Step 2 CK - FA Cases - Key info.

Failure to thrive

A 1-month-old Caucasian girl is sent to the emergency room by her pediatrician for failure to thrive. She was born at full term, weighing 2.72 kg (6 lb), via spontaneous vaginal delivery with no complications. She was discharged to home with her mother and has been feeding well; she takes 3-4 ounces of formula every 2-3 hours. Her parents deny any emesis, fevers, or diarrhea, although her mother notes frequent foul- smelling loose stools. Family history is unremarkable. She lives with her parents and four siblings. She is afebrile with normal vital signs. Her weight is 3.3 kg (7.3 lb) (< 5th percentile), length is 50 cm (19.7 in) (< 5th percentile), and head circumference is 37 cm (14.6 in) (at 10th percentile). She is cachectic but interactive. The remainder of her examination is unremarkable.

Ophthalmia neonatorum (Neonatal conjunctivitis)

A 10-day-old infant is brought by his mother to the pediatrician's office due to purulent discharge from the infant's right eye. The infant was born via spontaneous vaginal delivery without complications 30 minutes after the mother's arrival at the hospital. He had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The mother received no prenatal care during her pregnancy. On physical examination, the patient has a temperature of 38.3° C (100.9° F). His right eye is notably erythematous and draining purulent material. The left eye is currently unaffected.

Duodenal atresia

A 10-hour-old boy is admitted to the neonatal intensive care unit because of abdominal distention. The infant was born full term weighing 3 kg (6.6 lb) to a G1P1 mother by spontaneous vaginal delivery. There was no fetal distress. The pregnancy was complicated by polyhydramnios. Physical examination after birth revealed upper abdominal fullness. The infant was doing well without any respiratory distress. An x-ray of the abdomen is shown in Figure 13-2.

Acute otitis media

A 12-month-old girl is brought to the pediatrician for fever and fussiness. Her mother reports that her daughter has had a mild cough and nasal congestion for 1 week but has been acting normally. Two days ago, she developed a fever of 38.9° C (102.1° F) orally and became increasingly fussy. Her mother also notes that she has been tugging on her left ear. On physical examination, she is irritable and febrile to 38.8° C (101.8° F). Her left tympanic membrane (TM) is bulging and immobile. The remainder of her exam is unremarkable.

Thrombotic thrombocytopenic purpura with hemolytic uremic syndrome (TTP-HUS)

A 12-year-old African-American girl is brought to the emergency department (ED) by her parents for confusion, fevers, and a new rash over her legs. They report that she had a "stomach bug" two weeks previously but had been getting better except for occasional headaches. This morning, they had difficulty waking her, and she remained confused on the way to the ED. On physical examination, her temperature is 40.1° C (104.1° F), pulse is 106/min, blood pressure is 95/70 mm Hg, and respirations are 16/min. She is oriented only to person and seems lethargic. Her sclerae are icteric, and there is a pinpoint, nonblanching, macular rash over her lower legs. Initial laboratory findings include normal white blood cell count and differential, hemoglobin of 8.3 mg/dL, hematocrit of 28%, platelets of 13,000/mm3, blood urea nitrogen of 41 mg/dL, and creatinine of 1.6 mg/dL.

Neutropenic fever

A 12-year-old girl is admitted to the hospital for chemotherapy for refractory leukemia. With the exception of common side effects such as nausea, vomiting, loss of appetite, and malaise, her treatment course over the past year has been uneventful. Routine laboratory tests are ordered, and the medications are prepared. As she changes into a hospital gown, the patient notes that she is sweating, and a nurse determines that her temperature is 38.9° C (102.1° F). Her blood pressure is 90/55 mm Hg, pulse is 100/min, and respiratory rate is 17/min. An intravenous line is started with normal saline and broad-spectrum antibiotics plus antifungal coverage instead of her chemotherapeutic agents. Relevant laboratory results include a WBC count of 900/ mm3.

Eczema

A 13-month-old girl is brought to the pediatrician by her parents for itchy rashes on her arms, legs, and cheeks. The rashes appeared gradually over the past few weeks and seem to be worsening. Her skin has always been dry, and her parents have used baby lotion on her since she was a few weeks old. She has not had fevers or any recent illnesses. On physical examination, she has scaly, crusted, pink, ill-defined patches on the flexural surfaces of her arms and legs. Both cheeks are also red, with notable excoriations. The remainder of her examination is normal.

