MF2 Vignettes

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

Acromegaly

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

Acromegaly

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

Acute Cystitis

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

Acute Interstitial Nephritis

A 35-year-old man with a history of congenital valvular heart disease undergoes a dental procedure without appropriate antibiotic prophylaxis. Several weeks later, he presents with fever and respiratory distress. He is intubated, and Streptococcus viridans is isolated in all blood cultures drawn at the time of admission. Echo demonstrates a mitral valve vegetation. Laboratory tests reveal a rising serum creatinine and urine output decline. Urine analysis reveals more than 20 WBCs, more than 20 RBCs, and red cell casts. Urine culture is negative. Renal ultrasound is unremarkable. Serum ESR is elevated.

Acute Kidney Injury

A 65-year-old male smoker with hypertension, dyslipidemia, and diabetes mellitus presents with chest pain. ECG changes suggest an acute MI. He is taken for an emergent coronary angiogram. Three days later, he is noticed to have developed an elevated serum creatinine, oliguria, and hyperkalemia.

Acute Kidney Injury

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

Acute Liver Failure

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

Acute Pancreatitis

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

Acute Pancreatitis

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

Acute Pyelonephritis

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

Acute Tubular Necrosis

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

Acute Tubular Necrosis

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

Addison Disease

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

Addison Disease

A 38-year-old man presents to the emergency department for severe alcohol abuse with nausea and vomiting. He has a significant medical history of chronic heavy alcohol consumption of a half pint of vodka daily for about 5 years until 1 year ago; since then he has severe intermittent binge alcohol intake. He reports no other significant medical problems. The patient is confused and slightly obtunded, and hepatomegaly is discovered on physical exam. Patient's BMI is 22. Pertinent positive laboratory values show low hemoglobin, AST elevation > ALT elevation, normal PT and INR, and very high serum alcohol level. Ultrasound of the abdomen shows fatty infiltration in the liver.

Alcoholic Liver Disease

A 50-year-old man presents to his primary-care clinic physician with complaints of fatigue for 2 months. The patient also notes distention of his abdomen and shortness of breath beginning 2 weeks ago. His wife reports that the patient has been having episodes of confusion lately. The patient has a significant medical history of chronic heavy alcohol consumption of about a half pint of vodka daily for around 20 years. On physical exam the patient is noted to have scleral icterus, tremors of both hands, and spider angiomata on the chest. There is abdominal distention with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low hemoglobin, low platelets, low sodium, AST elevation > ALT elevation, and high PT and INR. Ultrasound of the abdomen shows liver hyperechogenicity, portal hypertension, splenomegaly, and ascites.

Alcoholic Liver Disease

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

Diabetes Mellitus, Type 1

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

Benign Prostatic Hyperplasia

A 12-year-old girl presents with sudden-onset severe generalized abdominal pain associated with nausea, vomiting, and diarrhea. On exam she appears ill and has a temperature of 104°F (40°C). Her abdomen is tense with generalized tenderness and guarding. No bowel sounds are present.

Appendicitis

A 22-year-old male presents to the emergency room with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the midabdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (100.5°F; 38°C), pain on palpation at right lower quadrant (McBurney sign), and leukocytosis (12,000/microliter) with 85% neutrophils.

Appendicitis

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

Benign Prostatic Hyperplasia

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

Celiac Disease

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

Cholecystitis

A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the RUQ that began after eating dinner and radiates through to her back. This pain gradually increased before becoming constant over the last few hours. She has had previous episodes of similar pain for which she has not sought medical advice. Her vital signs are normal. The pertinent findings on physical exam are tenderness to palpation in the right upper quadrant with no guarding or rebound.

