Exam Master 1-500

A 19-year-old man is brought into the ED following a motor vehicle crash in which he, the driver, sustained blunt trauma to the anterior trunk from striking the steering wheel and dashboard. The patient is alert, short of breath, hypotensive, and complains of acute chest pain. On auscultation, muffled heart sounds are heard.

Pericardial tamponade

A 47-year-old obese woman presents with left non-dominant shoulder pain and limited motion. The pain began about a month ago but has reduced over time. Her shoulder has progressively lost motion during that time; she cannot reach overhead with that arm. There is no history of trauma, it does not wake her at night, and she can sleep on the left side. Her past medical history is significant for type 1 diabetes and hypothyroidism. She is on regular insulin, NPH insulin, and levothyroxine.

MRI Decreased active and passive range of motion ≥50%

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

Trichinella spiralis

A 3-year-old boy presents with his mother; she reports that he is unable to walk without support. He is an only child who rarely leaves his tenth-floor apartment home. On examination, he has a rachitic rosary and genu valgum.

Vitamin D deficiency

A 33-year-old G5P4 woman presents to her gynecologist. She has been using condoms and would like to discuss alternative birth control options. She has regular periods and is not currently trying to get pregnant. She is sexually active with one partner. Past medical history includes asthma, deep vein thrombosis during her first pregnancy, and a C-section for her fourth pregnancy. She has no known drug allergies.

Levonorgestrel IUD

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

Hypertension

A 37-year-old overweight woman presents for a follow-up after an ER visit 4 days ago; her ER visit was the result of a fainting episode. Except for a blood pressure of 140/100, vital signs are all within normal limits. The patient denies a prior history of hypertension. Although the patient had an elevated BP, the ER physician felt that her fainting episode was more likely due to stress and poor eating habits; she had been attempting to lose weight before her wedding, which is occurring in a month. She was released from the ER with instructions to follow up with her PCP for evaluation and treatment of high blood pressure.

Hypertriglyceridemia

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

IV drug abuse

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

Increase hydrochlorothiazide dose to 25 mg daily.

You are currently on an inpatient pediatric hospitalist team; you see a preterm infant who has signs of failure to thrive. Other signs and symptoms found during the history and physical examination include tachypnea, bounding peripheral pulses, and a rough machine-like murmur.

Indomethacin

A 79-year-old man presents with severe chest pain and dyspnea. He has a past medical history of diabetes mellitus, hypertension, and hyperlipidemia. He appears pale, apprehensive, and diaphoretic. He is in a confused state and agitated. His pulse is weak and tachycardic, with a systolic blood pressure of 60 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, and significant jugular venous distention. His lungs are free of crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads.

Leading contributory cause is myocardial ischemia.

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

Mitral stenosis

A 36-year-old woman presents with chronic dyspnea that is worse while lying prone. The patient reports progressive worsening of the symptoms. On physical examination, a heart murmur is detected upon cardiac auscultation, heard best with the bell over the apex. The murmur is a non-radiating low-pitched diastolic rumble. A loud S1 and opening snap can also be heard in addition to an apical thrill and decreased pulse pressure. An EKG is done and shows atrial fibrillation.

Mitral stenosis

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

Mitral stenosis

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

Mitral valve

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

Mitral valve prolapse

A 27-year-old man with Marfan syndrome presents due to exercise intolerance and heart palpitations. On exam, you note a mid-systolic click and late systolic murmur heard at the apex of the heart. The click and murmur are noted later in systole with squatting and earlier in systole with sudden standing.

Mitral valve prolapse

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

Mitral valve prolapse

A 15-year-old girl is referred to a cardiologist's office for workup of hypertension. Her mother reports a normal pregnancy and birth. There is no family history of heart disease. On physical exam, BP 140/70 left and right upper extremities, 90/70 left and right lower extremities, HR 85/min, RR 20/min. Brachial and femoral pulses are incongruent. There are pulsations in the suprasternal notch. Cardiac auscultation reveals a III/VI systolic ejection murmur.

Rib notching and a notch in the aorta

A 72-year-old woman presents with a severe unilateral headache, jaw pain, and scalp tenderness. The patient states the headache is of a piercing quality; her jaw hurts only when she chews, and feels better a few minutes after she stops chewing. A pulsation of the temporal artery on the same side as her headache cannot be appreciated, and prednisone is prescribed until the patient can see a specialist.

Risk for blindness

A 47-year-old man presents for his annual physical exam. His past medical history is not significant, and he is not currently on any medications. He consumes 2 beers weekly and does not smoke. His blood pressure is normal during this visit. His primary care physician orders a fasting lipid panel with the following results:

Simvastatin

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

Symptoms can significantly improve with alcohol cessation.

A 15-year-old boy presents with abdominal pain and rectal bleeding. His family history is significant for the premature deaths of his mother and maternal grandmother from metastatic colon cancer. Both died before age 35; in both, autopsy findings included hundreds of colon polyps along with multiple primary colon cancers. Endoscopy of the boy also demonstrates extensive colonic polyp disease.

APC

A 73-year-old man presents to the emergency department after a suspected overdose. History is unobtainable; he is currently febrile; his blood pressure is 125/76 mmHg, respiratory rate 30 with increased breathing depth, heart rate 105; and laboratory results are as follows:

Aspirin

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

Avoid long-term use of docusate.

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

Barium study

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

CA125

A 10-day-old male newborn presents with bilateral conjunctivitis with moderate white discharge. He is acting normally, has no fever, and is feeding well. He was born full-term without any complications. His mother had minimal prenatal care. He has been gaining weight well. On exam, he is alert and active. Culture with immunofluorescence reveals inclusion bodies.

Chlamydia trachomatis

A 40-year-old woman is seen in the emergency department because of right upper quadrant pain and fever. She has been experiencing episodic epigastric pain over the past few months, but this is the worst her symptoms have been. She also reports anorexia and vomiting. She is in obvious distress. On physical examination, her doctor notes the presence of jaundice. Her lab results are as follows:

Cholangitis

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

Chronic pancreatitis

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

Colles' fracture

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

Colonoscopy

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

Congestive heart failure

A 27-year-old woman presents in active labor. She is G3P2 and at 39 weeks of gestation. She has been receiving prenatal care since 6 weeks gestation, and her pregnancy has been uncomplicated. Both of her prior births were normal spontaneous vaginal deliveries. Her cervix is 6 cm, 90% effaced, mid-position, and soft. The fetus is not engaged and is thought to be vertex. Initial fetal monitoring shows a heart rate in the 140s with good accelerations, and it is reassuring. Contractions are 4 minutes apart, and she is comfortable. 20 minutes later, she experiences a large gush of clear fluid, and severe variable decelerations appear on the fetal heart rate monitor.

Cord prolapse

A 15-year-old boy presents with bloody diarrhea and abdominal cramping. A double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. A biopsy finds an extensive inflammatory process in the mucosa and submucosa. The glands are filled with eosinophilic secretions; there is also mild involvement of the terminal ileum. Sulfasalazine treatment is attempted without improvement.

Corticosteroids

A 50-year-old man presents with the acute onset of chest pain. He describes the pain as sharp, worse with deep breaths, and improved with leaning forward. Physical exam is remarkable for a pericardial friction rub on cardiac auscultation.

Diffuse ST elevation

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

Diffuse ST-segment elevation

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

Diltiazem

A 19-year-old woman presents with vaginal pruritus, dysuria, and dyspareunia. On exam, a profuse frothy yellowish-green vaginal discharge with reddened vaginal mucosa is noted.

Evaluate vaginal discharge under microscopy.

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

Klinefelter syndrome (XXY)

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

Osteoma

A 50-year-old man presents with a 3-month history of weakness, fatigue, and abdominal discomfort. He acknowledges a lack of sexual desire. He denies any photosensitivity. On physical examination, his liver is enlarged, and his spleen is palpable. He has abnormal skin pigmentation on his face, neck, and elbows that gives his skin a metallic gray hue.

Hepatocellular carcinoma

A 34-year-old man presents for evaluation of right calf pain after being struck by a car. He reports burning pain in his calf and numbness and tingling in his right foot. Physical exam is remarkable for calf swelling, increased pain with passive muscle stretching, and muscle weakness and decreased sensation in his right ankle and foot.

Pain out of proportion to exam

A 66-year-old man presents with a 2-month history of bone pain and weight loss. Lytic lesions were discovered on a routine X-ray. You order additional lab work.

Hypercalcemia

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

Incision and drainage

A 17-year-old male college freshman presents with fatigue, back pain, and stiffness. The pain has been present for the past several months, but it appears to be worsening. The back symptoms are worse at night and first thing in the morning; they improve somewhat during the day. He reports the pain improves with exercise. He is having difficulty staying productive at school because he is always tired.

Increased erythrocyte sedimentation rate

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

Length of time the symptoms have been present

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

Metastatic osteogenic sarcoma

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

Mitral stenosis

A 22-year-old woman presents for her annual well-woman examination. She was seen last year and she had her first pap smear done, which showed no evidence of intraepithelial neoplasia. She is sexually active with one partner currently and a history of two partners total. She reports using condoms intermittently.

No cervical cancer screening recommended

Mandatory newborn screening has been conducted on a neonate born 36 hours ago. The abnormality found in the screening has resulted in counseling on initiating lifelong modification to the newborn's diet. It is explained to the mother this action must be taken in order to help decrease the incidence of severe intellectual disability, hyperactivity, and even seizures.

Phenylalanine

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

Polyarteritis nodosa

A 47-year-old man presents with abdominal pain and difficulties breathing. He has a history of alcohol abuse and confirmed cirrhosis of the liver. On examination, you see a malnourished and jaundiced patient with a distended belly. Percussion of the abdomen reveals a huge amount of fluid and wave sign.

Portal hypertension

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

Positive (+) drop arm test

A 40-year-old male recreational tennis player presents with pain in his playing-side elbow since a tournament last weekend. He played five matches of singles and two matches of doubles games. He cannot even hold a pen without pain. He says he needs to get better fast because he has another tournament coming in a week. On exam, he has pain with extension against resistance of his affected side wrist.

Prescribe an NSAID of choice and recommend skipping the next tournament.

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

Pseudomonas

Parents bring their 4-year-old daughter in because of knock-knee. She is otherwise healthy, and her height is in the 50th percentile for age. On examination, she has about 10 degrees of valgus.