Conduct disorder

A 13-year-old boy is brought to the pediatrician by his mother, who is concerned about his behavior. Over the past year, he has been suspended from school three times, once for fighting with another student and twice for stealing. His mother has also begun receiving calls from the local truancy officer, reporting her son's repeated absences from school. He was recently arrested by the police for breaking into a neighbor's car. He previously had a normal developmental course.

Osteosarcoma

A 13-year-old boy presents to the orthopedic surgeon with progressively worsening right leg pain of 6 weeks' duration. The patient says the pain began after being tackled in a football game 6 weeks ago. Since then, the pain has not improved despite ample rest, ice therapy, and ibuprofen. The pain also increases with activity. In addition, he noted a lump behind his knee after the game that has not resolved. On physical examination, there is a small but palpable mass in the popliteal region of the patient's right leg. In addition, there is a slight decrease in passive range of motion in the patient's right knee when compared to the left. The patient has full strength in all extremities and exhibits no neurological deficits. Plain anteroposterior and lateral radiographs of the patient's right knee reveal a large lesion with osteoblastic and osteolytic changes. On the posterior aspect of the supracondylar region of the femur, there is a prominent elevation of the periosteum.

Slipped capital femoral epiphysis

A 13-year-old boy presents to the orthopedic surgeon's office because of right knee pain of 8 months' duration. The pain is deep and achy and is concentrated on the medial side of the knee. Occasionally, the knee buckles while the patient is walking. Until recently, the patient was able to engage in physical activity, but the pain is too severe now. He has no history of trauma or injury and denies numbness, paresthesias, or weakness in his right leg. He also denies fevers, chills, or recent illnesses. On physical examination, he is an obese, young African-American boy in no apparent distress. The patient's right knee appears atraumatic on inspection, with no obvious inflammation or effusion. The right knee is nontender to palpation. Examination of the hips revealed no tenderness but is significant for increased passive external rotation and decreased passive internal rotation of the right hip compared to the left. Anteroposterior and lateral radiographs of the patient's right knee are normal. Lateral radiographs of the patient's right hip is shown in Figure 9-6.

Drowning

A 14-year-old boy arrives at the emergency department via ambulance accompanied by a neighbor who found him floating facedown in a nearby lake. The neighbor reports that he was jogging around the lake when he noticed an oddly shaped object floating out near the center of the water. He automatically jumped to save him. The neighbor reports that he seemed to "wake up" but has been acting funny since he was brought ashore. His vital signs include a temperature of 34.5° C (94.2° F), with a heart rate of 150/min, respiratory rate of 6/min, and pulse oximetry of 90%. On physical exam he appears cyanotic around the lips, withdraws to painful stimuli, uses inappropriate words and phrases, and opens his eyes to pain.

Tourette's syndrome

A 14-year-old boy is being evaluated by his pediatrician. Two years ago he began repetitively shrugging his shoulders. He does so repeatedly throughout the day, but more frequently during times of stress. He is able to control the urge briefly but explains that eventually he must "shrug." In the past few months, he has begun blurting out embarrassing obscenities in public. He realizes he is doing this, but again, can only exert brief control over it. He says this happens when he is alone and also at inappropriate times like in the classroom or at the movies. This has caused him to get in trouble with his teachers, although he is otherwise doing well in school and has no problems socializing with his peers. His mother was diagnosed with and is being treated for obsessive-compulsive disorder (OCD).

Testicular torsion

A 14-year-old boy presents to the emergency department with groin pain. He was playing basketball until he felt a sudden shooting pain originating from the left side of his scrotum and radiating upward into his belly. The pain has been severe and unremitting and has caused him to vomit more than once. Physical examination reveals a nervous adolescent in moderate distress with a temperature of 37.0° C (98.6° F), a pulse of 120/min, and a blood pressure of 105/60 mm Hg. The left side of his scrotum is erythematous, edematous, and exquisitely tender to palpation, with loss of cremaster reflex on the ipsilateral side. There is no relief of pain upon elevation of his left testicle that is lying horizontally.

