Case histories

A 55-year-old man with a history of hypertension (well controlled with medication) and tobacco use presents to his primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been steadily worsening in intensity. He says the pain radiates to his lower back and both groins at times. While he cannot identify any aggravating factors (such as movement), he feels the pain improves with his knees flexed. There is a palpable pulsatile mass just left of midline below the umbilicus. He is immediately referred for definitive management, but during transfer becomes hypotensive and unresponsive.

AAA

A 65-year-old man presents to his local aneurysm surveillance team for a screening ultrasound scan. He has been feeling well and in his usual state of good health. His medical history is notable for mild hypertension and he has a 100-pack-year tobacco history. On ultrasound an infrarenal AAA is identified.

AAA

56-year-old woman with a 6- week history of weight loss, anxiety, and insomnia presents with palpitation and dyspnoea. Her pulse rate is irregular at 140 to 150 bpm. Her BP is 95/55 mmHg. She looks thin, frail, and rather anxious and jittery. Her palms are sweaty and have fine tremors. She has a palpable smooth goitre. Examination of the eyes shows bilateral exophthalmoses.

AF

A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidaemia presents to the accident and emergency department with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest. These symptoms started acutely and have been present for 4 hours. Physical examination shows an irregularly irregular radial pulse at rate between 90 and 110 bpm, BP 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination.

AF

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

Peptic Ulcer Disease

A 27-year-old man with a 3-month history of rectal bleeding and diarrhoea is referred for evaluation. Laboratory tests show mild anaemia, 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.

UC

A 52-year-old man presents with a 6-month history of heartburn and atypical chest pain, both unrelated to food. He also described 'gurgling' sounds in his chest. A month before presentation he developed intermittent dysphagia to both solids and liquids, regurgitation, and weight loss of 3 kg.

achalasia

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

acute appendicitis

A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal 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 (38°C; 100.5°F), pain on palpation at right lower quadrant (McBurney's sign), and leukocytosis (12 x 10^9/L or 12,000/microlitre) with 85% neutrophils.

acute appendicitis

A 14-year-old boy with no significant past medical history presents 3 days after developing a red, irritated right eye that spread to the left eye today. He has watery discharge from both eyes and they are stuck shut in the morning. He reports recent upper respiratory tract symptoms and that several children at his day camp recently had pink eye. He denies significant pain or light sensitivity and does not wear contact lenses. On examination, his pupils are equal and reactive and he has a right-sided, tender pre-auricular lymph node. Penlight examination does not reveal any corneal opacity.

acute conjunctivitis

A 6-year-old girl with no significant past medical history presents 4 days after developing a red, irritated left eye. Her mother states that she has been wiping thick whitish-yellow discharge from her eye, and the eye is matted shut in the morning. She denies any exposure to an infected person, upper respiratory tract symptoms, or contact lens use. She also denies any significant pain or light sensitivity. On examination, the patient's pupils are equal and reactive. She does not have a tender pre-auricular lymph node. Penlight examination does not reveal any corneal opacity, but thick, whitish discharge is seen.

acute conjunctivitis

A 47-year-old overweight woman is admitted with generalised 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 department with over the past few months. An ultrasound obtained on her last visit to the emergency department 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 department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards 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, tachypnoeic, 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 62-year-old man is referred for management of atypical multiple myeloma. He has a mild anaemia of 120 g/L (12 g/dL), a urinary protein loss of 2.2 g/day with a urinary immunofixation showing free lambda light chains. However, the bone marrow shows only 5% plasma cells and does not fulfil criteria for multiple myeloma.a

amyloidosis

A 79-year-old man presents with dyspnoea on exertion for 1 year and lower extremity oedema. As part of a cardiac work-up, the echo shows concentric left ventricular hypertrophy. Cardiac catheterisation shows normal coronary arteries and he is referred for further evaluation of non-cardiac dyspnoea.

amyloidosis

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

anal fissure

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

angle closure glaucoma

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

angle closure glaucoma

A 32-year-old man presents to the emergency department complaining of perirectal pain and swelling. The symptoms began 24 hours earlier and have become progressively worse. The patient denies any rectal bleeding and describes the pain as very severe and localised to the area of the swelling. He relates a subjective history of fever but denies any change in bowel habits. He also denies any history of recent or chronic medical problems.

anorectal abscess and fistula

A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border. He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. The patient is taking hydrochlorothiazide for high blood pressure. Echocardiography reveals a left ventricular ejection fraction (LVEF) of 55%, left ventricular end-diastolic diameter of 70 mm, and end-systolic diameter of 50 mm.

aortic regurg

A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.

aortic stenosis

A 55-year-old factory maintenance worker falls at work. A CXR is performed to evaluate the patient for a possible broken rib. Bilateral pleural thickening is seen on CXR. Further history indicates he is very active without any respiratory symptoms. He smokes 20 cigarettes a day. There is no family history of lung disease. He does not take any respiratory medicine.

asbestosis

A 67-year-old retired construction worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack-year smoking history, but stopped smoking aged 50 years. There is no family history of lung disease. He does not take any respiratory medicine on a regular basis. With colds he has noticed wheezing and his doctor once prescribed an inhaler.

asbestosis

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 hypercholesterolaemia. He does not smoke or drink alcohol and there is no high-risk behaviour. 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. Examination is notable for a BMI of 37 kg/m^2, truncal obesity, and mild hepatomegaly.

hepatic steatosis

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

barrets oesophagus

A woman in her mid-40s with dark, leathery skin and intense wrinkling of the lower neck (signifying excessive sun exposure either in a form of frequent sun tanning beds or perhaps frequent beach visits) presents at your office. She reports she has had multiple facial lifts, to decrease wrinkles. The plastic surgeon she has consulted performed other cosmetic procedures, including botulinum toxin type A injections. She complains about a mole on her jaw that has recently started to bleed.

basal cell carcinoma

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

bladder cancer

A 65-year-old white woman presents to her doctor for a routine screening mammogram, which demonstrates a cluster of pleomorphic micro-calcifications that are located in the upper outer quadrant of her left breast. One year ago, her mammogram showed no abnormalities; the patient has been diligent in undergoing annual mammograms because her mother was diagnosed with breast cancer at the age of 50 years.

breast cancer

A 68-year-old white woman presents to her doctor with a 3-month history of a painless lump in the upper outer quadrant of her breast. During his clinical examination, her doctor notes that, in addition to the hard 2-cm mass that is located in the upper outer quadrant of her breast, the patient also has 3 enlarged ipsilateral axillary lymph nodes.

breast cancer

A 65-year-old woman presents to her primary care physician with a 4-month history of intermittent abdominal pain localised to the RUQ with radiation to the epigastrium; the pain increases with the ingestion of fatty food and decreases with fasting. In the last 2 weeks the pain has been more frequent and steady. The patient complains of nausea, pruritus, anorexia, and weight loss, which she relates to the lack of appetite. At physical examination, there is RUQ tenderness and jaundice of the conjunctival sclera. No lymphadenopathy or palpable masses are found.