Reassurance that this is normal for age

A 45-year-old woman presents with diarrhea and vomiting that started last evening. She says she warmed up leftover rice for supper last night and symptoms began shortly thereafter. She has no fever, and her blood pressure and pulse are within normal limits.

Reassure and send home with oral rehydration

A 74-year-old multiparous woman with a history of breast cancer has been referred to a gynecologist due to a sensation of vaginal fullness and pressure, sacral back pain with standing, coital difficulty, lower abdominal discomfort, and urinary frequency and incontinence. She states that she feels "a bulge" in the lower frontal vaginal area. She denies any fever, chills, flank pain, history of infectious diseases, changes in weight, dysuria, or hematuria. The physical exam is remarkable for an obese body habitus and non-tender bulge located anterior within the vaginal introitus that becomes more pronounced upon Valsalva and standing.

Recommend pelvic muscle exercises.

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

Refer for physical therapy

A 29-year-old man and his wife have been trying to have a child for the past 3 years. The wife was thoroughly evaluated for infertility; the workup revealed no abnormalities. Examination of the man's inguinal region reveals an ill-defined tortuous swelling that increases with standing and coughing. Ultrasonography is suggestive of varicocele. His initial semen analysis reveals mild oligospermia.

Repeat semen analysis

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

Semen analysis

A 33-year-old woman presents with joint pain and morning stiffness that lasts more than an hour. Her past medical history is significant for postpartum depression 2 years ago. Her BMI is 18. Physical examination is remarkable for bilateral pain and swelling of her metacarpophalangeal (MCP) joints and ulnar deviation. Laboratory evaluation reveals positive antibodies to citrullinated peptide.

Sex

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

Shigella sonnei

A 6-week-old boy presents with his mother, who reports that he has episodes of turning "blue all over," especially when eating or when he becomes upset. Physical exam reveals cyanosis of the lips when he is crying. Cardiac exam reveals a harsh systolic crescendo-decrescendo murmur in the left upper sternal border. A chest X-ray reveals right ventricular hypertrophy.

Tetralogy of Fallot

A 32-year-old woman presents with a 3-month history of right hand pain and paresthesia of the thumb, index, and middle fingers. She works in a retail sales office and spends much of the day typing.

Thenar atrophy

A 25-year-old man from China presents with a 1-month history of an inability to see well while walking home from work at night. He also reports that he has been getting sore throats more frequently. He is a recent immigrant from his home country; he lives alone and eats mainly a rice-based diet. On examination, you note pericorneal and corneal opacities.

Vitamin A deficiency

A 31-year-old Caucasian woman presents for genital itching that she has been experiencing for a while. She has treated herself with OTC medication for a yeast infection, which has not helped. Now she notices a lump, which appears to be raised and nodular on exam. Her menstrual cycles have remained unchanged since puberty. She is G0P0 and has been taking oral contraceptives for the past 11 years. Her family and social history are insignificant.

Vulva

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

AST>ALT by a factor of 2

A 52-year-old woman presents for a routine checkup. She has two children, and she attained menopause 1 year prior to presentation. Pap smears, mammogram, and DEXA bone scan are normal. She is a non-smoker. Her previous biennial checkups were always normal. Her BP is 142/86 mm Hg, and pulse is 72 bpm. Her lab values are as follows:

Diet and exercise

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

Dietary control

A 43-year-old woman who works as a secretary and spends most of her day typing on the computer has symptoms of carpal tunnel syndrome.

Electromyogram

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

Elevated AST and ALT

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

Fasciotomy

A 20-year-old woman presents with 2 weeks of anorectal pain. She notes streaks of blood on her stool and toilet paper. She reports "a tearing pain during each bowel movement." She dreads having a bowel movement, and she attempts to hold it as long as she can. She broke her leg in a skiing accident 4 weeks ago and was prescribed oxycodone/acetaminophen (Percocet) for the first few days due to her pain. An anoscope reveals an acute anal fissure.

High-fiber diet and stool softeners

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

Intrauterine device

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

Nitroglycerin 0.4 mg SL

An 88-year-old man with abdominal pain presents to the emergency room with his wife. A mini-mental status exam reveals pronounced forgetfulness and confusion. The patient is discovered to have acute appendicitis requiring immediate surgery. He is unable to understand the situation and cannot provide informed consent.

Obtain consent from his wife to perform surgery.

A 20-year-old male student presents with a "weird" heart sound. He indicates that while in the anatomy lab, they were practicing with stethoscopes and listening to each other's heart sounds as a part of the course curriculum. One student said that his heart had a rumbling sound. On further history of the patient, he indicated that he had acute rheumatic fever twice as a teen.

Patient lying on the left side, at the apex of the heart

A 55-year-old man visits his family physician for an accidental cut to the forearm with a rusty wrench. He works as a tank mechanic for the US Army and has been an Army recruit since age 18. The patient received his influenza vaccine a few months ago. He also received tetanus and diphtheria toxoid approximately 2 months ago when he had an unrelated injury. The patient has been consuming a lot of alcohol over the past few years. He admits wanting to cut down. He currently drinks a half bottle of red wine every day. He also admits to taking a shot of vodka in the morning to "tide" him through the day. The wound is cleaned and dressed appropriately, and his liver function is tested:

Pneumococcal vaccination, hepatitis A and B

A 73-year-old man has had a history of pain in that shoulder for over 6 months that kept him from sleeping on the left side; the pain would wake him often. He presents with an inability to actively raise his left non-dominant arm, which began a month ago after his shoulder pain improved. There was no specific injury he can recall, but he felt a pop a month ago while taking out the trash. On inspection, you notice the back of the shoulder appears sunken compared to the other shoulder.

Rotator cuff tear

A 29-year-old woman presents with a previous history of mitral valve prolapse with murmur of regurgitation confirmed on echocardiogram with prosthetic valve replacement 1 year ago.

Tooth extraction

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

Colposcopy

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

Intussusception

A 60-year-old Caucasian man comes to your office to establish care. He has no known medical problems and his only medication is daily ibuprofen for 5 years for musculoskeletal aches associated with his work as a handyman.

Gastrointestinal bleed

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

Hemostasis

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

Spicy foods

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

Thrombophlebitis

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

Thumb spica splint and referral to an orthopedic surgeon

A 36-year-old woman presents with a 24-hour history of sudden severe diarrhea described as profuse, gray, cloudy, watery stools without blood or fecal odor. She was recently in Bangladesh for work and returned yesterday, which was when the diarrhea began. She is also experiencing a mildly elevated temperature with a very dry mouth, headache, and severe fatigue.

Vibrio cholerae

A 49-year-old woman presents with dysphagia. She is having difficulty swallowing liquids and solids, and she notes regurgitation of undigested food. X-ray reveals a bird's beak appearance of the esophagus.

Achalasia

A 52-year-old man presents with rectal pain during bowel movements. He describes the pain as tearing. Physical examination reveals a tear in the anal mucosa.

Psyllium

A 17-year-old football player (punter) was tackled and forcefully slammed onto his right dominant shoulder 2 hours ago during a game. He had immediate pain, but it has subsided; he now experiences the same level of pain when he carries a heavy object. He wants to continue punting. He has full active and passive range of motion, but some pain (4/10) with abduction. There is no obvious deformity, and the skin over the shoulder is intact and not tented. There is no crepitus on palpation while moving the arm. Most of his tenderness seems to be on the superolateral right shoulder.

"You can continue to play if you are pain-free."

A 53-year-old woman presents for an annual examination. She has a history of asthma for which she takes inhaled steroids and ß-agonists. She has no history of bone fractures and no family history of osteoporosis. She exercises regularly. Her menses used to be regular, but have just started to show some irregularity. She believes she might be entering menopause and asks for advice to prevent osteoporosis.

1200 mg of calcium and 800 IU vitamin D daily

A 63-year-old woman presents with acute onset of abdominal pain that describes as a steady deep discomfort in the left lower quadrant. She was constipated initially, but she is now experiencing diarrhea. On physical examination, she has a temperature of 38°C. The abdomen is tender in the LLQ with guarding and rebound tenderness. She has positive fecal occult blood.

Abdominal CT

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

Abdominal ultrasound

A 63-year-old woman presents with a 1-hour history of left shoulder pain and nausea. She has a past medical history of coronary artery disease and had a stent placed 5 years ago. Troponin is elevated. An ECG shows large R waves and ST segment depression in leads V1, V2, and V3.

Acute posterior myocardial infarction

A 32-year-old woman is brought in via ambulance due to a fast heart rate. Her blood pressure is 114/76 mm Hg, and her heart rate is 156 bpm. She reports mild chest pain and shortness of breath. Her 12-lead EKG reveals retrograde P-waves that occur simultaneously with the QRS complexes but appear "hidden."

Adenosine 6 mg IV

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

Ankylosing spondylitis

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

Anti-inflammatory medications

A 26-year-old woman presents with dysmenorrhea that has become more bothersome over the last 3 months. She has difficulty taking ibuprofen (Motrin) due to a stomach ulcer.

Applying warm compresses locally

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

Ascorbic acid

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

Atrial fibrillation

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

Bacterial vaginosis

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

Campylobacter jejuni

An 18-year-old girl has had a small slightly tender swelling in her left upper eyelid for 10 days. For the first day or two, it was red and a little painful. Now it is painless, but it has grown in size. There has not been any drainage, visual changes, or itching noted. She has been well otherwise. On exam, vitals are normal, extraocular muscles are intact, and pupils are equal and reactive to light. Her left upper eyelid has a 1.5 cm round non-tender swollen mass that is mildly erythematous without any drainage. The underside of the lid is grayish-red.

Chalazion

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

Colonoscopy

A 67-year-old man is recovering following an uncomplicated total hip arthroplasty. His past medical history is significant for hypertension and mild asthma. On postoperative day 2, he begins to note stiffness in his right leg. On exam, his right calf is noted to be swollen and slightly warmer than the left leg. The remainder of the exam is unremarkable. He is afebrile, and his vital signs are stable.

Compression ultrasonography

A 51-year-old man with a history of Marfan syndrome presents to the emergency department with tearing chest pain that radiates to the back and neck. On examination, the patient is hypertensive; a high-pitched decrescendo diastolic murmur at the left sternal border and diminished peripheral pulses are noted.

Computed tomography scan of the chest and abdomen (CT scan)

A 22-year-old primiparous woman at 10 weeks gestation presents to the office. She works in an office, but she maintains a regimen of swimming and moderate weightlifting 3-4 times per week. She has had no vaginal spotting, and the pregnancy is progressing normally. She would like to continue with her exercise routine but is concerned about reports from friends that exercise has an adverse effect on pregnancy. Past medical history is otherwise unremarkable. Vital signs are normal, and examination is consistent with a 10-week gestation.