Cholelithiasis

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

Chron's Disease

A 54-year-old man with a 10-year history of DM and HTN, with complications of diabetic retinopathy and peripheral neuropathy, presents to his primary care physician with complaints of fatigue and weight gain of 4.5 kg over the past 3 months. He denies any changes in his diet or glycemic control, but does state that he has some intermittent nausea and anorexia. He states that he has noticed that his legs are more swollen at the end of the day but improve with elevation and rest. Physical exam reveals an obese man with a sitting BP of 158/92 mmHg. The only pertinent physical exam findings are cotton wool patches and microaneurysms bilaterally on fundoscopic exam and pitting, bilateral lower-extremity edema.

Chronic Kidney Disease

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

Chronic Pancreatitis

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

Chronic Pyelonephritis

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

Chronic Pyelonephritis

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

Cirrhosis

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

Cirrhosis

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

Crohn's Disease

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

Cushing Syndrome

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

Cushing Syndrome

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

Diabetes Mellitus Type 2

A 10-year-old African-American girl was seen by her primary care pediatrician during a routine well-child check. She was noted to be tall for her age (height >95% percentile) and obese (BMI >95%). On physical exam, she was found to have acanthosis nigricans on her neck and axilla and had a vaginal yeast infection. She was noted to be Tanner stage 3 for breast and pubic hair development. Urinalysis revealed glucose >1000 mg/dL with negative protein and ketones. A random blood glucose, obtained because of the glycosuria, was 349 mg/dL. Family history revealed both parents to be obese, and the mother had gestational diabetes during her last 2 pregnancies. Maternal grandparents have type 2 diabetes mellitus (T2DM), as do multiple maternal and paternal aunts and uncles. The maternal grandfather had a myocardial infarction at the age of 48 years and has hypertension and hypercholesterolemia. The child's father had coronary

Diabetes Type 2

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

Diabetic Ketoacidosis

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

Diverticular Disease

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

Diverticular Disease

A 23-year-old nulligravida presents with a 2-day history of sharp intermittent RLQ abdominal pain, nonradiating, without any alleviating factors, exacerbated with movement, progressively worsening, and not associated with any GI symptoms. Her last menstrual period was 7 weeks ago. She denies medical problems. Her gynecologic history is significant for a prior chlamydia infection as a teenager, but is otherwise negative.

Ectopic Pregnancy

A 33-year-old gravida 3 para 2 presents with 4-day history of vaginal bleeding along with lower abdominal discomfort and nausea. She states that her symptoms have worsened over the previous 24 hours. Her last menstrual period was 6 weeks ago. She denies medical, gynecologic, or social problems and her review of systems is negative except for the above complaints. Her obstetric history includes an abortion and 2 uncomplicated vaginal deliveries followed by an interval tubal ligation 1 year ago.

Ectopic Pregnancy

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

Glomerulonephritis

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

Essential Hypertension

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

GERD

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

Gastritis

A 70-year-old woman presents with a 2-month history of increasing fatigue, difficulty with ambulation, and memory deficits. Family history is notable for autoimmune disease. Laboratory evaluation is remarkable for a macrocytic anemia, a markedly reduced serum vitamin B12, and presence of antiparietal cell antibodies.

Gastritis

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

Glomerulonephritis

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

Graves Disease

A 10-year-old girl presents with headaches and poor vision. At 9 years of age, an urgent MRI scan of her brain revealed a suprasellar solid/cystic mass diagnosed as a craniopharyngioma. She was treated with surgery and cranial irradiation. Her pituitary evaluation 3 months later revealed a peak GH concentration (after glucagon provocation) of 0.3 micrograms/L, a peak serum cortisol concentration of 3 micrograms/dL, a peak TSH concentration (after TRH stimulation) of 2.3 mU/L with a peak free T4 of 0.57 nanograms/dL, and a peak serum prolactin of 16 nanograms/mL. Her peak serum gonadotropin concentrations (after LHRH stimulation) were 2.6 international units/L (FSH) and 1.9 international units/L (LH). A diagnosis of GHD with combined pituitary hormone deficiencies was made.