cholangiocarcinoma

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 diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), 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 and became 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 examination are tenderness to palpation in the right upper quadrant without guarding or rebound.

cholelithiasis

A 63-year-old woman is admitted to the hospital with new-onset ascites. She has a history of long-standing 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 examination reveals a lethargic-appearing woman with temporal wasting, massive ascites, and 2+ pitting oedema. She has numerous spider nevi over her chest wall and marked palmar erythema.

hepatic steatosis

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

hepatocellular carcinoma

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

hepatocellular carcinoma

A 24-year-old woman presents with a 3-day history of painful sores in the genital area, dysuria, fever, and headache. She is sexually active with men and has a new partner within the past month. She does not use condoms. Physical examination reveals a temperature of 38.3°C (100.9°F), stable vital signs, slight nuchal rigidity (implying aseptic meningitis), bilateral tender inguinal lymphadenopathy, and multiple tender 1- to 2-cm erythematous ulcerations without labial crusts. The cervix is oedematous with pustules and clear discharge. Cervical motion tenderness is also present.

herpes simplex infection

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

herpes simplex infection

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

herpes zoster

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

herpes zoster

A 51-year-old man with moderate obesity (BMI of 34 kg/m^2) is seen in consultation for heartburn and regurgitation. He ha a diagnosis of GORD and has been treated with proton-pump inhibitors. His heartburn is less severe with the medication, but he is still bothered by regurgitation. His physical examination is unremarkable. A barium oesophagram is ordered. The patient has free reflux to the level of the cervical oesophagus.

hiatus hernia

A 41-year-old alcoholic man has a 6-year history of recurrent attacks of pancreatitis characterised by epigastric pain radiating to the back. The initial attack required hospitalisation 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 steatorrhoea. Computed tomography imaging shows pancreatic calcifications but no cystic or mass lesions.

chronic pancreatitis

A 55-year-old man presents with a 6-month history of a large wound on his right lower leg. He has had chronically swollen legs for over 10 years. He notes that his brother (deceased, myocardial infarction) and mother (deceased, pulmonary embolism) had similar problems in their legs. He had 2 documented DVT in the affected leg 5 years earlier.

chronic venous insufficiency

A 70-year-old woman presents with gradual, progressive leg swelling. She also has itching, occasional skin flaking, and darkness of the leg. The swelling gets worse as the day progresses. Various topical agents have provided little relief.

chronic venous insufficiency

A 56-year-old man 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 examination 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 dyslipidaemia 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 46-year-old woman presents with fatigue and is found to have iron deficiency with anaemia. She has experienced intermittent episodes of mild diarrhoea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms such as diarrhoea, bloating, or abdominal pain. Examination reveals two oral aphthous ulcers and pallor. Abdominal examination is normal and results of faecal testing for occult blood are negative.

coeliac disease

A 9-year-old boy presents with vomiting for 5 days. His sister, who has coeliac disease, has had similar symptoms. His growth has been normal and he has not experienced any other possible symptoms of coeliac disease, except for intermittent constipation. Immunoglobulin A-tissue transglutaminase titre is 5 times the upper limit of normal.

coeliac disease

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

colorectal carcinoma

A 16-year-old girl presents with a progressively worsening pruritic eruption in the peri-umbilical region. She reports wearing blue jeans with metal buttons and a belt with a metal buckle on an almost daily basis. She previously developed pruritic eruptions around the neck and earlobes when wearing costume jewellery. Physical examination reveals erythematous to hyperpigmented peri-umbilical papules and plaques with sharp demarcation, and hyperpigmented patches on the neckline and ear lobes.

contact dermatitis

A 45-year-old male factory worker presents with pruritic eruption of his hands, which has been present for several months. He works in a manufacturing plant where cutting oils are used. While at work, he wears protective clothing that covers his trunk, arms, and legs, but he often neglects to wear gloves. He noticed an improvement when he was on holiday for 2 weeks. Physical examination shows hyperpigmented scaly plaques and fissuring, confined to the dorsal hands and digits, with sharp demarcation at the wrist.

contant dermatitis

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

crohn's disease

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

crohn's disease

A 50-year-old electrician was servicing a high-voltage transformer when a distant switch inadvertently sent current to the transformer, with a resulting arc and electrocution. The worker was thrown back by the force and his clothing was ignited. Physical examination reveals charring of the dominant hand, with deep arching injury across the antecubital fossa and axilla, consistent with passage of high-voltage current. The upper torso demonstrates leathery deep burns consistent with flame injury.

cutaneous burn

As a result of an accident in the kitchen, a 20-month-old toddler had boiling pasta and water spilled onto her head, face, and upper body. Physical examination reveals blistering sloughing skin with underlying wet, tender erythema.

cutaneous burn

A 45-year-old woman presents with a one-month history of poor sleep and irritable mood, in the setting of a recent divorce and ongoing custody battle with her former husband over their 2 teenage children. She has also just had a bad performance review at work due to her inability to meet deadlines and is fearful of losing her job. She explains that her work problems have arisen because she has been unable to keep her concentration focused on work. She expresses feelings of worthlessness and wonders sometimes what is the point of living. She has to force herself to stay engaged in her children's activities and other interests that she used to enjoy; she feels she is 'just going through the motions'. She had a similar episode after the birth of her second child, but pulled out of it after several months. There is a family history of suicide; her mother killed herself when the patient was 10 years old. Her examination is notable for poor eye contact and frequent tears. Her test results, including TSH, are normal.

depression

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

diverticular disease

A 57-year-old female with history of hypertension and hypercholesterolaemia 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 gastrointestinal (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 40-year-old woman presents with intensely pruritic rash of the hands and feet that is relapsing-remitting. She recalls that, 1 or 2 days prior to an eruption, she will notice an itching sensation in her palms and soles. The rash consists of small vesicles on the palms, soles, and lateral fingers. It lasts for a couple of weeks before desquamation, leaving no trace. She has several episodes a year and cannot cite specific triggers, although she does note that washing dishes makes it worse. Her medical history is otherwise unremarkable.

dyshidrotic dermatitis

A 23-year-old man presents with a history of recurrent erythematous lesions over the extremities with each outbreak of herpes labialis. The episodes have become more frequent, and each recurrence is more severe with time. He was prescribed oral valaciclovir 3 weeks previously, to be taken at the first sign of an oral herpes simplex virus outbreak. On examination he has target lesions over the extremities and a mild cold sore over his upper lip.

erythema multiforme

An otherwise healthy, white, 10-year-old boy complains of a sore throat. He is running a low-grade fever of 38.0°C (100.6°F). Red lesions have developed on his extremities, and he is having some difficulty breathing after exertion. Oral erosions have limited his food and fluid intake. On physical examination, there are target lesions on his upper and lower extremities with erosions on his lower lip and palate. High-pitched wheezing is heard over the lower lungs bilaterally, and the patient is in mild discomfort when sitting upright. He is unable to open his mouth fully due to crusted oral lesions.