Continue current exercise regimen.

A 55-year-old man became intoxicated at a bar after a serious argument with his wife about his diet and habits (he is overweight and a heavy smoker). On the way back home, he developed chest pain radiating to the left shoulder, shortness of breath, sweating, and anxiety. ECG shows pathological Q wave and ST elevation. Laboratory results are remarkable for an elevated troponin.

Injury to myocardial cell membrane

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

Dilated cardiomyopathy

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

Gluten-free diet

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

Hemolysis of red blood cells in the fetus

A 33-year-old African American woman with a PMH of sarcoidosis presents with loss of appetite. She reports constipation and lethargy. She thinks that her urine output has increased. On physical examination, some muscle weakness and hyporeflexia are present. Laboratory tests are ordered and are pending. An EKG shows a shortened QT interval.

Hypercalcemia

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

Hypercholesterolemia

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

Immobilization

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

Juvenile fibroadenoma

You are evaluating a 26-year-old man; he is suspected of being infertile. His past medical history is unremarkable. On examination, you note he is 6'4"; he has mild gynecomastia, sparse body hair, and small soft testes.

Klinefelter syndrome

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

Lactated Ringer's

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

Lasix (furosemide)

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

Liberal salt and fluid intake

A 56-year-old man presents with primary hypertension. His additional medical history includes only nephrolithiasis. Past analysis of his kidney stones has revealed a calcium oxalate composition.

Loop diuretics

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

MRI

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

Measurement of urine volume

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

Meloxicam

You are working in an adolescent health clinic. Protocols have been established to screen certain teenage patients for hepatitis B immune status with blood tests.

Patient B

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

NSAIDs

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

Niacin deficiency

A 51-year-old woman presents with difficulty swallowing. She reports a 2-month history of problems swallowing liquids and solids and bringing up undigested food. X-ray reveals a bird's beak appearance of the esophagus.

Nifedipine

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

No treatment

A 66-year-old man with a history of obesity and hyperlipidemia presents with an 8-month history of progressing "burning in his chest." This sensation is noted in the midline of his chest, and it is provoked when he bends over, when he wears tight clothing, after he eats a large meal, and when lying supine. He denies any chest pressure, cough, shortness of breath, palpitations, dizziness, lightheadedness, and diaphoresis. His physical examination is unremarkable. An upper endoscopy is performed. An upper endoscopy is performed and inflammation in the esophagus is noted.

Omeprazole

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

Perform a right knee radiograph.

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

Perform a transvaginal ultrasound.

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

Perform arthrocentesis of right ankle with analysis of synovial fluid.

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

Spinal stenosis

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

Progestin-only oral contraception pill

A 73-year-old man presents with the inability to actively raise his left non-dominant arm to retrieve plates from the kitchen cabinet. He further describes the inability to retrieve any objects with his left hand/arm because of the limited range of motion. He is worried because he is the only driver in his household, and he does not want to lose his driving privileges. He has a longstanding history of chronic shoulder impingement syndrome. On exam, he is found to have a (+) positive drop arm test.

Refer for physical therapy

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

Right hemisection of spinal cord

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

Topical nitroglycerin 0.2-0.4%

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

Ultrasound abdomen

A 75-year-old woman presents with heartburn and dyspepsia. She was diagnosed with osteoarthritis 4 years ago. For the past 18 months, she has been managing pain with naproxen. The gastroenterologist suggests that the patient be tested for Helicobacter pylori infection.

Urea breath test

A 36-year-old G1P1001 woman presents with a 4- to 5-week history of pain along her right lateral wrist; the pain worsens when she tries to grasp something. There was no trauma. She gave birth 6 weeks ago and carrying her baby is difficult secondary to pain. She is right-handed and has never had any issues like this before. On exam, there is tenderness and edema over the radial styloid. You then have the patient fully flex her thumb, adduct, and grasp it with that hand. You then place her hand in ulnar deviation, which reproduces the pain described above.

de Quervain tenosynovitis

A 49-year-old right-hand dominant woman presents with a 2-week history of progressive pain in her right thumb and wrist area. She says that her thumb seems to "stick" in place upon movement. She states that she has never experienced this before. You ask her if she has been using her hands more often than normal, and she tells you she recently began to crochet a sweater for a family member. On physical examination, her pain is markedly exacerbated when she places her thumb into the palm of her hand, and when you passively move her hand in an ulnar direction.

de Quervain's tenosynovitis

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

Absent femoral, popliteal, pedal pulses

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

Begin this patient on a beta-adrenergic blocker.

A 43-year-old man presents for a general physical exam. He states that he has no significant past medical history. On physical examination, you note that the patient has a 3/6 diastolic murmur; it is heard best in the right upper chest. Blood pressure is 152/62 mm Hg. No other abnormalities are noted.

Echocardiogram with color Doppler

A 64-year-old man with a history of a remote myocardial infarction and congestive heart failure presents for his 3-month follow-up. A recent echocardiogram reveals severe left ventricular dysfunction.

Implantation of a cardioverter-defibrillator device

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

It decreases with squatting.

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

Lisinopril

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

Perform mitral valvuloplasty.

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

Anterior/posterior, scapular lateral, and axillary radiographs

You have inherited three adolescent patients who had different early childhood malignancies that were treated in different ways according to the type and grade of cancer. They have been in remission now for over 5 years. In reviewing their charts, you consider the need to monitor for late effects of childhood cancer.

Bone and soft tissue sarcoma

A 25-year-old woman who is 36 weeks pregnant presents for her regular obstetrics care examination. She was diagnosed with hepatitis C a couple years ago. No viral RNA was detected during her pregnancy, which progressed smoothly and without major discomfort. She has no history of intravenous drug use or blood transfusions. She is HIV negative. She plans on breastfeeding, but she is concerned about transmitting the hepatitis C virus to the newborn.

Breastfeed, but temporarily stop if nipples crack or bleed.

A 15-year-old girl presents with short stature and primary amenorrhea; her neck is short and broad, her palate is high-arched, and her genitalia are infantile. Her parents recall several episodes of otitis media during childhood. Her serum FSH is elevated and estradiol is low.

45,XO

A young couple presents for advice about infertility. They have been married for 4 years and have never used contraceptive methods. They are both 27 years old, and the wife has an 8-year-old daughter from a previous relationship. Both are very eager to have a child; the husband is somewhat anxious about the results of 2 semen analyses that show azoospermia. He states that when he was 14 years old he was evaluated for delayed pubertal development; at that time, he had a chromosomal analysis that revealed that the problem is genetic. He was prescribed testosterone, which he used for only a few months. He is 6'8'' tall and has unusually long legs. His facial skin is smooth; there is no beard. There is palpable breast tissue bilaterally. His right fifth finger is curved towards the fourth finger. His pubic hair is substantially decreased for his age, and both testes are small (approximately 5 cm) and firm in consistency.

47,XXY

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

6 weeks

A 48-year-old woman with a past medical history of obesity presents with a 4-hour history of moderate severity epigastric and right upper quadrant pain. The pain is intermittent and occurs in "waves." She also notes nausea, vomiting, and radiation of pain to the right shoulder. Her physical exam reveals normal vital signs, but tenderness is noted in the right upper quadrant. There is no guarding or rebound. A bedside ultrasonography is obtained. Refer to the image.

A low-fat, low-cholesterol diet is recommended.

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

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

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

Abdominal computed tomography scanning

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never had this as bad as she does currently. The patient denies any other significant past medical history and is currently taking only a multivitamin daily. She admits to recently having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days. She hopes that after finals are over her headaches will subside. She also states she was given a 10-day course of amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stools, use of tobacco/alcohol, or coughing up blood. Physical examination is unremarkable for any abnormalities.

Acetaminophen

A 15-year-old boy is being treated at the dermatologist for lesions on his cheeks, forehead, chin, upper chest, and upper back with a history that has been progressively getting worse. Upon physical exam, open and closed comedones are present on the patient. Additionally, inflamed papules and some scarring are present. All labs are within normal limits.

Acne vulgaris

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

Acromioclavicular separation

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

Activation of the renin-angiotensin-aldosterone system occurs.

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

Acute cholecystitis

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

Acute compartment syndrome

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

Acute massive hemorrhage due to perforation

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

Acyclovir

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

Adenocarcinoma of esophagus

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

Alcohol abstinence

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

Anal fissure

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

Anal fissure

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

Anal fissure

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

Anal fistula

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

Anti-HBc

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

Antibodies to the Sm antigen

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

Antidepressant therapy is indicated for menopause-related mood swings.

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

Antihistamine

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

Atrial septal defect

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

Axillary

A 26-year-old woman at 29 weeks gestation presents with a 1-week history of vaginal discharge and dysuria. On genital exam, she has mucopurulent cervicitis. A cervical swab is obtained and results are positive for Chlamydia trachomatis infection.

Azithromycin

A 22-year-old woman presents with increased vaginal discharge. She is sexually active with two male partners and she uses birth control pills for contraception. Her last menstrual period was 12 days ago, and she has noticed an increased whitish vaginal discharge for the past week. Physical exam reveals a soft non-tender abdomen. On pelvic exam, she has a light-yellow cervical discharge with erythema of the cervical os. There is no cervical motion tenderness and no adnexal masses or tenderness. Wet mount of the vaginal discharge reveals epithelial cells and WBCs, and no yeast or protozoa. Gram stain of the vaginal discharge reveals many leukocytes. A urine pregnancy test is negative.

Azithromycin 1 g PO once and ceftriaxone 250 mg IM once

A 60-year-old man presents with a 6-month history of dysphagia to solids, regurgitation of undigested food, and halitosis. He denies a decrease in appetite, abdominal pain, weight loss, or change in bowel habits. His past medical history is significant for a total hip replacement. His lab work is as follows:

Barium swallow

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

Bartholin gland cyst

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

Bibasilar rales

A 77-year-old Caucasian woman is admitted to the hospital for episodes of dizziness. Her symptoms have been present for approximately 4 months, and they have been progressively worsening. She has no dizziness when sitting or lying down. She does note some rapid heart rate associated with her dizzy spells. The dizziness becomes severe enough that she must sit down and is unable to proceed with walking, which is now significantly interfering with her functional activities. She denies associated chest pain, shortness of breath, or nausea. Past Medical History: Hypothyroidism, single episode of atrial fibrillation 2 years ago. Usual home medications: Aspirin 81 mg daily, Levothyroxine 88 mcg daily. Social History: Patient is married and has 2 adult children. She denies any history of smoking, alcohol use, or use of recreational drugs. Review of systems: Notable only for occasional cough, occasional headache, and mild anxiety. Vital signs: Temp 98.2°F, pulse 98 and regular, respirations 16, blood pressure 94/62 mm Hg (sitting, right arm).