Acetaminophen overdose

A 14-year-old girl is brought to the emergency department by her father after several hours of nausea and vomiting. Her father reports that she has not been "acting like herself" for several months. She has been staying in her room and skipping school. Prior to coming to the hospital he found an empty bottle of acetaminophen on her dresser. Physical examination reveals a temperature of 37.0° C (98.6° F), a pulse of 94/min, and a blood pressure of 108/72 mm Hg. She is diaphoretic, pale, and actively vomiting. Her mucous membranes are dry and a fundoscopic examination is within normal limits. A urine pregnancy test is negative. Relevant laboratory findings include:

Celiac disease

A 14-year-old girl presents to her pediatrician with abdominal bloating and pain, watery diarrhea, and a blistering rash that has persisted for the past week. The rash is distributed across her elbows and knees. She also notes that over the past week she has unintentionally lost 2.3 kg (5 lb) and seems to bruise easily. She denies any fever, chills, recent camping trips, travel, or change in diet. Physical exam is notable for short stature and delayed puberty. She is at the 40th percentile for height and Tanner Stage I for breast development, and she has not had her first menstrual period. Her abdomen is slightly distended and diffusely tender to palpation. Peritoneal signs are absent. On her lower right leg is a golf ball-size hematoma. Labs are negative for fecal leukocytes and blood.

Sickle cell anemia

A 15-month-old African-American boy is brought to the emergency department by his parents because they have been unable to get him to stop crying. The child has been in distress for the past hour, ever since the family returned from a day hike. The parents deny any trauma, and he was healthy and happy earlier that morning. His mother notes that her pregnancy and delivery were both uneventful and that her son has been relatively healthy, with the exception of occasional colds. Upon examination, he appears uncomfortable and is crying inconsolably. He is tachycardic and tachypneic, and his lips are slightly cyanotic. His right knee appears swollen, and when the physician tries to examine it, the crying worsens and the child pulls away. His oxygen saturation on room air is 85%. Relevant laboratory results are as follows:

Tuberous sclerosis

A 15-year-old girl presents to a pediatric dermatologist with small pink papules over her nose and cheeks. She has had the papules for some time and has been treating them like acne. The papules have not resolved despite a number of different acne treatments. She also complains of a rough patch of skin on her lower back that she has had for as long as she can remember. On physical examination, multiple small, pink papules are observed in a nasolabial distribution on the face. A cobblestone textured plaque with an orange peel-like surface is observed on the lumbosacral region. A total of four hypopigmented, flame-shaped macules are scattered over the trunk and extremities.

Acne vulgaris

A 16-year-old boy presents to his pediatrician complaining of "pimples." He first noticed the bumps on his forehead around the hairline a few weeks ago, and since that time, new groups have come and gone on his nose and also on both cheeks. The bumps vary in appearance, some about the size of a pencil point and black, while others are white, a little larger, and have a ring of red around them. He has tried washing his face more often, but that has not helped. He does not complain of any constitutional symptoms. On physical examination, the patient is anxious but well appearing, and has papules and pustules ranging in size from 1 to 3 mm over his forehead, cheeks, nose, and upper back around his shoulders. The papules are black and smaller than the pustules, ringed with a thin erythematous border, and painful when pressed.

Asthma

A 16-year-old boy presents to his pediatrician complaining of worsening cough, shortness of breath, and wheezing. Until a few months ago, he would have these symptoms only while exercising during the winter; lately, he has had to sit out during gym class three times a week. He has also awakened from sleep unable to catch his breath four times in the past month. He is asymptomatic at present. On physical examination, he is afebrile, with a heart rate of 80/min, respiratory rate of 12/min, and blood pressure of 120/80 mm Hg. His cardiovascular examination reveals a regular rate and rhythm with a normal S1 and S2 and no extra heart sounds. His chest is clear to auscultation, without wheezes, crackles, or rhonchi. In the office, his peak expiratory flow reading (PEF) is within normal limits.

Minors

A 16-year-old girl presents to her pediatrician with her mother, complaining of vague abdominal pain. She states that her pain began early this morning and that it is not associated with any nausea, vomiting, diarrhea, or abnormal vaginal discharge. Her last menstrual period was 3 weeks ago. She is afebrile and healthy appearing, although she is noticeably anxious. The pediatrician asks the mother to step out of the room to have a few moments alone with the patient, and upon further questioning, the patient admits to having recently had her first sexual encounter. She is concerned about being pregnant.

Burn

A 17-year-old boy is carried into the emergency department by his friends after he caught on fire while attending his high-school pep rally. He was standing by the bonfire when there was a unanticipated eruption of flames that set both of his pant legs on fire. Physical examination reveals a temperature of 37.3° C (98.6° F), a pulse of 120/min, a weight of 75 kg (165 lb), and a blood pressure of 100/66 mm Hg. He is in severe distress and moaning in discomfort. He recoils in pain when his legs are touched. Blisters and black areas, some circumferential, encompass feet, legs, and thighs bilaterally.