erythema multiforme

A 25-year-old otherwise healthy woman awakens with a mild sore throat, fatigue, pain in both ankles, and red lesions on her legs. She reports weakness and fatigue for the past 2 days, but denies fever, chills, nausea, or night sweats. There is no history of using recreational drugs, oral contraceptives, or other medications. She has not travelled abroad for 3 years. Physical examination reveals red, tender, fixed, deep-seated nodules on both shins. Her ankles are mildly swollen and tender and she reports difficulty bearing weight. Chest, cardiovascular and ophthalmological examinations are normal. A chest x-ray shows left lower lobe infiltration. Her tuberculin skin test is negative. She is diagnosed with pneumococcal pneumonia.

erythema nodosum

A 28-year-old woman awakens with red eyes, photophobia, and nodules on her legs. She denies fever, malaise, cough, or joint pains. She enjoys dairy products, but denies recent consumption of raw milk or cheese. She does not take recreational drugs. Physical examination shows bilateral iritis and enlarged lachrymal glands. Chest and cardiovascular examinations are normal, though the skin examination reveals many dark red nodules on her legs and lower thighs. These skin nodules are tender and non-mobile. Her tuberculin test is negative, but a chest x-ray shows bilateral hilar adenopathy consistent with the diagnosis of sarcoidosis.

erythema nodosum

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 about 11 kg (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, palpitations, 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 50-year-old man with a history of obesity and heavy alcohol use presents with a 2-month history of weakness, jaundice, and ascites. He is found to be a C282Y homozygote after laboratory testing shows a transferrin saturation of 76% and ferritin of 11,000 picomols/L (5000 nanograms/mL). Imaging studies demonstrate a cirrhotic-appearing liver with an ill-defined mass in the right lobe and multiple pulmonary nodules suspicious for metastases. Hepatic iron overload with metastatic hepatocellular carcinoma is confirmed at autopsy.

haemochromatosis

A 57-year-old man is evaluated for progressive arthralgias. There is swelling and tenderness over the first, second, and third metacarpophalangeal joints of both hands. Findings on hand radiographs are suggestive of calcium pyrophosphate deposition, raising concern for haemochromatosis. Iron studies are obtained, showing a transferrin saturation of 88% and serum ferritin of nearly 2700 picomols/L (1200 nanograms/mL). HFE genotyping confirms that he is a C282Y homozygote.

haemochromatosis

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

haemorrhoids

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

haemorrhoids

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

hydrocele

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

idiopathic pulmonary fibrosis

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

idiopathic pulmonary fibrosis

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

infectious mononucleosis

A 68-year-old retired labourer presents to his primary medical doctor with a 3-week history of a dull dragging discomfort in his right groin toward the end of the day. The discomfort is associated with a lump while standing but disappears when lying supine. He denies any other significant past medical or surgical history. On physical examination, a bulge is present when standing that disappears when supine.

inguinal hernia

A 48-year-old female complains of intermittent diffuse abdominal pain, worse after eating meals. The pain has been present for the previous 6 months, but has worsened recently. She has had significant weight loss since the onset of symptoms. Her past medical history includes SLE, which has been difficult to manage medically.

ischaemic bowel disease

A 72-year-old male presents to the emergency department with sudden-onset, diffuse abdominal pain that began 18 hours ago. He has not been vomiting, but he has had several episodes of diarrhoea, the last of which was bloody. He was hospitalised 1 week ago for an acute MI.

ischaemic bowel disease

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

oral candidiasis

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

oral candidiasis

A 70-year-old woman presents to the emergency department after falling while getting out of bed. She sustained an intertrochanteric fracture of the right hip. Preoperative chest x-ray before repair of the hip reveals that she had existing asymptomatic vertebral fractures before her fall.

osteoporosis

A 45-year-old woman presents to her physician with vague upper abdominal (epigastric) pain. After treatment with proton-pump inhibitors, analgesics, and antacids over a period of 3 months, which were ineffective, the patient also started to experience back pain. This prompted an initial upper gastrointestinal endoscopy, which was normal. Nearly 4 months after initial presentation, an upper abdominal ultrasound reveals a pancreatic mass with liver metastases.

pancreatic cancer

A 70-year-old man who smokes heavily presents with a 6-month history of intermittent abdominal pain and nausea. He has lost 10 kg of weight in the past 2 months, which he thinks is due to a decreased appetite, and he complains of pruritus. On physical examination there is icterus in the conjunctival sclerae and epigastric tenderness but no abdominal mass or lymphadenopathy. Blood tests demonstrate elevated bilirubin and alkaline phosphatase; the rest of the blood tests are within the normal range.

pancreatic cancer

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

pericarditis

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

peripheral arterial disease

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

peripheral arterial disease

A 65-year-old man presents with fever and respiratory distress. He rapidly develops progressive hypoxia and hypotension requiring ventilator support and pressors. Efforts to reposition the patient result in marked desaturations. One week later, following stabilisation of his medical condition, he is noted to have an extensive area of tissue damage over his sacral region. The damage around the margin of the wound appears relatively superficial, with some signs of partial skin loss. Towards the centre, directly over the sacrum, is an area of necrotic tissue, which is starting to separate spontaneously, exposing a cavity containing viscous yellow slough. A purulent discharge is draining from this cavity.

pressure sores

An 80-year-old woman in a residential care facility, who has recently suffered a stroke with a resulting right hemiplegia, presents with a painful area on right heel. On examination the heel is found to be covered with a layer of hard, black, necrotic tissue with a leathery appearance.

pressure sores

A 50-year-old woman undergoing health screening is found to have a cholestatic pattern on her LFT results. Her alkaline phosphatase and gamma-GT concentrations are elevated, although transaminases, bilirubin, and albumin concentrations are normal. On questioning she mentions that she had been getting increasingly tired over the past few years but felt that this was simply a result of her age and work pattern. She also describes occasional itch that feels as if it is deep underneath the skin and that is not associated with a rash. She had no other past medical history but had a family member who had autoimmune thyroid disease. Clinical examination reveals no abnormal findings other than excoriations related to itch and xanthelasmata around the eyes.

primary biliary cirrhosis

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

sarcoidosis

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

sarcoidosis

A 2-month-old infant is brought for evaluation of scalp scaling. The infant is otherwise in good health, was born at a normal full-term birth, and has healthy parents. On examination, there is diffuse scaling of the occipital scalp. The nasolabial folds and other cutaneous surfaces appear normal.

seborrhoeic dermatitis

A middle-aged man complains of greasy scaling in the nasolabial folds and on his anterior scalp. In the past 6 months, his symptoms have waxed and waned, flaring in times of stress. Itchy, irritating scaly and flaky lesions are also present on his posterior scalp.