Blood pressures lying, sitting, and standing

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

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

A 26-year-old woman presents to her gynecologist's office with a 4-month history of amenorrhea. She has had some breast tenderness, but she denies nausea, vomiting, fatigue, and abdominal pain. She was sexually active until about 6 weeks ago when she broke up with her boyfriend, but she states that they used condoms.

Bluish appearance to cervix

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

Boerhaave syndrome

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

Boil water before using.

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

Bone

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

Candidiasis

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

Carcinoid syndrome

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

Cardiogenic shock

A 24-year-old woman presents with lower abdominal pain, nausea, and vomiting that has persisted for about 12 hours. She rates the pain at a 4 last night when it began, but she currently puts it at a 9; she states the pain seems to be worsening with each passing hour. She states she had her menses 1 week ago and noted an irregular flow and excessive vaginal discharge since it ceased. She is single. She admits to not being monogamous, and she only occasionally uses barrier contraception during sexual encounters. She takes a daily oral contraceptive pill.

Ceftriaxone 250 mg IM and doxycycline 100 mg BID for 14 days

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

Ceftriaxone and vancomycin

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

Cholesteatoma

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

Coarctation of the aorta

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

Common bile duct stones

A 58-year-old woman presents with a 3-month history of postprandial abdominal pain that always occurs 30 minutes after eating. Due to these symptoms, the patient has lost 30 pounds and is afraid to eat. Her past medical history includes hypertension treated with enalapril and coronary artery disease for which she has undergone a right coronary artery stent; she underwent a carotid endarterectomy for symptomatic carotid stenosis. She has smoked 2 packs of cigarettes a day for 30 years.

Computerized tomography angiography

A 5-year-old girl presents after falling off a shopping cart, tripping, and then falling onto her right arm. On examination, temp is 98.7, pulse 97, respirations 18, blood pressure 127/80 mm Hg. She is alert, oriented, and in no acute distress. Significant findings related to the right arm, which was mildly swollen, deformed, and diffusely tender. There was decreased range of motion of the right elbow due to pain. Sensation was intact. Pulses are within normal limits bilaterally. A radiographic examination was performed.

Cubitus varus

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

Decrease milk consumption

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

Determine the medication history of the patient.

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

Diet and insulin if blood glucose remains high despite diet control

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

Elevated LH: FSH ratio

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

Elevated serum phenylalanine

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

Emergent percutaneous coronary intervention

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

Erythromycin ointment

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

Erythromycin-induced hepatic injury

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

Esomeprazole

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

Esomeprazole (Nexium)

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

Esophageal adenocarcinoma

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

Essential hypertension

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

Estrogen

A 46-year-old woman presents because she has not had her period for almost a year, has hot flashes, and feels fatigued most of the time. She complains of insomnia, and states that she keeps smoking despite trying many times to quit. Her libido is low and she does not use any hormone-based birth control. Her blood analysis indicates a TSH (thyroid-stimulating hormone) level of 3.1 mcU/mL and a FSH (follicle-stimulating hormone) level of 55.3 mIU/mL.

FSH level is consistent with menopause.

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

FSH levels

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

Factor V Leiden

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

Long head of the biceps brachii tendon rupture

A 50-year-old woman presents with "swelling in my right groin" when she stands. On physical examination, you note a reducible bulge that is 3 cm below her right groin crease and is lateral to her pubis. The bulge is on the ventromedial surface of the anterior thigh.

Femoral hernia

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

Fibroadenoma

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

Fibroadenoma

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

Fibrocystic condition

A 45-year-old man presents with a 30-minute history of substernal chest pain. He describes the pain as burning. He denies any trauma to the chest. He has had similar episodes like this many times. He denies any additional symptoms such as shortness of breath or diaphoresis, but he states that his voice is often hoarse. His medical issues include diabetes mellitus and heavy alcohol use.

Gastroesophageal reflux

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

Gastroesophageal reflux disease

A 14-year-old girl presents with a 4-day history of flatulence, foul-smelling stools, and abdominal distention. Her appetite has also been decreased. She has not seen any blood in her stools. She returned from a 2-week camping trip in the mountains of the western United States 1 week ago. Others in her expedition group are asymptomatic. Her physical examination reveals a well developed and well nourished adolescent with slight abdominal distention and tenderness; otherwise, everything is within normal limits.

Giardia lamblia

A 3-year-old boy is evaluated for a 24-hour history of diarrhea. His mother reports that he had five episodes of foul-smelling watery diarrhea associated with decreased appetite. A few other children at the same daycare center have presented with the same problem. On physical examination, the child is well hydrated and his abdomen is tender. Stool microscopy shows the presence of motile trophozoites representing the etiological agent.

Giardiasis

An 18-year-old man presents for a screening physical exam to join his college freshman lacrosse team. He reports no medical problems, and he does not take any medications. Physical exam is unremarkable. His immunizations are current, and he denies sexual activity or smoking. Review of routine labs reveals an elevation in unconjugated bilirubin. His total bilirubin level 4 mg/dL. Liver enzymes, serum electrolytes, complete blood count, and conjugated bilirubin level are within normal limits.

Gilbert's syndrome

A 19-year-old man presents with pain and deformity of his right dominant shoulder after a sudden jerking movement to that shoulder from a wrestling competitor approximately 1 hour ago. He was unable to continue wrestling and has pain with any movement of the right shoulder. On exam, you see a loss of normal shoulder contour anteriorly. There is no focal joint or bony tenderness.

Glenohumeral dislocation

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

Glucose-6-phosphate dehydrogenase deficiency

A 25-year-old man presents for evaluation of intermittent chest pain. He reports a burning sensation in his chest 1-2 days per week after eating. The symptoms are worse with large meals, eating late at night, and excessive alcohol consumption. He denies difficulty swallowing, weight loss, night sweats, chest pain, use of tobacco, or coughing up blood. His vital signs and physical examination are unremarkable.

H2-receptor antagonists

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

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

A 63-year-old man with long-standing right shoulder pain from impingement syndrome presents because he cannot lift his arm after pulling the starter cord on his lawn mower 1 month ago. An AP view of his right shoulder is ordered.

High-riding humeral head

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

Higher risk of endometrial cancer

A 27-year-old woman presents with cramping abdominal pain and vaginal bleeding. Further history reveals amenorrhea for the past two menstrual cycles. On examination, she is found to have left lower abdominal tenderness and an adnexal mass. Lab values reveal an elevated beta HCG level.

History of PID

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

History of tricyclic antidepressant use

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

Home visit to identify potential lead sources

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

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

A 42-year-old man has had systolic blood pressure in the 140s and diastolic blood pressure in the 80s on several occasions despite changing his diet and exercise regimen. His physician decides to start him on hydrochlorothiazide.

Hypokalemia

A 5-month-old girl presents with a 3-day history of vomiting. She is exclusively breastfed, and her mother states that today she has vomited within 15 minutes of each feeding. Her last wet diaper was 10 hours ago. On physical examination, she is afebrile, tachycardic, and irritable, and she does not express tears when crying. She was a full-term vaginal delivery. She has no significant past medical history. Her 3-year-old sister has had gastroenteritis for the past few days.

Hypokalemia

A 34-year-old man is brought to the emergency department after a single-car motor vehicle collision. Preliminary radiologic studies show a comminuted fracture of the left tibia. The patient is describing a markedly increasing amount of pain felt in the injured extremity. He describes the pain as being a 10/10 that is becoming worse with each passing minute. With anguish on his face, he describes it as a deep achy burning pain. You quickly examine the left leg and note pallor, a tense "wood-like" feeling of the extremity, diminished sensation, and muscle weakness.

IV opioids

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

Immediate screening colonoscopy

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

Increased follicle stimulating hormone (FSH)

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

Increased pressure within the tissue space, leading to venous obstruction

A 40-year-old man presents with ongoing back pain; there is increased stiffness in the morning, and the pain has been going on for a few months. The patient reports that it can take him up to 30 minutes after waking up for the discomfort to improve. Physical examination and diagnostic testing confirms the diagnosis of ankylosing spondylitis.

Indomethacin

A 45-year-old man presents with extreme asthenia and weight loss. He has been suffering from celiac disease for the past 12 years. He is at the highest risk of developing what type of intestinal malignancy?

Intestinal lymphoma

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

Injection of betamethasone

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

Intestinal ulcers

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

Insulin-producing tumor

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

Intravenous drug abuse

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

Intravenous fluids and abdominal ultrasond

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

Kyphosis

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

Laparoscopic fundoplication

A 29-year-old woman is taking D-penicillamine for Wilson's disease. Today, her laboratory findings (including liver function tests) are within normal limits; there are no neurological signs. Her work requires frequent travel (3-5 days per week), including international overnight travel all over the world. She wants contraception that is both effective and convenient in terms of application.

Levonorgestrel-releasing intrauterine system

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

Loss of normal surface contour of the shoulder

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

Lower back pain

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

Magnetic resonance imaging (MRI)

Examination of a newborn revealed an abnormal appearance of the back. There is a presence of hairy patch with central dimple present on the lower back.

Maternal folic acid deficiency in first trimester

A 54-year-old woman presents for her annual pelvic examination. Her last menstrual period was 1 year ago, and her last few cycles were extremely irregular. She describes multiple daily episodes of severe, intense heat in the face and trunk accompanied by sweating. She states that these "heat episodes" have been occurring 4-6 times daily for 4 months, and they interfere with her everyday activities and sleep. She reports no other symptoms. She has received yearly annual pelvic examinations and clinical breast exams and mammograms without any significant findings. Her past medical history is negative for cardiovascular disease, blood clots, and breast cancer. Her pelvic examination has findings of excessive dryness and apparent vaginal wall atrophy.

Menopausal hormone therapy

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

Menopause

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

Menopause

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

Methotrexate

A 15-year-old girl presents with a 3-day history excessive vaginal discharge without itching or burning. She denies ever being sexually active. Her last menstrual period was 10 days ago. On examination you find a thin, white, homogeneous discharge that has a distinct amine odor when potassium hydroxide is added. On saline wet mount, epithelial cells are covered with bacteria.

