose, occasionally mixed with some blood. A few weeks ago the bridge of her nose started to collapse. She has a prominent saddle nose deformity and nasal septal defect. Sinus biopsy shows only chronic inflammation, but her cytoplasmic-pattern antineutrophil cytoplasmic autoantibody (c-ANCA) titer is 1:160, consistent with granulomatosis with polyangiitis (Wegener granulomatosis)

Systemic vasculitis

A 75-year-old man with an unremarkable past medical history presents with a complaint of new headache for the past 2 weeks. He notes that the headache is localized over the left temple. Two weeks prior to the onset of headache, he noted pain and stiffness in the shoulders and hips, which made it difficult to rise from bed in the morning, but progressively improved throughout the day. A few days prior to his evaluation, he noted jaw pain on chewing, and notes in retrospect that he had begun to avoid certain foods (such as steak) because of the associated discomfort. Laboratory evaluation demonstrates evidence of inflammation, including an elevated ESR, C-reactive protein, and platelets. The complaints of new headache and jaw claudication in the setting of systemic inflammation are consistent with a diagnosis of giant cell arteritis.

Systemic vasculitis

A 28-year-old woman presents with new left-arm pain. She was previously well but for 2 months has had episodes of low-grade fever, night sweats, and arthralgia. She works as a store clerk and has noticed left-arm pain when she stocks shelves. Her only medication is an oral contraceptive. She does not smoke cigarettes. On examination, her blood pressure is 126/72 in her right arm, but it cannot be measured in her left arm. The left radial pulse cannot be detected. There is a bruit over the left subclavian artery. Carotid pulses are normal but there is a bruit over the right carotid artery. Femoral and pedal pulses are normal and no abdominal bruits are heard. The left hand is cool but has no other evidence of ischemia.

Takayasu arteritis

A 39-year-old woman presents with headaches of insidious onset over 3 months. She has lost 3 kilograms during this time but feels otherwise well. On examination, bilateral blood pressures taken in the arms are 190/110 on the right and 200/110 on the left. She is taking a multivitamin but no other medications. For the past 20 years she has smoked 10 cigarettes a day. Urinalysis reveals estimated protein of 360 mg/24 hour.

Takayasu arteritis

A 45-year-old woman, with a history of type 1 diabetes diagnosed when she was a teenager, presents to the emergency department complaining of abdominal pain, nausea, and shortness of breath that woke her up from sleep.

Unstable angina

A 65-year-old man, who smokes and has a history of hypertension and peripheral vascular disease, now presents with increasing frequency and severity of chest discomfort over the past week. He reports previously having chest pain after walking 3 blocks but now is unable to walk more than half a block without developing symptoms. The pain radiates to the left side of the neck and is only eased after increasing periods of rest.

Unstable angina