seborrhoeic dermatitis

A 78-year-old woman presents with confusion, agitation, and visual hallucinations. She has become progressively confused over the past 2 years and has had trouble managing her affairs, including shopping and paying bills. It is unclear when her confusion started. Initially, she was having trouble following conversations and got lost on several occasions. Her memory, which was previously good, has begun to deteriorate. At night, she sees children playing in her house and has called the police on several occasions. She gets angry easily and has been paranoid about her relatives and their intentions. Her behaviour tends to fluctuate from day to day. She started to shuffle about 6 months ago and had difficulty getting out of chairs, and getting dressed to go out seemed to take hours. On one occasion, she fell and was taken to the emergency department but was subsequently discharged with no diagnosis given.

lewy body dementia

A 35-year-old man presents with a right thigh nodule and a recurrent left chest wall nodule at the site of a prior scar. He states that he noticed a bump on his right lateral thigh 2 years previously and that the left chest wall lesion had been removed in clinic 3 years prior. The nodules have grown slightly over recent months. He also states that they bother him when he touches them. On physical examination, the nodules are 1 cm x 2 cm, soft, and mobile, and they feel subcutaneous.

lipoma

A 55-year-old woman presents with a right flank mass. She states she was recently diagnosed with diabetes mellitus, which she has been able to control with diet modifications. She lost 9 kg (20 pounds) within 3 months and then noticed a mass over her right lower rib cage. She denies pain but does report discomfort when she wears a jogging bra. On physical examination, the mass is soft, superficial, and mobile, and it measures 5 cm in diameter.

lipoma

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

mallory weiss tear

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

mallory weiss tear

A 28-year-old woman in her second post-partum week presents with recent-onset breast pain and a tender wedge-shaped area in one breast that feels firm, warm, and swollen, and appears erythematous. She has decreased milk output, flu-like symptoms, pyrexia of 38°C (100.4°F), and myalgia, in addition to feeling fatigued.

mastitis

A 30-year-old woman with a history of mastitis presents with sharp shooting breast pain and an exquisitely tender, swollen, red, and warm fluctuant peri-areolar breast mass.

mastitis

A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain, or haemoptysis. Past medical history is significant for chronic obstructive pulmonary disease and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy was palpable on examination and breath sounds were diminished globally without focal wheezes or rales.

small cell lung cancer

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

oesophageal cancer

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

oesophageal cancer

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

oesophageal varices

A 60-year-old white woman presents with an enlarging scaly pink plaque on her forearm that is friable and bleeds easily. She has been taking ciclosporin (cyclosporine) for 4 years following a kidney transplant.

squamous cell carcinoma

A 70-year-old previously healthy white man presents with multiple, hyperkeratotic, scaly papules on the face, scalp, and hands. Some papules have grown to become larger nodules that sometimes bleed and fail to heal. In the past he has had significant sun exposure including multiple blistering sunburns. Previously, he has had skin cancer on the face.

squamous cell carcinoma

A 50-year-old man presents for a routine eye examination with no symptoms. He has elevated intra-ocular pressure of 25 mmHg in the right eye and 30 mmHg in the left eye. On dilated examination, the cup-to-disc ratio is 0.5 in the right eye and 0.8 in the left eye. Corneal thickness and gonioscopy are normal. Subsequent automated testing of visual fields demonstrates peripheral visual field loss greater in the left eye than in the right. Repeated automated visual field testing shows that the visual field defects are reproducible.

open angle glaucoma

A 33-year-old woman with a past medical history of hypothyroidism presents with complaints of hives for the past 4 months. She describes red, raised, itchy lesions that involve her entire body, including her face. She also reports 2 episodes of face and tongue swelling, each of which prompted her to report to the nearest emergency department. In addition to itching, the lesions sometimes cause a burning sensation. The lesions and symptoms resolve over 24 to 36 hours. Despite countless attempts, she has not been able to associate the hives with any specific triggers. The patient voices extreme frustration and feelings of depression, which she attributes to her recent condition.

urticaria

A 50-year-old man with a past medical history of HTN and a recent diagnosis of osteoarthritis presents to his primary care physician with complaints of hives over the past 2 weeks. He reports red and raised lesions that are intensely pruritic and involve his torso and bilateral extremities. He denies any swelling or pain associated with the episodes. The patient also denies any unusual food ingestions or recent changes in his environment (e.g., soaps, detergents). However, he has recently started using scheduled ibuprofen for osteoarthritis.

urticaria

A 30-year-old woman presents with onset of bilateral decreased vision associated with floaters. Slit-lamp examination of the anterior segment shows no abnormality. However, on dilated fundoscopic examination, vitreous cells and a choroiditis are apparent.

uveitis

A 40-year-old man presents to the emergency department complaining of red eye without purulent discharge. He also has pain, photophobia, blurred vision, and tearing. On slit-lamp examination, the attending ophthalmologist notices a small irregular pupil, conjunctival injection around the corneal limbus, and WBCs in the anterior chamber.

uveitis

A 36-year-old man undergoing chemotherapy for non-Hodgkin's lymphoma presents with fever, shortness of breath, haemoptysis, and a diffuse rash. His family recalls that he had a fever the previous day, and that the rash started on his chest and progressed rapidly. In a review of recent exposures, his wife recounts that she was told that a child who visited their home later developed 'chickenpox'. His current medications are levofloxacin and an antidepressant. A review of his medical history indicates negative serological tests for varicella-zoster virus prior to starting chemotherapy, and his family does not recall him receiving the varicella vaccine. On examination he has a temperature of 40.1°C (104.2°F), a heart rate of 145 bpm, and an O2 saturation of 83%. Lung examination demonstrates bilateral crackles, and the patient has diffuse vesicular lesions, some of which appear to be haemorrhagic. Initial laboratory testing indicates a low haematocrit and platelets, a low absolute lymphocyte count (<100 cells/mL), and mild transaminitis. A chest x-ray demonstrates ground glass opacities or diffuse small nodular infiltrates.

varicella zoster

A 6-year-old boy presents with fever, headache, and a diffuse, pruritic, vesicular rash, which is most prominent on the face and chest. He has had generalised malaise and low-grade fever for a few days prior to presentation. He developed high fever and a rash in the last 48 hours. Physical examination demonstrates a temperature of 39°C (102°F) and heart rate of 140 beats/minute. He has a few scattered vesicular lesions in his oropharynx and his lung fields are clear. The lesions are prominent on the face and chest, but all extremities are also involved. In some areas the lesions are crusted, while in others they appear newly formed. He has no nuchal rigidity or other meningeal signs.

varicella zoster

A 65-year-old man presents with difficulty in decision-making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence. On examination there is evidence of focal neurological deficit with pseudobulbar palsy and extrapyramidal signs. Neuroimaging indicates a probable vascular aetiology with white matter changes and infarction.