Metronidazole

A 25-year-old woman presents for an annual gynecological visit. Menses onset was at age 12; duration of menses is 6 days, every 30 days. She is nulliparous with no history of abnormal pap smears or diagnosed STIs. She does not smoke and has been in a monogamous relationship with 1 partner for the past year. The patient mentions a whitish-gray vaginal discharge that increases after intercourse, accompanied by a distinct musty odor; she denies pain from this discharge. Physical examination and a positive result of a whiff test support the suspected diagnosis.

Metronidazole by mouth

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never experienced heartburn as bad as she does currently. She is treating it with over-the-counter histamine-2 receptor antagonist, famotidine, 1 tablet daily. The patient denies any other significant past medical history and is currently taking a daily multivitamin and an antihistamine for seasonal allergies. She recently admits to having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days; she hopes that her headaches will subside after finals are finished. She also states that she was given amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stool, use of tobacco or alcohol, or coughing up blood. Physical examination is unremarkable.

NSAID

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

NSAIDs and thumb spica splint

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

Nasogastric feeding

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

Neer test

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

Negatively birefringent needle-shaped crystals

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

Nitroglycerin ointment

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

Neovascularization

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

Nitroglycerin

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

No diagnostic tests required

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

Non-alcoholic steatohepatitis

A 45-year-old Caucasian woman presents with a 2-month history of a lump in her right breast. She has had no children. Her menstrual periods began at age 15 and are still regular. She is a successful businessperson who does not smoke cigarettes and drinks 6 cups of coffee per day. She gets 30 minutes of physical activity at least 5 times weekly. On examination, she has a nontender lump in the upper outer quadrant of her right breast. Several matted right axillary lymph nodes are also palpable.

Nulliparity

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

Nutritional deficiency

A 35-year-old man presents with a groin mass. The patient states that the mass is painless; there is no known trauma to the region. The mass is present when the patient stands, and it disappears when the patient is lying flat. Past medical history is significant for obesity, hypertension, and hyperlipidemia. Past surgical history is significant for lipoma removal from the left shoulder. The patient denies tobacco use; he tells you that he drinks about 6 beers per week. In office ultrasound confirms diagnosis and surgical repair is scheduled.

Obesity

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

Obtain an echocardiogram

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

Oral contraceptives

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

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

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

Oral NSAIDs

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

Oral diltiazem

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

Osgood-Schlatter disease

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

Osteoarthritis

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

Osteoid osteoma

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

Ovarian fibroma

A 49-year-old woman presents with a 1-month history of a rash on her right breast. She reports that it has not been responding to the creams that she has been applying and she is having some burning and itching at the rash. On examination, she has an erythematous area that is sharply demarcated with scaling and vesicles over her right areola and nipple. There is a nontender lump in the upper outer quadrant. Her left breast is normal.

Paget's disease

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

Patent ductus arteriosus

A 24-year-old woman presents with a 12-hour history of lower abdominal pain, nausea, and vomiting. She rates the pain at a 4 last night when it initially began, but she currently puts it at a 9; she states that the pain seems to be worsening with each passing hour. She states she had her menses 1 week prior, noting an irregular flow and excessive vaginal discharge since it ceased. She is single and admits to not being monogamous; she only occasionally uses barrier contraception during sexual encounters. She takes a daily oral contraceptive pill.

Pelvic inflammatory disease

A 16-year-old girl with a 2-year history of ulcerative colitis presents with signs of an acute exacerbation: abdominal pain and frequent passing of large quantities of blood and mucus from the rectum. It is treated with sulfasalazine, glucocorticoids, and intravenous alimentation. Diarrhea decreases markedly, but her status continues to deteriorate. Tachycardia, volume depletion, and electrolyte imbalance develop; temperature is 101.8° F. Physical examination finds abdominal tenderness but no mass. Plain radiography shows the transverse colon is dilated up to 7 cm.

Perform colectomy.

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

Phenylalanine

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

Phenylketonuria

A 45-year-old man with no significant medical history presents with what he refers to as "anxiety attacks." He describes them as recurring bouts of palpitations, headaches, anxiety, and sweating that he has experienced for a few weeks. Last night, his wife witnessed him having an episode during dinner. She was concerned and immediately took his blood pressure: 195/105 mm Hg, so she brought him in today. On further questioning, he comments that he sometimes gets lightheaded when he stands up too rapidly; his mother had similar problems. On physical examination, his blood pressure is 165/90 mm Hg and his heart rate is 80 beats/min. A 24-hour collection of his urine test is positive for vanillylmandelic acid.

Pheochromocytoma

A 4-month-old girl has been gaining weight well and achieving normal milestones. She was a full-term infant born via vaginal delivery without complication. Her past medical history is significant only for a mild URI the previous month, and she is current with her vaccines. She has been exclusively breastfed since birth. Her mother eats a well-rounded diet that includes meat and dairy.

Vitamin D

A 29-year-old woman, G4P2011, LMP 9 months prior, presents with sudden onset of severe lower abdominal pain. The pain is sharp and tearing and was not preceded by the contractions she recalls from previous deliveries. She also endorses vaginal spotting prior to presentation. There is no history of prior medical problems or surgery, and she is on no medications. All previous deliveries were vaginal. She has smoked 1 pack of cigarettes a day over the past 10 years. She denies alcohol use but does admit to a remote history of heroin abuse by insufflation. On physical examination: Temp 99.4°F; BP 110/70 mm Hg; Pulse 85/min; RR 20/min. Pertinent findings on the PE were relegated to the pelvic exam; fundal height measures 39 cm, and there is profuse bleeding from the vagina. Fetal monitor shows contractions every minute with elevated baseline uterine tone. Fetal tachycardia is evident at 180 beats/minute, and late decelerations are also present.

Placental abruption

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

Placental ischemia

A 17-year-old male high school football player presents after being tackled and slammed onto his right dominant shoulder forcefully 2 hours ago during a game. He had immediate pain but was able to continue playing. He has full active and passive range of motion, but some pain (6/10) with abduction. There is no obvious deformity, and the skin over the shoulder is intact and not tented.

Plain film radiograph

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

Plain radiograph subchondral sclerosis

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

Plain radiography (X-ray)

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

Polycystic ovarian syndrome

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

Positive Neer and Hawkins signs

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

Postpone cardioversion procedure.

A 52-year-old woman presents with left hip pain. There is no known history of trauma to the area. Past medical history includes Crohn's disease, type 2 diabetes, and hypertension. She is currently taking metformin, metoprolol, and mesalamine. She recently completed a prednisone taper for her Crohn's disease. She also finished a course of ciprofloxacin, which she took for a urinary tract infection. An X-ray is obtained, revealing a collapsed left femoral head.

Prednisone

A 66-year-old man presents with monoarticular arthritis. He has stage 3 chronic kidney disease. His affected joint is warm to the touch. You suspect gout. He is allergic to aspirin.

Prednisone

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

Pregnancy

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

Primary dysmenorrhea

A 12-year-old girl presents to the emergency room with worsening foot pain. 2 weeks ago, she stepped on a nail while wearing rubber-soled tennis shoes. The area was thoroughly cleaned, but she has developed worsening pain, redness, and drainage from the area. X-ray shows periosteal changes at the site of the wound. A wound culture is obtained.

Pseudomonas aeruginosa

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

Reassurance that this is normal

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

Reduced gonadotropin-releasing hormone from hypothalamus

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

Reduction by air enema

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

Reduction of running exercises

A 33-year-old man with no past medical history presents with groin mass. He denies pain and trauma to the region. When the patient stands, there is a round swelling in the inguinal area. If the patient is supine, the mass disappears.

Referral to general surgeon

A 27-year-old man is admitted to the hospital following a motor vehicle accident. He sustained lacerations to his arms bilaterally and has fractures of the right tibia and fibula. A cast is placed and the patient is scheduled for surgery the following day. A few hours after the cast is placed, he develops severe pain; the pain is unresponsive to several doses of intravenous morphine. His pain increases when he extends his right leg. Peripheral pulses are weak but present.

Remove cast and check compartment pressure.

A 32-year-old nulliparous woman presents for a routine gynecological exam. She has been married for 5 years and plans to start a family in the near future. Menarche occurred at age 11. Menstrual cycles are regular, occurring every 28-30 days, and lasting for 4-5 days each. She denies menorrhagia and dysmenorrhea. She has used oral contraceptive pills since age 18; she recently discontinued them and began taking prenatal vitamins. On physical examination, you palpate a mass on the left side. A transvaginal ultrasound confirms a 3 cm complex cystic mass on the left ovary, without free fluid detected within the pelvis. The patient has no family history of any malignant tumors.

Repeat ultrasound in 2-3 months

A 39-year-old man presents with a 1-week history of severe chest pain. He states that the pain seems to worsen when he lies down. He describes the pain as radiating to the back and worsening when he takes a deep breath. His vital signs are as follows: blood pressure 124/84 mm Hg, respiratory rate 18/min, temperature 101°F, and pulse 74 beats per minute. On auscultation of the chest, you cannot distinguish an S1 or S2 but hear a scratching or grating sound.

Rest and NSAIDs

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

Right ankle fracture

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

Rotator cuff tendonitis

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

Rotavirus

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

Routine symptomatic treatment

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

Rovsing's sign

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

Salmonella species

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

Send stool studies and refer to for colonoscopy.

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

Small lower extremity joints

A 40-year-old Caucasian man presents to your office to ask for advice regarding the inability of his wife to conceive. She is younger than him by 8 years and he believes she is in good health. Additionally, she has two children from a previous marriage, both pregnancies without complication. He was also married once before, but his first wife did not conceive children. He has not yet undergone any fertility tests.

Spermatogenesis and motility

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

Start bisphosphonate therapy.

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

Start omeprazole.

A 55-year-old man presents for a follow-up from a recent hospitalization. He had two coronary stents placed 3 days ago after presenting to the emergency department with chest pain and a 40 pack-year smoking history. He quit smoking 2 years ago. He was not on any medications when he presented to the ER. Lipid panel revealed total cholesterol 200 mg/dL, LDL cholesterol 100 mg/dL, HDL cholesterol 40 mg/DL, triglycerides 395 mg/dL.