Hypertrophic cardiomyopathy

A 17-year-old cross-country runner presents to his primary care physician complaining of occasional chest pain and light-headedness during meets. He says that when he gets out of breath, he feels like he might pass out and his chest feels "tight." After a thorough examination, the physician assures him that everything is okay but tells him that he should stay well hydrated and be careful not to run too hard in the heat. That afternoon, the patient returns to school and, after climbing stairs to reach his classroom, loses consciousness and falls to the floor. He quickly regains consciousness but is taken to the emergency room.

Primary amenorrhea

A 17-year-old girl is referred to a reproductive endocrinologist by her pediatrician because she has not yet menstruated. Both her mother and grandmother started their periods at age 16. She is in the 30th percentile for height, 50th percentile for weight, and is otherwise healthy and preparing to start college in the fall. Physical examination reveals a temperature of 37° C (98.6° F), heart rate of 65/min, and blood pressure of 130/80 mm Hg. She is Tanner stage I, with no breast development or pubic hair. Speculum examination reveals normal prepubescent genitalia with a patent vagina and uterus palpated on rectoabdominal examination.

Infectious mononucleosis

A 17-year-old girl presents to her pediatrician with fatigue and a sore throat of several weeks' duration. She says that she is still able to attend classes at her high school but falls asleep as soon as she gets home. She has never had anything like this before but notes that several of her good friends have missed school recently. On physical examination, her vital signs include a temperature of 39.1° C (102.4° F), heart rate of 76/min, blood pressure of 110/75 mm Hg, and respiratory rate of 12/min. Her throat is markedly erythematous with occasional exudates on the tonsils. She has tender posterior cervical lymphadenopathy bilaterally and mild hepatosplenomegaly. The remainder of her exam is within normal limits. A peripheral blood smear reveals atypical lymphocytosis.

Placental abruption

A 19-year-old G3P0111 woman at 34 weeks' estimated gestational age presents to the emergency department complaining of 3 hours of persistent lower abdominal pain and increased vaginal discharge. She states that she cannot remember what she was doing when the pain began, but it began suddenly and since then she has noticed dark brown fluid soaking her underwear. She has had no prenatal care. On examination, the patient is an anxious-appearing woman, 152 cm (5′4′′) and 50.9 kg (122 lb). Vital signs are blood pressure of 167/74 mmHg, heart rate of 98/min, and temperature of 37.9o C (100.3o F). She has 4.5-mm pupils and appears pale and diaphoretic. Sterile speculum exam reveals dark blood in the vaginal vault. The remainder of her physical exam is normal.

Appendicitis

A 19-year-old man is brought to the emergency department by his roommate. He has been experiencing abdominal pain of 6 hours' duration with loss of appetite and vomiting. He reports 9/10 pain "all over," greater on the right side; the pain is dull and is not improved or exacerbated by anything in particular. On physical examination, his temperature is 38.0° C (100.4° F), blood pressure is 120/70 mm Hg, pulse rate is 80/min, and respiratory rate is 10/min. His abdominal examination is notable for absent bowel sounds and severe tenderness on deep palpation in both the right and left lower quadrants. He is also tender on passive internal rotation of the right hip. WBC count is 14,000/mm3, and urinalysis shows few RBCs and few WBCs. CT scan of the abdomen is shown in Figure 17-1.

Psoriasis

A 19-year-old man presents to his primary care physician complaining of a rash on the extensor surfaces of his elbows and knees. The patient has no past medical history and is otherwise healthy. On physical examination, the patient's vital signs are normal. Well-demarcated, dark red plaques with silvery-white scales are present on the extensor surfaces of the elbows and knees bilaterally. Examination of the nails reveals the presence of pitting. A representative image is shown in Figure 2-6.

Amphetamine intoxication

A 19-year-old student is being evaluated at his student health center. The physician notes the young man is tachycardic at 101/min with a blood pressure of 145/93 mm Hg. His pupils are dilated, and there is a fine tremor in his hands. The patient appears agitated and is sweating. The student says he is just anxious about upcoming final examinations, but when questioned further he becomes angry and belligerent. He finally admits that for the past 2 weeks he has been taking pills his roommate gave him in order to help him stay awake. He says they improve his concentration and allow him to get by on only a few hours of sleep. He has not been eating as much and says his clothes are fitting more loosely on him. He does not see a problem with this, saying many people in the dormitory do the same thing and that he will stop taking the pills after his exams are done. The rest of the physical examination is unremarkable. On mental status examination, he is alert and oriented to person, place, and time. He is mildly uncooperative, and his speech is rapid. He describes his mood as "terrific," but his affect is angry. He denies suicidal or homicidal ideation, perceptual disturbances, or delusions. He does not have a prior history of mental illness.