vascular dementia

A 35-year-old man presents to an accident and emergency department with palpitations, shortness of breath, dizziness, and chest pain of 4 hours' duration. An ECG demonstrated narrow-complex short RP tachycardia that responded to intravenous adenosine. The ECG during sinus rhythm revealed ventricular pre-excitation.

wolff parkinson white syndrome

A 42-year-old man complains of palpitations followed by dizziness and brief loss of consciousness. His wife reports that he is pale and short of breath. Emergency medical services were called and found him pulseless. The ECG revealed a rapid, irregular wide complex tachycardia. Later he was successfully resuscitated with two successive direct-current shocks.

wolff parkinson white syndrome

A 70-year-old woman with a history of hypertension, diabetes mellitus, hyperlipidaemia, and prior myocardial infarction presents to the emergency department with palpitations and shortness of breath. These symptoms started 2 days ago. She was diagnosed to have AF with rapid ventricular rate response a year and a half ago, at which time an attempted direct current cardioversion and a trial of sotalol to maintain sinus rhythm and prevent further episodes of AF were unsuccessful. The patient was treated with digoxin and metoprolol to control rate and warfarin to prevent stroke. Current physical examination shows that she is febrile and has an irregularly irregular radial pulse at a rate between 90 and 110 bpm, BP 100/70 mmHg, and respiratory rate of 26 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. The breath sounds are of bronchial character associated with crepitations over left basal lung area.

AF

A 54-year-old black woman is referred to the neurology clinic by her general practitioner for evaluation of memory problems. The patient is brought to the clinic by family members who are concerned that she has been forgetful in the past year. They report that she has difficulty in recalling birthdays and anniversaries and is not managing common household tasks such as cooking and paying bills. The patient's sister had onset of dementia in her early 40s and was institutionalised because she was unable to care for herself. The patient was last seen by her primary care physician 3 months ago, when she had a routine work-up, which was reported to be unremarkable. Neurological examination revealed no significant abnormalities. Neuropsychological testing demonstrated severe impairment in executive function, deficits in visuo-spatial testing, and delayed speed of processing information. Mini-Mental State Examination score is 20/30.

Alzheimers dementia

A 76-year-old white woman is brought to her general practitioner by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt. On a past visit to her physician, she had normal laboratory tests for metabolic, haematological, and thyroid function. The current evaluation reveals no depressive symptoms and 2/15 on the Geriatric Depression Scale short-form. Her Mini-Mental State Examination score is 20/30.

Alzheimers dementia

A 68-year-old man presents for a routine physical examination and follow-up for his hypertension, hyperlipidaemia, and hypothyroidism. He complains of mild fatigue but is otherwise healthy. Laboratory evaluation is remarkable for a haematocrit of 0.34 (34%), with an MCV of 110 fL (110 micrometres^3). On further query, he denies alcohol use and any other symptoms.

B12 deficiency

A 65-year-old woman presents with a chief complaint of dizziness. She describes it as a sudden and severe spinning sensation precipitated by rolling over in bed onto her right side. Symptoms typically last <30 seconds. They have occurred nightly over the last month and occasionally during the day when she tilts her head back to look upwards. She describes no precipitating event prior to onset and no associated hearing loss, tinnitus, or other neurological symptoms. Otological and neurological examinations are normal except for the Dix-Hallpike manoeuvre, which is negative on the left but strongly positive on the right side.

BPPV

A 63-year-old man with sun-damaged skin presents with a small nodule on the left aspect of his forehead. He mentions that it is itchy at times, and he thinks that he may have seen a colleague 2 years previously for removal of some keratoses or scabs. The patient indicates that these were either cauterised or frozen. On examination there is a pearly white nodule with prominent telangiectasia on its surface.

Basal cell carcinoma

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

Bell's palsy

A 54-year-old man with a 10-year history of diabetes and hypertension, 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 glycaemic 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 examination reveals an obese man with a sitting blood pressure of 158/92 mmHg. The only pertinent physical examination findings are cotton wool patches and micro-aneurysms bilaterally on fundoscopic examination and pitting, bilateral lower-extremity oedema.

CKD

A 34-year-old mother of three 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 three 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 examination, the only finding is some mild tenderness in the right lower quadrant. No mass is felt.

IBS

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 gynaecologist's advice, she has tried more fibre 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 examination is entirely normal. Rectal examination reveals normal consistency stool. Stool samples test negative for occult blood.

IBS

A 40-year-old woman presents with a 1-year history of recurrent episodes of vertigo. The vertigo spells are described as a sensation of the room spinning that lasts from 20 minutes to a few hours and may be associated with nausea and vomiting. The spells are incapacitating and are accompanied by dizziness, vertigo, and disequilibrium, which may last for days. No loss of consciousness is reported. The patient also reports aural fullness, tinnitus, and hearing loss in the right ear that is more pronounced around the time of her vertigo spells. Physical examination of the head and neck is normal. A horizontal nystagmus is noted. She is unable to maintain her position during Romberg's testing or the Fukuda stepping test. She turns towards the right side and she is unable to walk tandem. Her cerebellar function tests are normal.

Meniere's disease

A 36-year-old prima gravida presents with dyspnoea on exertion and 2 pillow orthopnoea during her second trimester. Previous physical examinations had disclosed no cardiac abnormalities. On current physical examination, she has a loud S1 and a 2/6 diastolic rumble.

Mitral stenosis

A 52-year-old woman presents with gradually increasing dyspnoea on exertion over the past 2 years. Recently she has required 2 pillows at night to alleviate recumbent dyspnoea. On examination, she has an apical diastolic murmur.

Mitral stenosis

A 32-year-old women presents with a chief complaint of difficulty becoming pregnant. She was prescribed oral contraceptives at the age of 17 years because of irregular periods (4 to 6 periods per year). She continued with oral contraception until 30 years of age, at which point she and her husband decided they wanted to have a baby. Since ceasing oral contraception, she has gained weight and has only 3 to 5 periods per year. She has actively been trying to conceive, with no results.

PCOS

An 18-year-old woman presents with a chief complaint of hirsutism. She needs to wax her upper lip and chin twice a week. This has been a problem for 4 years. She also has excess hairs on her upper back and lower abdomen. Her periods are irregular, occurring every 2 to 3 months. Embarrassment about the facial hirsutism has affected her social life, and she is finding she feels depressed much of the time.

PCOS

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

PE

A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid haemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness. Brain computed tomography (CT) reveals diffuse subarachnoid blood in basal cisterns and sulci.

SAH

A young man is brought to the emergency department after being involved in a high-speed motor vehicle accident. He was an unrestrained driver, and no airbags were deployed. He has multiple areas of abrasions, lacerations, and ecchymosis on his scalp and face. On neurological examination, he does not open his eyes to painful stimuli; he is intubated, and he withdraws his left side to pain. His right side is plegic. His right pupil is 3 mm and reactive to light and his left pupil is 8 mm and non-reactive.