Growth Hormone Deficiency

Parents of a 5-year-old boy have been increasingly worried about his height for the past 18 months. His height is well below the 0.4th centile (98 cm). His weight is on the 9th centile and midparental height is on the 50th centile. He has a small face with frontal bossing and a lot of fat around his belly. image His height at 4.2 years was 95 cm and at 3.6 years was 93 cm, giving him a growth velocity that is suboptimal at 5 cm over 1.6 years. His 2 brothers are both of an "average height."

Growth Hormone Deficiency

A 50-year-old man presents with several months of gradually worsening abdominal swelling, intermittent hematemesis, and dark stool. He denies chest pain or difficulty breathing. Past medical and family history are not contributory. Past surgical history is significant for back surgery requiring blood transfusion in 1980. Social history is significant for occasional alcohol use. BP is 110/80 mmHg. Physical examination is significant for spider angiomata on the upper chest, gynecomastia, caput medusae, and a fluid wave of the abdomen. The rest of the examination is normal.

Hepatitis C

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

Hepatic Encephalopathy

A 42-year-old man is referred to the liver clinic with mild elevation in alkaline phosphatase and aminotransferases for several years. He has a medical history significant for obesity, hypertension, and hypercholesterolemia. He does not smoke or drink alcohol and there is no high-risk behavior. He has a family history of premature cardiac disease. He is taking a diuretic and discontinued a statin several months ago. Other than complaints of mild fatigue, the patient feels well. Exam is notable for a BMI of 37 kg/m^2, truncal obesity, and mild hepatomegaly.

Hepatic Steatosis

A 63-year-old woman is admitted to the hospital with new-onset ascites. She has a history of longstanding diabetes and hypertension. She has never formally been given a diagnosis of liver disease. Despite increasing abdominal distension, she has lost 13.5 kg in the last year. Physical exam reveals a lethargic-appearing woman with temporal wasting, massive ascites, and 2+ pitting edema. She has numerous spider nevi over her chest wall and marked palmar erythema.

Hepatic Steatosis

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

Hepatitis A

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

Hepatitis B

A 40-year-old man presents with ascites. He has a history of hepatitis C and cirrhosis. He complains of fever, increased abdominal discomfort, and decreased urine output. On examination he is febrile, with BP 90/70 mmHg and jaundiced. He has tense ascites and generalized abdominal tenderness. There is pitting edema to the level of his upper thighs.

Hepatorenal Syndrome

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

Hiatal Hernia

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

Hypercholesterolemia

A 45-year-old African-American man with a history of type 2 diabetes is admitted directly from clinic for a serum glucose of 970 mg/dL. He was started recently on basal bolus insulin therapy after several years of treatment with oral antiglycemic agents. However, he reports not having filled his insulin prescription owing to its high cost. For the past 2 weeks he has had polyuria, polydipsia, and has lost 5 kg in weight. He has also noted a progressively worsening cough for approximately 3 weeks that is productive of greenish brown sputum. On examination, he is febrile with a temperature of 101.3°F (38.5°C), tachypneic (respiratory rate of 24 breaths per minute), and normotensive. Urinalysis reveals trace ketones but serum beta-hydroxybutyrate is not elevated. Serum bicarbonate is 17 mEq/L and venous pH is 7.32.

Hyperosmolar Hyperglycemic State

A 72-year-old man is brought to the emergency department from a nursing home for progressive lethargy. The patient has a history of hypertension complicated by a cerebrovascular accident (CVA) 3 years previously. This has impaired his speech and rendered him wheelchair bound. He also has a schizothymic disorder for which he was started recently on clozapine. On presentation, he is disoriented to time and place and febrile with a temperature of 101°F (38.3°C). Vital signs include a BP of 106/67 mmHg, heart rate of 106 beats per minute, and a respiratory rate of 32 breaths per minute. Initial laboratory workup reveals a serum glucose of 950 mg/dL, a serum sodium of 127 mEq/L, BUN of 59 mg/dL, and a serum creatinine of 2.3 mg/dL. Serum osmolality is calculated as 338 mOsm/kg. Urinalysis reveals numerous white blood cells and bacteria. Urine is positive for nitrates but negative for ketones. Serum is negative for beta-