Statin

A 38-year-old man presents with a 2-day history of a mass and severe pain in his scrotum. Physical examination reveals that his right testicle appears much larger than his left. On palpation, you note a small hole in his inguinal canal, and you are unable to place the contents into the canal. The contents of the hernia appear ischemic.

Strangulated

A 23-year-old woman presents with an extremely painful right arm. She also reports numbness and tingling of her right hand and fingers. She burned her arm on the stove 1 week ago and was prescribed a silver-containing cream. Physical exam is remarkable for swelling and tenderness of the right forearm. She also has decreased sensation in her right hand and weakness of the right thenar muscles. Tissue pressure in the arm is 55 mm Hg (normal <8 mm Hg).

Surgery

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

Surgery Colonoscopy

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

Surgical excision

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

Thyroid function studies

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

Thyroid function tests

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

Topical diclofenac gel

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

Total hip replacement

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

Toxic megacolon

A 34-year-old woman presents to your clinic with a 3-month history of a mildly tender mass on the dorsocentral aspect of her dominant right wrist. She says the lump "comes and goes," but this time it has stayed and become tender. She denies any known trauma of the wrist or hand.

Transilluminating the mass

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

Transthoracic echocardiography

A 65-year-old woman presents with bloating, early satiety, changes in her bowel habits, and an unintentional 10 lb weight gain over 3 months. Upon further questioning, you discover that she never had children and her sister passed away 20 years ago from some sort of cancer in her belly. On her physical exam, an adnexal mass is felt.

Transvaginal ultrasound

An 86-year-old man has been experiencing fatigue, leg swelling and loss of appetite. His exam shows dependent edema, hepatomegaly, and JVD. Diuretics have been given to the patient and have worsened his renal function.

Tricuspid valve

A 16-year-old sexually active girl is seen for a 2-month history of amenorrhea. She denies unprotected sex but relies on her partner to use a condom. She has vomited in the early morning twice this week and had vaginal spotting for 3 days accompanied by cramping lower abdominal pain that became sharp. Onset of menses was at age 12, with normal regular periods since then. No history of sexually transmitted disease. Normal vital signs. Slight right and left lower quadrant abdominal tenderness without guarding and rebound is present. Cervix is closed. No blood is seen in the vaginal vault. The uterus is not palpable. Serum β-HCG: 5200 mIU/mL. Vaginal spotting has increased, and abdominal pain has become more frequent. Repeat examination 3 days later is unchanged. The uterus is still not palpable. Repeat serum β-HCG is 6800 mIU/mL. Transvaginal ultrasound fails to reveal an intrauterine pregnancy or gestational sac.

Tubal ectopic pregnancy

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

Ulcerative colitis

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

Ultrasound

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

Ultrasound

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

Ultrasound

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

Urgent referral to orthopedic surgery

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

Use of proton pump inhibitors

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

Uterine atony

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

Vaginal pessary

A 52-year-old man presents with a 3-day history of persistent diarrhea. He reports seven watery, non-bloody bowel movements daily. He has associated lower-abdominal cramping and mild nausea. He denies recent travel out of the country. He does not recall eating anything unusual, and none of his family members are sick. Past medical history is significant for GERD, for which he takes pantoprazole daily. He recently completed a course of oral levofloxacin for pneumonia. A stool sample is negative for ova and parasites, but PCR testing is positive for Clostridium difficile.

Vancomycin

A 44-year-old man with a history of coronary heart disease presents to the emergency department with crushing chest pain and heart palpitations. He smokes 3 packs of unfiltered cigarettes daily. He has periods of wide-complex rapid regular tachyarrhythmia at 160 beats per minute that last for 20-30 seconds. When you reach his examination room, you note his monitor also reveals evidence of a QRS width of 0.16 seconds.

Ventricular tachycardia

A 28-year-old woman presents to the emergency department due to a 3-hour history of nausea, abdominal cramping, vomiting, and watery diarrhea. She recounts her lunch approximately 8 hours ago, which consisted of a shrimp salad and a diet soda. She denies any neurological or other symptoms. She also denies any similar problems prior to this episode and was feeling well just before this incident. She denies fever or recent travel.

Vibrio parahaemolyticus

A 50-year-old woman with a family history of colon cancer underwent a total colonoscopy per screening guidelines for colon cancer. 2 polyps, 5 mm each, were noted on exam. The doctor advises the patient to repeat her colonoscopy in 3 years due to her polyp pathology.

Villous adenoma

An 8-month-old female infant presents with a 2-day history of increasing irritability and decreased appetite. She has also had some diarrhea and low-grade fever. On exam, she is afebrile, fussy, and hard to console, but she appears alert and active. She lies with her hips and knees flexed, crying harder with any movement. A few petechiae are noted on her skin. Leg X-rays are done to look for a possible fracture that shows a pencil-thin cortex and a ground glass appearance of the bones. Further history reveals that she has been given evaporated milk since birth to save money, and she has not yet been started on solids.

Vitamin C

A 32-year-old woman presents with a 1-month history of bleeding gums when brushing her teeth. She also reports that her wounds are taking longer than usual to heal. She is a stay-at-home mother and is breastfeeding her 6-month-old twins. On examination, you note multiple splinter hemorrhages on her nails and ecchymoses over her lower limbs.

Vitamin C deficiency

A 16-year-old girl presents for continuing concerns about her weight. She has a family history of diabetes and has tried to lose weight before without success. Her BMI (body mass index) is at the 99th percentile for age, and she is given a trial of orlistat. Within 2 weeks, she returns to her pediatrician with bowel movement changes, flatulence, oily discharge, and mild abdominal pain. She lost 5 lb and would like to continue the treatment if the side effects could be eliminated.

Vitamin D

A 12-year-old boy has jaundice, non-tender hepatomegaly and splenomegaly, and tremor. He has been healthy and is on no medications. He is afebrile. Golden-brown rings on the peripheral corneas are noted on slit lamp eye exam. Laboratory studies reveal low levels of serum ceruloplasmin and elevated 24-hour urine copper excretion.

Wilson disease

A 56-year-old Asian woman presents to establish care for a wellness exam. She recently relocated from out of state; she brings a copy of her medical notes and labs from her previous medical provider. The patient tells you that sexual intercourse is very uncomfortable for her. She admits insertional dyspareunia and poor lubrication, but she denies deep dyspareunia. Outside of intercourse, she denies pelvic issues. She denies vaginal bleeding, pruritus, or discharge. She also denies urinary issues, such as dysuria, frequency, and incontinence. She has occasional hot flashes, but she feels they are tolerable. Her relationship is otherwise healthy, and she does not feel pressured into intercourse against her will. She is a G2P1. Surgical history includes open fracture reduction of the left ankle at age 22 and a dilatation and curettage (D&C) at age 24 for a spontaneous abortion (SAB). She is divorced, and she has been in her current monogamous relationship for 1.5 years. She is a non-drinker and non-smoker; she denies recreational drug use. Family history is unremarkable.

Vulvar and vaginal atrophy

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

Weight loss

A 66-year-old woman presents for a health maintenance visit. She reports no issues and has no history of chronic illness except postmenopausal osteoporosis, with a bone mineral density >3 standard deviations below the mean. She takes supplemental calcium and is being treated with denosumab IM every 6 months. Her only recent fracture was a compression fracture at T-6, diagnosed 5 months ago. Although she had previously enjoyed tennis, dancing, and gardening, she has drastically reduced her activity for fear of suffering further fractures. She asks if she should resume any sort of regular physical activity. Past medical history is otherwise unremarkable except for anemia, which is now resolved. Vital signs are normal, as is the remainder of the examination.

Work toward resuming former exercise program.

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

Acute appendicitis

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

Amylase 310 U/L and lipase 760 U/L

A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a longstanding history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure, mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Echocardiogram reveals concentric left ventricular hypertrophy without significant valvular abnormalities.

Angiotensin-converting enzyme inhibitor

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

Aortic regurgitation

A 28-year-old man presents with "burning mouth." The patient states he has had an unusual burning sensation on the inside of his right cheek for the last 3 days; he feels that the burning is worsened with hot, spicy, or acidic foods. After performing a comprehensive oral exam, you note three lesions on the buccal mucosa on the right side of the oral cavity. You further document the description of these lesions as the following: three round lesions, each measuring approximately 3 mm in diameter with presence of a white-yellow center surrounded by a red halo.

Aphthous ulcers

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

Esophageal laceration

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

Bone densitometry at age 65

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

Excision of thrombosed external hemorrhoid

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

Chest pain that is reproduced with palpation

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

Cervical motion tenderness

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

Early mobilization

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

Echocardiography

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

Endometrial biopsy

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

Endometrial cancer

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

Endometritis

A 30-year-old man presents with a 1-hour history of severe nausea and vomiting. Before falling ill, he was at a party where he ate pudding and other food. Physical examination reveals a normal temperature with mild diffuse tenderness of the abdomen. The organism isolated is a gram-positive coccus that occurs in grape-like clusters, is catalase- and coagulase-positive, and forms a golden-yellow colony on agar.

Enterotoxin

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

Esophagus neoplasm

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

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

A 1-month-old infant is evaluated for rapid breathing, feeding difficulty, lethargy, and poor weight gain. Physical exam is notable for tachypnea, tachycardia, a cardiac gallop, and a medium-pitched systolic murmur best heard posteriorly in the interscapular area with radiation to the left axilla, apex, and anterior precordium. A prominent anterior chest heave is also observed. The lower extremities demonstrate a 12 mm Hg pressure difference compared to the upper extremities. There are delayed femoral pulsations; upper extremity pulsations are normal.

Evaluation by a cardiovascular surgeon

A 13-year-old boy presents with pain in his right leg, present for about 2 months but worsening over time. He has developed a low-grade fever. He denies any known injury to the area. On examination, there is tenderness and mild swelling near the right fibula. X-ray reveals an invasive lesion involving the right fibula, with a periosteal onion-skin reaction.

Ewing's sarcoma

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

Flagellated protozoan

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

Fibromyalgiaq

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

Fluoxetine

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

Folic acid deficiency

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

Foreign body

A 62-year-old woman with a history of breast cancer and rheumatoid arthritis presents with stiff neck and severe headache that started a couple of days ago; symptoms are worsening. Upon awakening the morning of presentation, she felt nauseated and vomited twice. Your neurological examination shows right-sided hemiparesis and dilated and non-reactive left pupil.