SDH

An older man with a longstanding history of atrial fibrillation on anticoagulation with warfarin is brought into the emergency department by his carer, who states his concern about the patient's confusion at home. The carer describes frequent falls over the last several months and says that the patient is dropping utensils from his right hand. On neurological examination, his pupils are equal, round, and reactive to light. He has a right-sided pronator drift and is weaker on his right side than on his left. His mental status testing reveals poor concentration and attention, and impaired short- and long-term recall and registration.

SDH

A 6-month-old healthy girl presents with a bulge at her umbilicus that her parents have noticed since birth. She has no accompanying symptoms and has been growing and developing normally. Physical examination of the abdomen reveals a soft, non-tender bulge at the umbilicus that is easily reduced into the peritoneal cavity with gentle pressure. Reduction allows palpation of the abdominal fascia, revealing an 8 mm fascial defect.

Umbilical hernia

A 60-year-old man presents with acute onset of shortness of breath, fever, and cough. A chest x-ray shows a right lower lobe infiltrate, and sputum has gram-positive diplococci. He is given intravenous antibiotics but his respiratory status declines over 24 hours. He becomes hypotensive and is transferred to the intensive care unit. He is intubated for hypoxaemia and requires vasopressors for septic shock despite adequate volume resuscitation. He requires high levels of inspired oxygen (FiO₂) and positive end-expiratory pressure (PEEP) on the ventilator to keep his oxygen saturation >90%. Repeat chest x-ray shows bilateral alveolar infiltrates, and his PaO₂/FiO₂ ratio is 109.

acute respiratory distress syndrome

A 58-year-old man with pancreatic adenocarcinoma, who had a plastic stent placed in his common bile duct 6 weeks ago to relieve obstructive jaundice, presents to the emergency department after 1 week of progressive nausea and occasional vomiting after eating. He has generalised abdominal pain that is worse in the RUQ. He has experienced subjective fever/chills and states that his bowel movements are pale. Laboratory results show a WBC of 14.0 x 10^9/L (14,000/microlitre) (reference range 4.8-10.8 x 10^9/L or 4800-10,800/microlitre) with 8% (reference range 0% to 4%) bands and PMNs of 77% (reference range 35% to 70%). AST is 214 units/L (reference range 8-34 units/L), ALT is 181 units/L (reference range 7-35 units/L), alkaline phosphatase is 543 units/L (reference range 25-100 units/L), total bilirubin is 183.0 micromol/L (10.7 mg/dL) (reference range 3.4-22.2 micromol/L or 0.2-1.3 mg/dL), and amylase is 110 units/L (reference range 53-123 units/L).

acute/ascending cholangitis

A 65-year-old woman presents to the emergency department with a 2-day history of progressive RUQ pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have started to become loose but with no diarrhoea, bright red blood, or black tarry stools. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs (NSAIDs) or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Faecal occult blood test is negative. Laboratory results show a WBC of 18.0 x 10^9/L (18,000/microlitre) (reference range 4.8-10.8 x 10^9/L or 4800-10,800/microlitre) with 17% (reference range 0% to 4%) bands and PMNs of 82% (reference range 35% to 70%). AST is 207 units/L (reference range 8-34 units/L), ALT is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 107.7 micromol/L (6.3 mg/dL) (reference range 3.4-22.2 micromol/L or 0.2-1.3 mg/dL), and amylase is 82 units/L (53-123 units/L).

acute/ascending cholangitis

A 45-year-old man presents to the emergency department with restlessness and tremors. He is anxious, pacing in the hallway. Initial vital signs show a heart rate of 121 beats per minute and blood pressure of 169/104 mmHg; other vital signs are normal. On further questioning by the nurse he states that he is nauseous and wants something to help with the shakes. During physician interview, the patient admits to heavy alcohol use and that he is trying to cut down on drinking. He also says that his current symptoms started to develop about 5 hours after his last drink.

alcohol withdrawal

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 half a pint of vodka daily for about 5 years until 1 year ago; since then he has had 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. His BMI is 22. Pertinent positive laboratory values show low haemoglobin, 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 general practitioner with complaints of fatigue for 2 months. The patient also notes distension 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 half a 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 distension with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low haemoglobin, 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 59-year-old man presents to the emergency department with a sudden onset of excruciating chest pain, which he describes as tearing. There is a history of hypertension. On physical examination, his heart rate is 95 bpm. BP is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.

aortic dissection

A 31-year-old black man presents to clinic for the first time for a routine physical examination. He denies any complaints. On physical examination the only abnormality is a systolic murmur best heard over the second right intercostal space and an early diastolic murmur best heard over the third left sternal border. LVEF is 55% to 60% with mild LVH. Left ventricular end-systolic diameter is 45 mm and aortic root diameter is 3.5 cm.

aortic regurg

A 65-year-old man underwent induction chemotherapy for recently diagnosed acute myelogenous leukaemia. Antimicrobial prophylaxis included norfloxacin, fluconazole, and aciclovir. During chemotherapy-induced neutropenia, he received empirical antibiotic therapy for the fever without an obvious source of infection. Blood cultures were negative and fever subsided. During the third week of neutropenia, fever recurred with dry cough and left-sided pleuritic pain. Physical examination demonstrated no significant abnormalities. Blood cultures remained negative. CXR was normal. However, a high-resolution CT scan of his chest revealed a 2 cm peripheral nodule with a surrounding 'halo' sign in the left upper lobe.

aspergillosis

A 67-year-old man with COPD presents with recent changes in his CXR. He has shortness of breath that has not changed from his baseline status. On examination, he is afebrile with clinical evidence of chronic lung disease. The CXR reveals a right upper lobe cavitary lesion with an intracavitary mass and adjacent pleural thickening.

aspergillosis

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

asthma

A 12-year-old female presents with dry, itchy skin that involves the flexures in front of her elbows, behind her knees and in front of her ankles. Her cheeks also have patches of dry, scaly skin. She has symptoms of hay fever and has recently been diagnosed with egg and milk allergy. She has a brother with asthma and an uncle and several cousins who have been diagnosed with X

atopic eczema

A 76-year-old man presents with progressive symptoms of dyspnoea and increasing peripheral oedema. He denies palpitations. He has a history of CHF from hypertensive heart disease. He reports that he is taking his medications as directed and has had no recent medication or dietary changes.

atrial flutter

A 77-year-old man presents with complaints of palpitations and new shortness of breath, especially with exertion. He has a history of rheumatic fever in childhood. He has been told he has a murmur but does not recall having had an echocardiogram. He is otherwise healthy.

atrial flutter

A 45-year-old woman presents with insidious onset of fatigue, malaise, lethargy, anorexia, nausea, abdominal discomfort, mild pruritus, and arthralgia involving the small joints. Her past medical history includes coeliac disease. Physical examination reveals hepatomegaly and spider angiomata.