Hyperosmolar Hyperglycemic State

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

Hypertensive Emergency/Malignant

Mary Jane Thompson, age 25, has a seven-year history of type 1 diabetes. She is a teacher for handicapped children and spends most of her workday trying to get the youngsters engaged in activities. Her classroom is on the second floor of the school building. Mary Jane's blood sugar this morning was 205 mg/dL. Most mornings her blood sugar is above the normal limits. Mary Jane's nurse practitioner has advised her to monitor her blood sugar before each meal and before going to bed. Her insulin regime to treat her diabetes is: Lispro, 4 units before breakfast Lispro, 6 units at lunch Lispro, 6 units at dinner Glargine, 15 units at hour of sleep Today, she ate a piece of toast for breakfast and had a cup of coffee to drink on the way to school. Recently, Mary Jane has developed the habit of skipping her before-lunch blood glucose check if there is another teacher in the lounge. However, she did take her lunchtime insulin

Hypoglycemia

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

Hypoparathyroidism

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

Hypoparathyroidism

A 32-year-old woman presents to her doctor with a 10-month history of depression, hot flashes, weight gain, reduced libido, lethargy, cold intolerance, and amenorrhea. She delivered a healthy baby boy 10 months ago; however, the delivery was complicated by a significant post-partum hemorrhage requiring multiple blood transfusions. She was unable to breastfeed her baby and has been amenorrheic since that time. Physical exam is remarkable for a flat affect, bradycardia, weight loss, and delayed relaxation of her reflexes.

Hypopituitarism

A 40-year-old man has a 12-month history of progressive headaches, weight loss, poor appetite, lethargy, cold intolerance, and erectile dysfunction. He has difficulty seeing the periphery when driving his car. Physical exam is remarkable for bradycardia, gynecomastia, scant body hair, delayed relaxation of his reflexes, and bitemporal hemianopia.

Hypopituitarism

A 23-year-old white man with an unremarkable past medical history presents to the clinic for a routine physical exam including a urine analysis required for his job. This shows invisible hematuria and mild proteinuria. The physical exam reveals no significant abnormal findings

IgA Nephropathy

An otherwise healthy 22-year-old Japanese-American man presents with visible hematuria accompanied by flank pain. He has a 2-day history of sore throat, fever, chills, malaise, and headache. Physical exam reveals erythema and inflammation of the uvula and pharynx, enlarged tonsils with patchy greyish-white exudates, and tender anterior cervical lymphadenopathy. The rest of the exam is normal. Urinalysis shows cola-colored urine with hematuria and 3+ protein.

IgA Nephropathy

A 34-year-old nulligravid woman presents to her gynecologist with a complaint of inability to conceive. She has been married for 2 years and stopped using contraception 1 year ago. Her menstrual cycles occur regularly every 28 days and are associated with moliminal symptoms (breast tenderness, bloating, and mood changes). She denies dysmenorrhea or dyspareunia. She has no significant medical history, has never had a sexually transmitted disease, and has never had surgery. Her husband is 34 years old and has never fathered a child. He has a history of hypertension controlled by beta-blockers.

Infertility

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

Irritable Bowel Syndrome

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

Irritable Bowel Syndrome

A 20-month-old boy is admitted to the hospital with a history of having passed a bloody stool 8 hours before presentation. He has previously been well. On examination, he is pale and distressed but has no abdominal mass or tenderness. A contrast enema proves negative for intussusception.

Meckel Diverticulum

A 68-year-old man presents to the ER with a 24-hour history of colicky central abdominal pain associated with anorexia and intractable constipation (obstipation). The pain is associated with nausea and vomiting. He has had no previous abdominal surgery. On examination he is dehydrated with no clinical signs of sepsis. His abdomen is distended and diffusely tender with no rebound tenderness or guarding. He has no hernias. Laboratory studies reveal an elevated white blood cell count. The abdominal plain x-rays show grossly dilated small bowel loops with paucity of gas in the colon. However, after 24 hours of treatment for small bowel obstruction, his abdominal pain worsens.