Fundoscopic examination

A full-term female newborn has facial defects affecting the eyes, nose, and upper lips. She is the first child of non-consanguineous parents. The mother has a history of gestational diabetes, which began at the start of pregnancy. She contracted German measles a month before delivery. During the course of infection, her self-prescribed daily treatment was 3 tablets of aspirin, at least 6 cups of herbal tea, and a double dose of folic acid. Imaging studies showed prosencephaly.

Gestational diabetes

A 26-year-old woman presents after a syncopal episode. She has lost of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and a III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage.

Hypertrophic cardiomyopathy

You are performing an annual physical examination of a 14-year-old girl. Over the last 3 years, she has been treated for the depression related to her parents' divorce process. She complains of frequent constipation followed by loose stools and is treated for dermatitis herpetiformis. She participates in swimming competitions and spends about 18-20 hours per week training. However, her mother is worried because she has not grown enough and still has not gotten her period (her mother had her period when she was 12 years old). The rest of her personal and family history is not contributing. Your patient's BMI is 15 (percentile 3%); she is in Tanner stage 2 (the same as last year); and her bone age is 12.5 years. The rest of the physical examination is normal, and complete blood count results are within normal limits.

Hypogonadotropic hypogonadism

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

Immunosuppressant (systemic corticosteroids)

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

Increased serum follicle-stimulating hormone (FSH)

A 50-year-old man presents to the emergency department with epigastric pain. Pain is sharp with radiation into the back and accompanied by nausea and vomiting. On exam, the patient exhibits tenderness to palpation of the upper right quadrant and upper left quadrant without rigidity or guarding. Laboratory findings reveal the following:

Intravenous normal saline

You are evaluating a 34-year-old African American man for a 5-week history of increasing right groin pain. He denies any injury or history of similar pain. The pain is worse with movement and has progressed to the point that the patient has severe pain with bearing weight. He denies fever, chills, urinary symptoms, or any other issue at this time. He has a past medical history of sickle cell disease and hypothyroidism. Physical exam reveals tenderness upon palpation of the groin with increased pain on both active and passive range of motion of the hip. Homan's sign is negative. Distal pulses and sensation are intact and normal.

MRI of the right hip with and without contrast

A 20-year-old woman presents with intermittent nose bleeds for the past 2 weeks. She also reports that her menstrual periods have increased in number in the past 2 months. She recently underwent surgery for small bowel resection and eats only one meal a day. Laboratory investigations reveal prolonged prothrombin time, prolonged activated partial thromboplastin time, and a normal platelet count.

Vitamin K deficiency

An otherwise asymptomatic, thin 18-year-old woman presents with a history of scoliosis and the presence of a mid-systolic click that is auscultated during physical examination. The patient most likely has what valvular disease?

Mitral valve prolapse

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

Mitral valve prolapse

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

Modification of activity, NSAIDs, and physical therapy

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

Obesity

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

Oral NSAIDs

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

Order a dual-energy X-ray absorptiometry test.

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

Order a mammogram.

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

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

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

Osteomyelitis

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

Osteomyelitis

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

Osteoporosis

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

Osteoporosis

A 75-year-old woman presents due to intense pruritis of the vulva and occasional bleeding. She is unsure if the bleeding is caused by her scratching. She has tried some OTC preparations to alleviate the itching without relief. She denies vaginal discharge or dysuria. On physical examination, you notice excoriations and some scattered lesions that look like eczema on the vulva; they do not scrape off. Also noted was inguinal lymphadenopathy. You decide to do a punch biopsy. The pathology report reveals large eosinophilic cells.

Paget's disease

A 34-year-old woman presents Monday morning with knee pain. She states that she was playing with her two children in their backyard over the weekend and fell onto solid ground, landing directly on her knees. She noted immediate and significant right knee pain. She notes significant swelling; it accompanies the knee pain, which she rates as an 8/10 on a numerical pain scale. Physical examination reveals significant obvious joint effusion and exquisite focal tenderness to palpation over the patellar area of the right knee; the left knee has no obvious abnormalities. Results of the anterior drawer, McMurray, and varus/valgus stress testing are within normal limits.

Patellar fracture

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

Patellofemoral pain syndrome

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

Restrict dietary sodium.

A 2-week-old female infant is seen for her newborn well-baby exam after a normal birth and delivery. She has been nursing well, has regained her birth weight and her development appears normal for her age. Physical examination is normal with the exception that ophthalmoscopic evaluation reveals a faint white reflex in her right eye.

Retinoblastoma

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

Retinol

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

Rotator cuff tendinitis

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

Ruptured ectopic pregnancy

A 55-year-old woman presents with weakness, bone pain, and lethargy. A 24-hour urine sample reveals a spike of M protein. Based on the most likely diagnosis, what additional finding on bone marrow aspirate would support the diagnosis?

Russell bodies

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

S3 gallop

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

Small bowel obstruction

A 22-year-old man presents with what he describes as a change in his heart rate. He indicates that his heart rate seems to speed up and then slow down for the past few hours. He adds no other symptoms. An EKG is ordered: irregular rhythm, a PR interval of 0.16 seconds, a P to QRS ratio of 1:1, heart rate of 75 bpm when exhaling and 86 bpm when inhaling, PP interval varies >0.12 seconds, and an RR interval that is noted to accelerate and decelerate during the respiratory cycle similar to the way the patient described.

Sinus arrhythmia

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

Stress urinary incontinence

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

Subinvolution of the placental site

A 22-year-old woman presents for evaluation of knee pain. The patient appears in moderate distress and is unable to fully bear weight as she moves to the exam table. Her physical exam reveals a swollen and tender left knee. She is tender at the lateral femoral condyle, lateral tibial plateau, and tibiofemoral joint line. Lachman and anterior drawer tests are positive. Posterior drawer, Apley grind, patellar grind, and McMurray tests are negative. There are no sag or apprehension signs. Valgus and varus stress tests are normal. An X-ray shows no fractures.

Sudden landing playing basketball

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

Surgical referral

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

Systemic lupus erythematosus

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

Tenderness over the acromioclavicular joint

A 21-year-old man presents with a 3-month history of pain in his left shoulder. He is a left-handed pitcher for his college baseball team and states that the pain began at spring training and has gradually worsened since that time. In addition to the pain, the patient is now having difficulty lifting his left arm above his head. He denies any injury to the shoulder itself and states that ibuprofen provides some relief. You suspect rotator-cuff tendinitis.

Tenderness to palpation just under the acromion

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

Tendinitis

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

Unprotected vaginal intercourse Prescribe empiric antibiotics

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

Upper GI endoscopy

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

Utilize crutches for any ambulation.

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

Vaginal pH of 5.2

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

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

A 62-year-old woman presents due to urine leakage for 2 years that has worsened. She leaks urine when she coughs or sneezes; she wears a pad daily as a result. The amount of leakage varies. The patient denies hematuria, dysuria, and pelvic pain. She sometimes feels vaginal pressure and fullness. She is considering quitting her job from embarrassment. Past medical history includes 4 vaginal deliveries. No other known medical conditions, medications, or allergies. She is married and works part-time at a call center; she denies tobacco, alcohol, and recreational drugs. On physical exam, she is obese, with an atrophic vulva/vagina. Pelvic examination reveals downward and forward rotation of the vaginal wall, with an anterior bulging when the patient is asked to strain. A dipstick urinalysis is normal.

Weight loss

A 12-year-old boy presents with fatigue and jaundice. His past medical history is not significant for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On further eye examination using a slit lamp, brown-yellow rings encircling the iris in the rim of the cornea are noted bilaterally. AST and ALT are elevated, and a serum ceruloplasmin level is reported as low and confirms the diagnosis.

Wilson disease

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

Amiodarone (Cordarone)

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

Acute myocardial infarction

A 62-year-old woman is being treated for chronic congestive heart failure. She has been put on hydrochlorothiazide therapy. Her serum electrolyte levels are being monitored and show a persistent hypokalemia.

Amiloride

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

Amiodarone

While rounding on a 2-hour-old male neonate at the hospital, his mother remarks that although her pregnancy and delivery were unremarkable and the baby was term, she has attempted to initiate breastfeeding even though the neonate "doesn't seem interested." On heart auscultation of the neonate, a late systolic murmur that radiates to the back is appreciated. Vital signs while the baby is awake are BP 90/50 mm Hg in the right arm and 58/42 mm Hg in the right lower extremity, HR 140, RR 40, axillary temp 37.0° C, and O2 sat 90% on room air.

Coarctation of the aorta

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

Aortic stenosis

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

Atorvastatin, 80 mg daily

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

Beta blocker

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

Decrease pulmonary congestion

A 58-year-old man with recently diagnosed type 2 diabetes on metformin has developed Stage I hypertension over the past 3 months. When deciding what antihypertensive medication to begin for this patient, what is the primary reason for using an ACE inhibitor?

Delay the progression to end-stage renal disease

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

Heart failure

A 21-year-old man with a history of cocaine and methamphetamine abuse is brought to the emergency department after being found unconscious. He is placed on a non-rebreather mask and admitted to the ICU with findings of acute heart failure. Echo shows enlarged left ventricle, decreased cardiac contractility, and systolic dysfunction. He vastly improves over 24 hours. He is currently awake and alert. No history of cardiac disease. BP 132/88 mm Hg, HR 86 and regular, RR 20, Temp 98.2°F, and O2 sat of 100% on 3L via nasal cannula. Physical exam reveals no murmur, clear lung sounds, and no peripheral edema.

Wean oxygen

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

Diabetes mellitus

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

EKG

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

Echocardiogram

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

Digoxin toxicity secondary to renal failure

A 55-year-old man presents with a 2-day history of confusion, increased respiratory rate, rapid pulse, notable malaise, thirst, and less-than-normal urination. In the morning, his wife gave him a multivitamin pill hoping that it would help; she tells you that he has long-standing hypertension and he injured his neck in a car accident 1 week ago. On examination, you find BP 92/41 mm Hg, HR 150, RR 35, rapid and weak pulse, cutis marmorata, cold edematous extremities, and bluish discoloration of the tongue and nails.

Cardiogenic

A 48-year-old man presents for an annual physical exam. He has a past medical history of obesity and a 5-year history of hypertension that is currently not well-controlled. He was also recently diagnosed with type 2 diabetes mellitus (DM). He is a 20 pack-year smoker and drinks 2-3 beers per night. On exam, his BMI is 41, and BP is 145/92 mm Hg. The remainder of his exam is unremarkable.