Bulimia nervosa

A 19-year-old woman presents to her primary care physician for a routine examination. She denies any complaints at present. The patient is 160 cm (5′3′′) tall and weighs 52 kg (115 lb). Physical examination reveals a temperature of 37.0° C (98.6° F), pulse of 82/min, and blood pressure of 118/70 mm Hg. The patient is also noted to have some dental enamel erosion, slightly enlarged parotid glands bilaterally, and scarring over her right second and third metacarpophalangeal joints. Relevant laboratory findings are as follows:

Wilson's disease

A 19-year-old woman presents to her primary care physician for recent changes in her mood. Over the past 6 months she has felt increasingly depressed and anxious. She believes that her symptoms have affected her extracurricular activities, as she feels uncoordinated on the soccer field. Physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 74/min, and blood pressure of 118/82 mm Hg. An abdominal examination reveals hepatomegaly without signs of jaundice. Neurological examination shows a subtle resting tremor and increased tonicity. An ophthalmologic examination is significant for green-brown deposits in the cornea bilaterally.

Pelvic inflammatory disease

A 19-year-old woman presents to the emergency department complaining of abdominal pain. She states that the pain is worse in her lower abdomen. She has had multiple sexual partners and rarely uses condoms since she is taking an oral contraceptive. She has noticed increased pain with sexual intercourse over the past few weeks. Her last menstrual period was 5 days ago. On physical examination, her temperature is 39.0° C (102.2° F), blood pressure is 110/70 mm Hg, and heart rate is 80/min. Her abdomen is soft but tender to palpation in the lower quadrants. The pelvic examination reveals a purulent discharge from the cervical os with cervical motion tenderness. A Gram stain of the discharge reveals intracellular gram-negative diplococci.

Respiratory distress syndrome

A 2-hour-old neonate boy in the newborn nursery is found to have respiratory distress. He was born at 37 weeks' gestation to a 25-year-old G1P1 mother who had an uncomplicated pregnancy and normal prenatal laboratory values. His Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. On examination, he is afebrile with heart rate of 170/min, respiratory rate of 80/min, blood pressure of 65/40 mm Hg, and oxygen saturation of 95% on 2 L/min oxygen via mask. His length, weight, and head circumference are at the 50th percentile. He is in obvious respiratory distress. His head is normocephalic and his anterior fontanelle is open and flat. He has some nasal flaring. Lung and cardiac auscultation are normal, although mild to moderate retractions are present. His skin is pink without petechiae, ecchymoses, or lesions. The remainder of his examination is unremarkable. An x-ray of the chest reveals streaky, perihilar densities and small, scattered, patchy densities bilaterally.

Congenital adrenal hyperplasia - 21-Hydroxylase deficiency

A 2-week-old girl is admitted to the neonatal intensive care unit (NICU) with hypovolemic shock and is found to have hyponatremia and hyperkalemia. She was born full term and was noted to have ambiguous genitalia with hypospadias and a marked ventral chordee that could have been either a penis or an enlarged clitoris. An ultrasound on her second day of life revealed a normal uterus and ovaries, as well as normal kidneys and bladder. Chromosomal analysis showed a 46,XX karyotype. In the NICU, she is found to have markedly elevated plasma 17-hydroxyprogesterone levels and low plasma cortisol levels.

Down syndrome

A 2-week-old girl is brought to the clinic for her first checkup. She was born full term to a 37-year-old G6P3 mother who received no prenatal care and delivered the infant at home. Weight and height are both under the 5th percentile. She is dysmorphic, with upslanting palpebral fissures, epicanthal folds, small ears, and a protruding tongue. Physical examination is significant for a 3/6 harsh holosystolic murmur best heard at the left mid- to lower sternal border and generalized hypotonia. Her extremities are warm and well perfused. She has a transverse palmar crease on both hands.