Meckel Diverticulum

A 27-year-old woman presents with abdominal obesity, hirsutism, acne, and polycystic ovaries on gonadal ultrasonography. She reports 3 to 4 menstrual periods per year. On examination, her BMI is 33 kg/m^2, waist circumference is 37 inches (94 cm), and BP is 130/83 mmHg. Her serum total testosterone level is elevated (101 nanograms/dL; normal range 20-75 nanograms/dL). She has an impaired fasting glucose (117 mg/dL), and the lipid profile shows high triglycerides (190 mg/dL), high total cholesterol (201 mg/dL) and LDL-cholesterol (125 mg/dL) levels, and low HDL-cholesterol (38 mg/dL) levels.

Metabolic Syndrome

A 55-year-old man presents with elevated aminotransferases on laboratory investigation. He also has episodes of sleep apnea. He smokes about 20 cigarettes a day and his father had an MI at the age of 52 years. Physical exam reveals hypertension (BP 152/90 mmHg) and abdominal obesity (waist circumference 43 inches [110 cm]). He has an impaired fasting glucose (113 mg/dL), and the lipid profile shows high triglycerides (240 mg/dL), high total cholesterol (213 mg/dL) and LDL-cholesterol (130 mg/dL) levels, and low HDL-cholesterol (35 mg/dL) levels.

Metabolic Syndrome

A 5-year-old boy presents with a short history of facial edema that has now progressed to total body swelling involving the face, abdomen, scrotum, and feet. Other symptoms include nausea, vomiting, and abdominal pain. The parents report that the child had a viral illness with fever a few days before the development of the swelling. On examination, he has facial edema, ascites, scrotal edema, and pitting edema of both legs up to the knees.

Minimal Change Disease

A 45-year-old woman presents for evaluation of her obesity. She has been obese all of her life and has tried multiple weight-loss programs without success. In the last 6 months, she has undergone a physician-supervised diet and exercise with minimal change in her weight. She weighs 120 kg and stands 5 feet 5 inches tall (165 cm). Her comorbidities include hypertension, diabetes, obstructive sleep apnea, and GERD.

Obesity

A 54-year-old woman with a height of 5 feet 4 inches (163 cm) and weight of 80.3 kg presents to her family physician with a chief complaint of vaginal bleeding. She is postmenopausal, and her medical history consists of hypertension, type 2 diabetes, hypercholesterolemia, osteoarthritis of both knees, and depression. She has also had a caesarean section and a cholecystectomy.

Obesity

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

Obesity Hypoventilation Syndrome

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

Painless Thyroiditis

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

Painless Thyroiditis

A 15-year-old black girl presents for evaluation of irregular periods and acne. Excessive weight gain is not a primary concern of the family, and they feel that she is simply "big-boned." However, her weight has been above the 97th percentile since 5 years of age, with acceleration further above the normal weight curve since. Both parents are obese with type 2 diabetes. Her father also has hyperlipidemia and had a myocardial infarction at 47 years of age. The child drinks at least 5 cans of regular soda daily and eats at fast food restaurants several times weekly. She has limited physical activity. Her height, weight, and BMI are 168 cm, 121.2 kg, and 42.8, respectively.

Pediatric Obesity

An 8-year-old white girl presents for further evaluation of excessive weight gain and acanthosis nigricans. She was born at term following a pregnancy complicated by gestational diabetes, and had a birth weight of 4.5 kg. Her weight was above the 95th percentile for height by 2 years of age and has been accelerating further away from the normal weight curve since. She has followed the 95th percentile for height. She has a large appetite with excessive calories eaten throughout the day. She has limited activity, and watches 5 to 6 hours of television daily. She had a tonsillectomy and adenoidectomy for obstructive sleep apnea at 6 years of age. There is an extensive family history of obesity, and her father's BMI is 35 and mother's BMI is 45. The child's height is 143 cm, and weight 80 kg, giving her a BMI of 38.8, which is markedly greater than the 95th percentile for age and gender.