Cigarette smoking

A 1-month-old full-term male infant has been diagnosed with tetralogy of Fallot. His disease is being classified as moderate, and he has been admitted to the neonatal intensive care unit for monitoring. He is now stable and is doing well. During a consultation between the infant's parents and the pediatric cardiologist, treatment options are being discussed.

Closure of ventricular septal defect and pulmonary valvulotomy

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

Echocardiography needs to be performed with follow-up.

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

Echocardiography/Doppler

A 79-year-old man with a past medical history of coronary artery disease, diabetes mellitus, hypertension, smoking, alcohol use, and hyperlipidemia presents with severe chest pain and dyspnea. He appears pale, apprehensive, and diaphoretic. He is in a confused state and agitated. His pulse is weak and tachycardic, with a systolic blood pressure of 60 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, and significant jugular venous distention. His lungs are free of crackles. Bedside electrocardiogram revealed anterolateral ST segment elevations and "tombstones" across the precordial leads.

Eliminate smoking and alcohol.

A 78-year-old woman is an inpatient status post-colectomy for colon cancer. On postoperative day 3, her oral temperature is noted to be elevated to 100.6°F. Chest X-ray and urinalysis are both negative for signs of infection. An infectious disease consult is placed in order to better define the patient's new fever. You suspect superficial thrombophlebitis.

Erythema and tenderness along the vein with IV insertion

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

Fludrocortisone and compression stockings

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and swelling in her ankles. Symptoms started around the time of her son's wedding 6 weeks ago. She dismissed them as stress-related, but symptoms have worsened in intensity and frequency. Now she becomes very short of breath with any exertion, such as climbing stairs in her home. She feels like she may pass out and has to sit when she gets lightheaded. Her breathing is more difficult when lying down. She denies productive cough, fever, or chest pain. She has had no medical care for several years. Her past medical history is unremarkable, with no known medical conditions and no surgeries. She is menopausal and does not take any medications, nor does she have any allergies. She denies the use of tobacco, alcohol, and drugs. Vitals are shown in the table. Physical exam was performed by the provider on an earlier shift, and the patient's care was turned over to you.

Hepatojugular reflux Untreated hypertension

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

Hypertension

A 78-year-old man with known left-sided congestive heart failure presents due to cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms?

Increased pulmonary venous pressure

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

Infective endocarditis

A long-standing patient of yours is experiencing acutely worsening symptoms and signs of dilated cardiomyopathy. Symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, and clubbing. Physical exam is significant for an S3 gallop and jugular venous distention. Daily medications include a β-blocker, adult dose aspirin, and an ACE inhibitor.

Initiation of a diuretic

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

Lisinopril

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

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

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

Monitoring of hypertension and valvular dysfunction

A 30-year-old woman presents for routine analysis of cholesterol levels. The results show plasma cholesterol levels of 300 mg/100 mL. You prescribe the drug simvastatin (Zocor). She is reluctant to take drugs to treat her hypercholesterolemia. After further discussion, she agrees to take a vitamin to treat the elevated cholesterol. She also has questions concerning familial hypercholesterolemia.

Nicotinic acid

A 45-year-old woman presents with chest pain. The pain developed about an hour prior to arrival in ED and was precordial. No positional or pleuritic component was present. Nitroglycerin relieved the pain. Her EKG reveals ST elevations. She undergoes cardiac catheterization; all of her vessels are clean and no revascularization is performed.

Nifedipine

A 34-year-old woman presents with a 2-week history of severe fatigue, increased swelling in both feet, and slight pain in the right abdomen. She gives a history of shortness of breath on severe exertion. Exam reveals an afebrile patient with pedal edema and hepatomegaly. There are prominent A waves of the jugular venous pulsations (JVP). Auscultation reveals a tricuspid opening snap. A diastolic murmur is heard over the left sternal border, which increases on inspiration. A widely split S1 is also heard. Diagnostic testing reveals a normal CBC. Right atrial enlargement is seen on the chest X-ray, and the echocardiogram shows thickened tricuspid leaflets with limited mobility, increased velocity rough diastolic flow, and prolonged pressure half-time.

Obstructed venous flow to the right ventricle

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

Orthostatic hypotension

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

Patent ductus arteriosus

A 2-week-old female neonate presents for her scheduled newborn visit. The mother notes that the newborn has been feeding poorly and seems to have difficulty catching her breath when crying. On examination, a continuous machine-like murmur is heard at the left first intercostal space.

Patent ductus arteriosus

A newborn child is routinely evaluated in the pediatrician's office 1 month after delivery. The mother reports that the patient is behaving normally and is feeding well. The physical exam is remarkable for a murmur, which is located at the second left intercostal space. The murmur is continuous throughout cardiac systole and diastole, non-radiating, and of a "machinery" quality. There is additionally a widened pulse pressure. The skin and mucosa are without cyanosis, and there is no evidence of fluid retention.

Patent ductus arteriosus

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

Percutaneous transluminal angioplasty

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

Primary hyperaldosteronism

A 5-year-old boy presents with a 6-day history of fever, fatigue, and rash. He has no significant past medical history. His vaccinations are current, except for varicella, which his parents have refused in the past. On exam, his temperature is 101.3°F, heart rate is 110 bpm, and blood pressure is 94/62 mm Hg. He has bilateral conjunctival injection, an erythematous pharynx without exudate, cracked red lips, and an erythematous right tympanic membrane. He has shotty enlarged anterior cervical lymph nodes bilaterally, the largest nodes measuring 1.6 cm on the right side and 1.5 cm on the left side. His lungs are clear, and his heart has a regular rhythm. His abdomen is soft. He is in no acute distress, and he has a generalized maculopapular rash.

Sterile pyuria, leukocytosis

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

Surgical intervention provides the only definitive treatment. Metoprolol

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

The louder associated murmur is a good sign.

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

Thoracic aortic dissection

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

Transthoracic echocardiography

A 72-year-old man is admitted with an acutely severe myocardial infarction. His status quickly deteriorates. His symptoms include hypotension, altered mental status, cold clammy skin, and metabolic acidosis seen on laboratory tests.

Vasopressors

A 3-month-old Caucasian male infant presents for a well-baby check. There have been no other changes since the last visit. Upon exam, the infant is pink and well-appearing. Cardiovascular exam reveals a grade III/VI high-pitched, harsh pansystolic murmur heard best at the left sternal border, fourth intercostal space (ICS). No additional murmurs are heard. The remainder of the exam is unremarkable.

Ventricular septal defect

A 40-year-old man presents with irregular heartbeats over several days. His past medical history is significant for the presence of mitral valve stenosis and atrial fibrillation (AF). He takes beta blockers regularly. His ECG shows atrial fibrillation with an irregular heart rhythm around 80 bpm.

Warfarin

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

Atrial septal defect

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

Beta-blockers

A 73-year-old man presents with worsening shortness of breath with activity over the last few months. He is not able to complete as many physical activities during the day as he could manage 3 months ago. Physical examination reveals hypotension, tachycardia, extremities that are cool to the touch, expiratory wheezing, and rhonchi auscultated during the pulmonary exam; there is also a diminished first heart sound with an S3 gallop heard during the cardiac exam.

Congestive heart failure Diuretic Limiting salt

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

Echocardiography

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

HDL value of 35 mg/dL

A 55-year-old man presents for re-evaluation of his blood pressure; he has no significant past medical history. At his visit 3 weeks ago, his blood pressure was 145/90 mm Hg. He admits to somnolence, confusion, and non-specific bilateral visual disturbances over the past month; he denies any eye pain, blindness, ocular discharge, or floaters. His blood pressure today is 185/110 mm Hg. His fundoscopic exam reveals the following. Refer to the image.

Headache

A 45-year-old woman presents with vision loss. The patient states that she was watching TV the other day and experienced vision loss in her right eye for a few minutes. She describes the loss as a curtain being brought down over the right eye; it stayed there for a few minutes and then lifted back up.

Internal carotid artery

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

Intravenous diuretic

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

Intravenous labetalol

A 37-year-old Caucasian man presents with shortness of breath. History reveals that the patient has been extremely fatigued the last few weeks, experiencing excessive night sweats with a worsening cough, chest pain, and general aches and pains. He is not taking any medications and is allergic only to penicillin. He has a history of on-and-off intravenous drug use and admits to last using around 1 month ago. Along with an urgent inpatient admission, you plan to initiate orders to have the patient undergo an echocardiogram and obtain blood cultures, among other actions.

Intravenous vancomycin

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

Lactate levels

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

Rosuvastatin

A 16-year-old boy with no significant past medical history presents to learn the results of a lipid panel that was performed. The lipid panel was ordered due to periorbital and extensor tendon xanthomas on the patient's body. The patient consumes a low-fat and low-calorie diet, and he exercises daily. He denies any bothersome symptoms, and his physical exam is otherwise unremarkable.

Reduction in the amount of LDL receptors on hepatocytes

A 72-year-old man presents for worsening shortness of breath, orthopnea, and chest pain for the last few weeks. He admits some chronic heart problems, fatigue, dyspnea, and non-productive cough, but he feels like symptoms have worsened recently. He denies fever, chills, and productive cough. On physical exam, he has mildly increased respiratory effort but does not appear in distress. He is barrel-chested. Breath sounds are diminished bilaterally, with dullness to percussion over right and left lower lungs. No pleural friction rub noted. S3 gallop, mild tachycardia (110 bpm), clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention are noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on chest X-ray.

Renal sodium and fluid retention leading to increased capillary pressure

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

Restricted cardiomyopathy

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

Synchronized cardioversion

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

Tachycardia

A 68-year-old man with a past medical history of hypertension, hyperlipidemia, cluster headaches, polymyalgia rheumatica, and type 2 diabetes mellitus presents due to a 2-day history of constant left-sided throbbing headache of moderate severity. He admits to associated symptoms, such as pain across his mandible when he eats, fever, fatigue, and muscle aches. Most alarming to the patient was a single episode of complete left eye blindness that lasted for 30 minutes but has since resolved. He denies extremity numbness, tingling, muscle weakness, incontinence, and changes in mental status. He further denies rhinorrhea, ocular discharge, nausea, and vomiting. The physical exam was remarkable only for a tender left scalp with a noticeable pulsation underlying the tender area.

Temporal arteritis

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate is 120 bpm, and respiratory rate is 34/min. Physical examination findings include neck negative for bruits/JVD, lungs clear to auscultation, regular heart rhythm, normal S1/S2 with an S4 present, and a grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray is obtained.

Widening of the superior mediastinum