autoimmune hepatitis

A 55-year-old post-menopausal black woman presents with 2 new areas of breast nodularity that do not resolve. Mammography is negative.

breast cancer in situ

A 58-year-old white woman has clustered microcalcifications in the right breast on routine mammography, which were not seen on her previous mammogram. She is post-menopausal, has used hormone replacement therapy for 6 years, and has a BMI of 26. She has one sister who was diagnosed with breast cancer.

breast cancer in situ

A 50-year-old woman presents with a long history of atypical flushing, initially attributed to menopause. The flushing is associated with purplish discolouration of the face with each episode lasting 30 minutes. She also reports palpitations on exertion and recurrent episodes of abdominal pain.

carcinoid syndrome

A 60-year-old man presents with a 3-year history of diarrhoea, with no clear precipitating factors. Over the past few months he has noticed flushing affecting his face. These episodes occur at any time but are worse during times of stress and exercise. His wife has also noticed intermittent reddening of his face, which lasts for a few minutes. More recently he has not tolerated alcohol, chocolate, or bananas.

carcinoid syndrome

A 27-year-old man presents following an incident where he was struck in the left eye with a paint ball. He notices a sudden decrease in vision in the left eye, from 20/20 before the accident, to counting-fingers vision after the accident. On examination, the left pupil appears whitish, and visual acuity is greatly decreased. The patient does not have any history of other medical problems. On dilated eye examination, the lens in the left eye appears whitish anteriorly, with a spoke-like pattern. On direct ophthalmoscopy, the red reflex is diminished and retinal details are indistinct.

cataracts

A 65-year-old man presents with generally decreased vision and difficulty driving at night due to glare from oncoming headlights. He describes having trouble reading the small print on his television screen. He is healthy and has no history of any other eye problems. His best corrected visual acuity is noted to be 20/50 in the right eye and 20/40 in the left eye. On examination, a yellowish opacification of the lens in the left eye is noted. On ophthalmoscopy, the red reflex in the left eye is obscured centrally, and the details of the fundus are indistinct. No other abnormalities are found.

cataracts

A 45-year-old man presents with acute onset of pain and redness of the skin of his lower leg. Low-grade fever is present and the pretibial area is erythematous, oedematous, and tender.

cellulitis

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

central hypothyroidism

A 38-year-old man presents with fever of 38.5°C (101.2°F), chills, myalgias, non-productive cough, and dyspnoea. Other than tachypnoea, tachycardia, and bibasilar rales, the rest of the physical examination is normal. He reports that this happens almost every month the day after he cleans out the bird cages in which he keeps the pigeons that he breeds and races.

extrinsic allergic alveolitis

A 36-year-old woman notices a lump in her breast while taking a shower. It is tender to palpation.

fibrocystic breasts

A 42-year-old woman presents with bilateral breast pain of mild-to-moderate intensity. Pain is worse just before and improves a few days after the start of her menstrual period. Gynaecological history is significant for grava 2 para 2. She does not take an oral contraceptive. Physical examination of the breasts demonstrates diffuse nodularity throughout both breasts.

fibrocystic breasts

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

folate deficiency

A 35-year-old man with no past medical history presents to the emergency department after he noted cola-coloured 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. Examination reveals a non-blanching purpuric rash over both his legs. There are no other abnormalities.

glomerulonephritis

A 42-year-old man with a medical history of HIV infection presents to his general practicioner with generalised swelling progressive for the past week. HIV was diagnosed a year ago and he has been non-compliant with the therapy prescribed. He denies orthopnoea, abdominal pain, nausea, and blood in his urine. He has non-pitting oedema mostly over the lower extremities but extending up to mid-abdomen.

glomerulonephritis

A 55-year-old man who worked as a technician developed difficulty finding words 2 years earlier, which has evolved into dysfluency, frequent repetition of remarks and questions, stereotypies (purposeless behaviours or fragments of speech frequently repeated, without regard to context), and echolalia (reflexive repetition of another's speech). In the past year, he has also become forgetful. His work efficiency deteriorated due to his poor comprehension, reasoning, planning, and completion, resulting in disability leave. He also became unfeeling, intrusive (indiscriminately approaching strangers), child-like, and impulsive. He developed rigid routines (e.g., insistence on the same TV shows) and coarse manners (e.g., eating out of serving bowls, jumping queues, and walking away from conversation). Restlessness is marked: each day he bikes, swims many laps, runs 10 km, and 'volunteers' at a local nursing home, making the rounds with all maintenance crews. On examination, he is pleasant and cooperative. Given opportunity, he quizzes the examiner on trivial facts (such as listing capital cities). Depression is not evident, and he does not have euphoria, psychosis, or paranoia. Speech is mildly non-fluent. Verbal fluency is impaired. Mini-mental state examination score is 29.

frontotemporal dementia

A 58-year-old male teacher developed dysnomia, spelling errors, impaired comprehension of reading and conversation, and diminished singing ability. He also has impaired attention, planning, and organisation, along with declining self-care, child-like behaviour, and altered social habits (e.g., eating meals with his fingers). He developed anxiety. Two years into the illness, a neurologist suspected early dementia. Folstein mini-mental state examination score was 27 points and the neurological examination was normal. Brain magnetic resonance imaging showed temporal lobe atrophy, predominantly left-sided. Three years later, his partner complains about impulsive, obstinate, and gluttonous behaviour. Formal neuropsychological testing shows mini-mental state examination score of 28, impaired memory and learning, impaired word and sentence comprehension, marked dysnomia, grammatical and spelling errors, and poor copying of a complex figure.

frontotemporal dementia

A 56-year-old man with history of poorly controlled diabetes mellitus and alcoholism presents with severe scrotal pain and fever for 3 days. He denies perianal tenderness. His vital signs are blood pressure 125/60 mmHg, heart rate 120 beats per minute, respiratory rate 25 breaths per minute, and temperature is 38.6°C (101.5°F). His scrotum is extremely tender, black, and malodorous. The adjacent perineal and femoral skin is crepitant.

gangrene

A 60-year-old man with a history of diabetes, hypercholesterolaemia, and heavy smoking for over 20 years presents giving a 3-week history of increasing pain in his left forefoot, which is affecting his ability to walk and is disrupting his sleep. On examination, his left foot is pale, cold, devoid of hair, and his lateral two toes are dusky and discoloured. No foot pulses are palpable and are only just detectable by Doppler probe.

gangrene

A 77-year-old man presents to his general practitioner with weight loss of 6.8 kg (15 lbs) and a 3-month history of dysphagia and abdominal pain. The only abnormal finding on physical examination is stools positive for occult blood. He is referred for an upper endoscopy, which shows an exophytic, ulcerated mass in the cardia of the stomach. Biopsy reveals moderately differentiated adenocarcinoma.