Anaphylactic shock

A 2-year-old boy is brought to the emergency department after eating lunch. His mother reports that he just finished eating a peanut butter sandwich when he started becoming irritable, scratching at his throat, and crying. He then developed hives over his chest and arms and began having difficulty breathing. Physical examination reveals an oral temperature of 37.5° C (99.6° F), a pulse of 170/min, a respiratory rate of 30/min, and a blood pressure of 92/44 mm Hg. He appears flushed all over his body, diaphoretic, and fussy. Examination of the oropharynx suggests laryngeal edema and the respiratory examination reveals diffuse wheezing bilaterally. Urticaria is noted on the chest and upper and lower extremities.

Chickenpox - Varicella

A 2-year-old girl is brought to her pediatrician for evaluation of a new rash. Her mother notes that she had a fever to 38.3° C (101.0° F) yesterday and complained of headache and abdominal pain. She awakened this morning with a pruritic rash on her face. She has no past medical history, but neither she nor her sister, who is also sick, is up to date on their vaccinations; her last immunizations were received at 9 months of age. On examination, she is playful and interactive. Her temperature is 36.9° C (98.5° F), heart rate is 85/min, blood pressure is 95/75 mm Hg, and respiratory rate is 14/min. There are small vesicles across her face, and the skin surrounding each vesicle appears erythematous. and shoulders. Linear excoriations are present. A few papules are visible on her neck.

Febrile seizure

A 2-year-old previously healthy girl is brought to the emergency department (ED) after a seizure. She had been watching television when she developed full-body stiffening, followed by convulsions and twitching of all four extremities. According to her parents, the seizure lasted approximately 5 minutes and was followed by a brief postictal period of drowsiness. She had had a runny nose for 1 day, which her mother attributed to sick contacts at day care. On examination, she has a temperature of 39.9° C (103.8° F), heart rate of 140/min, respiratory rate of 22/min, blood pressure of 95/75 mm Hg, and pulse oximetry of 99% on room air. She is well appearing and in no acute distress. She has moist mucous membranes with rhinorrhea. Lung examination is significant for decreased breath sounds at the base of the right lung. The remainder of her physical examination is unremarkable.

Acute intermittent porphyria

A 20-year-old college student is brought to the emergency department by her boyfriend following a seizure. The patient is still confused, but her boyfriend states that she was complaining of abdominal pain when she woke up. They had attended a party the night before, and the boyfriend believes she took some sort of pills in addition to drinking. He also reports that she has been on a diet and that her eating has been very erratic. On physical examination, she is confused but responsive. Vital signs include a temperature of 37.8° C (100.1° F), heart rate of 115/min, and blood pressure of 110/75 mm Hg. Her abdomen is soft, but she groans on palpation. Neurologic exam is normal except for global areflexia. A Foley catheter is inserted and returns 200 cc of dark reddish-brown urine. Her urinary excretion of aminolevulinic acid (ALA) and porphobilinogen (PBG) is markedly elevated.

Meningitis

A 20-year-old college student presents to the clinic with fever and headache 2 days after returning from spring break in Mexico. The headache began the night before and has significantly disrupted her routine. She describes it as a 10/10, nonpulsating headache, exacerbated by moving her neck. She also notes that loud noises and bright lights seem to bother her much more than usual. On physical examination, her temperature is 39.1°C (102.4°F), pulse is 112/min, and the respiratory rate is 14/min. She is unable to touch her chin to her chest, and she experiences significant pain upon flexion of her thigh with extension of her leg. There is a macular purple rash over both shins, which she had not noticed before. Her funduscopic exam is normal, and she has no focal neurologic deficits. A lumbar puncture (LP) reveals cloudy fluid and the following results:

Diabetic ketoacidosis

A 20-year-old college student presents to the emergency department after 24 hours of nausea, vomiting, and severe abdominal pain. Two days prior, he attended an end- of-semester party at which he drank at least six beers. He notes that he has lost about 9.1 kg (20 lb) in the past 3 weeks, despite being excessively hungry and thirsty. He also mentions having experienced frequent urination for the past month. On physical examination, he appears pale and diaphoretic, and his breath smells fruity. He has a pulse of 130/min, blood pressure of 100/65 mm Hg, and respiratory rate of 20/min. Relevant laboratory test results are as follows:

Schizophrenia

A 20-year-old man is brought to his primary care physician by his mother, who is concerned about his behavior. Over the past year, he has become increasingly withdrawn and has stopped socializing with his friends. He typically spends the majority of each day alone in his room, although his mother often hears him talking loudly. When questioned, he states, "The FBI is looking for us, and all of my friends are working for them." He admits to auditory hallucinations. He refuses a physical examination but is noted to have a flattened affect.