Pediatric Obesity

An 18-year-old female college student with a history of prior chlamydia infection presents with low-grade fever and nonspecific lower abdominal pain. Examination reveals mild diffuse lower abdominal tenderness on deep palpation. She has cervical motion tenderness and a mucopurulent vaginal discharge on pelvic examination.

Pelvic Inflammatory Disease

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

Peptic Ulcer Disease

A 4-year-old boy presents with rapid growth. Examination reveals a height on the 75th centile (previously on the 25th) and weight on the 50th centile. Midparental height is on the 25th centile. He has pubic hair stage 4, axillary hair stage 2, penile growth, scrotal changes, and a bone age of 9 years. However, his testes only measure 3 mL bilaterally (prepubertal).

Precocious Puberty

A 6-year-old girl presents with advanced breast development. On examination, some pubic hair is also observed. Parents mention that the breast development started about 6 months ago but the pubic hair is recent. She has been outgrowing clothes rather rapidly this year. Neurologic examination is normal.

Precocious Puberty

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

Primary Hyperparathyroidism

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

Primary Hypothyroidism

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

Renal Artery Stenosis

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

Renal Artery Stenosis

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

Secondary Hyperparathyroidism

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

Secondary Hyperparathyroidism

A 78-year-old woman presents to the hospital for an elective right hemicolectomy. She has a past medical history of hypertension, angina on exertion, and diabetes mellitus. She is independently mobile, does her own shopping, and has a 30-pack-a-year history of smoking. The operation was uncomplicated. On day 5 post-surgery, she becomes confused. On examination, she has a Glasgow coma score of 14/15. She has a respiratory rate of 28 breaths/minute, and has oxygen saturations of 92% on 2 L of oxygen. She is tachycardic at 118 bpm, and her BP is 110/65 mmHg. On chest auscultation, she has coarse crackles in the right lower chest. Her surgical wound appears to be healing well and her abdomen is soft and not tender.

Sepsis

A preterm male infant develops transient apneas and bradycardic episodes while in the neonatal ICU. Two weeks prior to this event, he had been born at 30 weeks' gestation after spontaneous onset of preterm labor. He had required intubation and mechanical ventilation for 48 hours following birth for neonatal respiratory distress syndrome. Standard dosing of surfactant was administered during this time. He required respiratory support with continuous positive airway pressure for 1 week after his extubation, and was cycling on and off high-flow oxygen therapy at the time of this event. He had established full enteral feeding after a period of parenteral feeding via a percutaneous central venous catheter (long-line). The long-line was still in situ at the time of this event, and was planned for removal that day. In addition to the apneas and bradycardias, it was noted that he had temperature instability and increased cap

Sepsis

A previously well 1-year-old girl presents to the emergency department with a history of lethargy and fever for 24 hours. She recently had symptoms suggestive of a viral upper respiratory tract infection. Her parents report that for a few hours prior to presentation she had become drowsy and difficult to rouse. They also report that they had noticed a rash developing on her trunk and limbs shortly before presentation. On initial assessment the following features are identified: reduced level of consciousness (response to painful stimulus only); tachycardia (heart rate 190 bpm); prolonged capillary refill time (>5 seconds peripherally); cold peripheries (core-toe temperature gap >18°F [>10°C]); fever (core temperature 102°F [39°C]); tachypnea (respiratory rate 40 bpm) and grunting on expiration; widespread, nonblanching, purpuric rash on trunk and limbs.

Sepsis

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

Subacute Thyroiditis

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

Toxic Thyroid Adenoma

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

Ulcerative Colitis