gastric cancer

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

gastritis

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

gastritis

A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4 to 6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. The patient has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m (5 feet 4 inches), weight 77.1 kg, and BP 140/88 mmHg. The remainder of the examination is unremarkable.

gastro-oesophageal reflux disease

A 36-year-old fair-skinned woman presents with a dark, irregular, pigmented patch that she noted 4 months ago on the right posterior calf. It has gradually increased in size. She reports approximately 6 sunburns in the past and has been using tanning beds several times yearly for the past few years. Family history is positive for melanoma in her uncle. On physical examination, approximately 15 normal-appearing naevi, ranging in size from 3 mm to 5 mm, with symmetry, uniform brown coloration, and regular borders are noted elsewhere on the torso and extremities. The pigmented lesion on the right calf is asymmetrical along 2 axes, measures 1 cm x 0.8 cm, is deeply pigmented with several shades of brown, and has a jagged border. The popliteal nodes are not clinically palpable.

melanoma

A 51-year-old man presents with a large, dark, bleeding nodule on his back. He reports that it has been present and growing in size for at least 2 years, but he did not seek medical attention until now. On examination, a 2-cm ulcerated black nodule with an irregular border is present overlying the left posterior scapula. The left axillary nodes are clinically palpable.

melanoma

A 72-year-old man presents to his primary care physician with a history of increasing shortness of breath over a period of several months. Before his retirement he was a construction worker. Physical examination reveals decreased breath sounds in the right lung base associated with dullness to percussion.

mesothelioma

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

migraine

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

migraine

A 52-year-old woman presents with dyspnoea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, or lower extremity oedema. On physical examination her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac examination reveals a slightly displaced apical impulse with a palpable P2. Cardiac auscultation reveals III/VI holosystolic murmur at the apex that radiates to the axilla with diminished S1 and P2 greater than A2.

mitral regurgitation

A 5-year-old white boy presents with a history of 2 months of bumps in the left axilla. Initially there was just 1 lesion; now the parents note that the child has 6 lesions. Some of the areas have been inflamed, and the child has pruritus, which keeps him up at night. One of his cousins, with whom he swam, may have such lesions as well. The child also suffers from seasonal allergies.

molluscum contagiosum

A sexually active female university student presents complaining of itchy growths on the escutcheon and the inner thighs, of 1 month's duration. The patient has been using a condom when she is sexually active with her boyfriend of 3 months. She is seen every 6 months by her gynaecologist, and had a negative Pap smear 2 months ago. Pearly papules with a central dell can be observed on the escutcheon and inner thighs. Some have surrounding erythema and excoriations.

molluscum contagiosum

A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain or haemoptysis. Medical history is significant for COPD and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or crackles.

non-small cell lung cancer

A 41-year-old obese man presents with loud chronic snoring and gasping episodes during sleep. His wife has witnessed episodic apnoea. He reports unrefreshing sleep, multiple awakenings from sleep, and morning headaches. He has excessive daytime sleepiness, which is interfering with his daily activities, and he narrowly avoided being involved in a motor vehicle accident. His memory is also affected. He has been treated for hypertension, gastro-oesophageal reflux, and type 2 diabetes.

obstructive sleep apnoea

A 70-year-old man, 6 months after renal transplantation and on corticosteroid treatment, presents with severe back pain. X-ray evaluation of the thoracic and lumbar spine discloses evidence of multiple vertebral compression fractures.

osteoporosis

A 43-year-old single woman presents after seeing a television advertisement describing depressive symptoms. She relates she has been depressed since childhood but has never been diagnosed or treated for depression. On questioning she says she has 'sporadic' depressive symptoms but, overall, more depressed days than well days. She describes chronic fatigue, ongoing low mood, rarely feeling pleasure or enjoyment, and is chronically socially avoidant. She has been evaluated by her primary care physician for annual check-ups but has never had a significant physical disorder. She is taking no medication except for vitamins, and her thyroid has been tested in the past and is normal. Her vital signs and physical examination are normal.

persistent depressive disorder

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

pneumoconiosis

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

pneuoconiosis

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

polycystic kidney disease

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

polycystic kidney disease

A 45-year-old white woman presents with symptoms of fatigue, depression, and mild weight gain. Physical examination demonstrates heart rate of 58 beats per minute, coarse dry skin, and bi-lateral eyelid oedema. Serum TSH is 40 milli-international units/L (mIU/L) (normal range, subject to laboratory standards, 0.35-6.20 mIU/L), and free T4 is 6.44 picomol/L (0.5 nanograms/dL) (usual normal range, subject to laboratory standards, 9.00-23.12 picomol/L [0.8 to 1.8 nanograms/dL]). Therapy is begun with levothyroxine 100 micrograms daily and the patient's symptoms improve. Repeat testing 6 weeks later reveals a normal TSH (5 mIU/L). The patient is maintained on this dose and repeat TSH testing is planned yearly or if symptoms recur.

primary hypothyroidism

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

primary sclerosing cholangitis

A middle-aged man with a known history of psoriasis presents with white scaly papules and plaques on his elbows, extensor arms, knees, and shins. In the past 6 months, these lesions have become much worse and have started to appear on his waist and hip. Scaly and flaky eruptions are also present on his scalp, ears, and eyebrows. He describes the lesions as being itchy and irritating. He is a heavy smoker and has been unsuccessful in a previous attempt at smoking cessation.

psoriasis

A young man without a known history of psoriasis or skin disorder had a sudden onset of wide-spreading, white-scaly, oval- to round-shaped erythematous papules, which have been present for 2 weeks. Lesions are primarily on his trunk but also appear scattered on his arms and legs. He recalls a recent episode of sore throat and upper respiratory tract infection. A short course of antibiotics seemed to help, but did not clear the lesions.

psoriasis

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

pulmonary TB

A 34-year-old white woman presents for evaluation of a persistent cough lasting 3 weeks after having symptoms of an upper respiratory tract infection. Her vital signs record indicates that she is currently smoking. Further information about her smoking indicates she smokes 1 pack per day and has her first cigarette within minutes of waking in the morning.

substance abuse

A 60-year-old man with spirometry demonstrating airflow obstruction is seen for a follow-up appointment. He continues to smoke 1 pack per day, but he recently attempted to stop and stopped smoking for more than 2 days before relapsing. He expresses a strong interest, but little confidence, in trying to stop again. During the recent attempt to stop he tried nicotine gum, but used it only once or twice daily. Additional past history is significant for hypertension under control and a remote history of a seizure disorder.

substance abuse

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

testicular torsion

A 6-year-old previously healthy boy presents with acute onset of fever of 39°C (102°F), severe throat pain that is exacerbated by swallowing, headache, and malaise. On examination his tonsils are symmetrically enlarged and red, with purulent exudate. He has multiple enlarged, painful anterior neck lymph nodes, but no other lymphadenopathy and no splenomegaly. He has no runny nose or cough, and no difficulty breathing.

tonsillitis