Neck trauma

A 20-year-old man is brought to the emergency department by ambulance after being stabbed in the neck. The paramedics at the scene report that neither the assailant nor the weapon was present upon their arrival. Physical examination reveals an oral temperature of 37.0° C (98.6° F), a pulse of 115/min, a respiratory rate of 19/min, and a blood pressure of 106/64 mm Hg. He is able to speak without difficulty and is oriented to person, place, and time. The stab wound is horizontal and approximately 3 cm long on the left side of the neck below the angle of the mandible and above the inferior cricoid cartilage. Although it appears that the weapon penetrated the platysma muscle, the wound does not appear to be actively bleeding. No other injuries are noted.

Chronic kidney disease

A 20-year-old woman with idiopathic membranoproliferative glomerulonephritis presents for her second visit to a nephrology clinic. In the course of 2 months, her serum creatinine concentration has increased from 2.2 to 4.0 mg/dL. Despite antihypertensive therapy with an angiotensin-converting enzyme (ACE) inhibitor, which was started after her first visit, her blood pressure is 160/100 mm Hg. Her weight is 67 kg (148 lb), up 1 kg (2.2 lb) from her last visit, and her legs are more edematous. She has been experiencing tension headaches, which are relieved by nonsteroidal anti- inflammatory drugs (NSAIDs), including ibuprofen and a cyclooxygenase-2 (COX-2) inhibitor. She is also increasingly fatigued. Laboratory values from her first and second visits are listed below:

Zollinger-Ellison syndrome

A 40-year-old man presents to his primary care physician for recurrent abdominal pain. He reports that, despite strict adherence to his peptic ulcer disease medication regimen, he has frequent episodes of burning abdominal pain. He also reports diarrhea and an unintentional weight loss of 4.5 kg (10 lb) over the past 6 months. He adds that he is very concerned about his symptoms because of a strong family history of tumors. His brother was recently diagnosed with a pituitary tumor, and his father had "some sort of tumor in his pancreas" at age 46. Physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 83/min, and blood pressure of 130/70 mm Hg. His physical examination is otherwise unremarkable.

Addison's disease (Hypoaldosteronism)

A 40-year-old man presents to his primary care physician with a month-long history of fatigue, light-headedness, and muscle weakness. He notes decreased appetite and a 4.5-kg (10-lb) weight loss over this time, as well as darkening of his skin, particularly over his appendectomy scar, his knuckles, his belt line, and both knees. The light- headedness is particularly severe when he gets out of bed in the morning or rises from a seated position. Throughout the interview, the patient appears irritable and agitated. His blood pressure is 115/70 mm Hg supine and 90/60 mm Hg standing. Relevant laboratory findings are as follows:

Hypercholesterolemia

A 40-year-old man with a history of hypertension presents to the clinic for his annual checkup. He denies recent complaints, and his history and physical examination are unremarkable except for a blood pressure of 150/90 mm Hg. He currently takes hydrochlorothiazide for his hypertension. He is found to have a total serum cholesterol of 250 mg/dL, low-density lipoprotein (LDL) cholesterol of 200 mg/dL, and high- density lipoprotein (HDL) cholesterol of 50 mg/dL on a routine fasting lipid profile. He has no family history of coronary artery disease and does not smoke.

Organophosphate poisoning

A 40-year-old man with no significant past medical history is brought to the emergency department by his wife, who reports that he has been drooling, vomiting, wheezing, and sweating uncontrollably for the past hour. He is an otherwise healthy man who takes no medication, denies allergies, and works as a tomato farmer. He appears somewhat lethargic and is having trouble speaking due to his shortness of breath. His wife reports that he was testing a new pesticide that morning. On physical examination, his temperature is 37.0° C (98.6° F), blood pressure is 100/70 mm Hg, pulse rate is 40/min, and respiratory rate is 6/min. His cardiac examination is notable for a regular but slow rhythm, and his skin is moist with sweat.

Hyperparathyroidism

A 40-year-old woman is brought to the emergency department with confusion and left lower quadrant abdominal pain. One hour earlier, her husband found her wandering around the house looking for the family dog, which had died 3 years ago. The patient is unable to describe the pain but is clearly in distress and is holding her left side. Her husband mentions that she was treated for a kidney stone at the same hospital 9 months earlier. Since then, she has lost approximately 6.8 kg (15 lb) and regularly complains of fatigue and muscle weakness. Upon examination, her blood pressure is 136/72 mm Hg, heart rate is 115/min, and respiratory rate is 16/min. There is tenderness with guarding in the left lower quadrant, as well as tenderness over her lower back. The patient is alert but is not oriented to time or place. Relevant laboratory values are as follows:

Atypical pneumonia

A 40-year-old woman presents to her physician complaining of a cough, headache, low- grade fevers, nausea, loose stools, and malaise for the past 2 weeks. Physical examination reveals a temperature of 38.0° C (100.4° F), heart rate of 90/min, and respiratory rate of 15/min. Chest examination reveals faint diffuse rales and wheezes in bilateral lung fields. X-ray of the chest shows bilateral interstitial infiltrates. Her CBC does not reveal any leukocytosis or other abnormality.

Bipolar I disorder

A 21-year-old man is brought to the emergency department by his girlfriend because of his "wild" behavior over the past 2 weeks. His girlfriend reports that during this period of time he has slept very little each night and that he seems to be talking faster than usual. He also has stopped attending his classes at the local community college. He frequently writes in a notebook, although his girlfriend states that the excerpts she has read make no sense. She also reports that he has depleted his bank account on a buying spree at a department store. When questioned, he confirms his recent purchases and states that he will make more money after he completes the novel he is writing.

Condyloma acuminata

A 21-year-old sexually active college student visits the student health office complaining of "bumps" on the posterior introitus. She denies dyspareunia, vulvar itching, change in vaginal discharge, or dysuria. She admits to having multiple sexual partners. She uses oral contraceptive pills; her partners use condoms rarely. On physical examination, there are multiple 2-3-mm flesh-colored, pedunculated papules on the posterior introitus and the labia.

Microcytic anemia

A 21-year-old woman presents to her gynecologist after 1 year of dysmenorrhea and menorrhagia. She recalls having seven or eight periods over the past 12 months, all of which were heavier than normal. She previously went to the gym five times per week but is now unable to exercise because she feels she "cannot keep up." In addition, she has been feeling tired for the past 3 months and has trouble waking up each morning because she feels exhausted instead of refreshed. She is not taking any medications and denies smoking, alcohol consumption, and illicit drug use. She eats a well-balanced diet, and coagulation studies are normal. Her vital signs include a heart rate of 92/min, blood pressure of 135/80 mm Hg, and respiratory rate of 20/min. Her examination is otherwise unremarkable. Relevant laboratory results are as follows:

Factor V Leiden

A 21-year-old woman presents to her primary care physician with pain and swelling of her right lower leg. The pain began the night before following a 12-hour plane flight and did not improve with resting overnight. She denies fevers or trauma to the leg. Her only medication is an oral contraceptive. When questioned, she notes that multiple family members have suffered similar symptoms and that her maternal grandmother died from a pulmonary embolism. On physical examination, she is afebrile with normal vital signs. Her lateral right lower leg is erythematous without a palpable cord, and she reports increased pain with passive dorsiflexion of the right foot.

Disseminated gonococcal infection

A 21-year-old woman presents to the emergency department because of progressively worsening left wrist pain and malaise over the past 36 hours. The night before admission she developed a fever and loss of appetite. She also developed pain in her palms bilaterally. She denies any history of trauma or unusual physical activity. She does not have any nausea, vomiting, diarrhea, or hematochezia. On examination, she has a temperature of 38.7° C (101.7° F), heart rate of 85/min, respiratory rate of 16/min, and blood pressure of 110/80 mm Hg. The examination is notable for swelling, warmth, and erythema of her left wrist. The wrist joint is extremely tender to palpation. Skin examination is notable for several tender bilateral palmar violaceous pustular eruptions. She is a college student and lives in a sorority house on campus. She drinks and smokes socially and is sexually active with more than one partner.

Preeclampsia

A 22-year-old G2P0 woman presents to her obstetrician's office at 36 weeks' gestation complaining of a mild headache. She has a history of a missed abortion at 12 weeks' gestation 2 years ago, which required a dilation and curettage. Her pregnancy has been uncomplicated until last week, when she presented with a headache and blood pressure of 142/78 mm Hg. No proteinuria was noted at that time. Currently, the patient denies any complaints other than a mild headache and reports no uterine contractions or vaginal bleeding. On physical examination, her temperature is 36.6° C (97.9° F), her heart rate is 92/min, and her blood pressure is 148/88 mm Hg. Her urine dipstick result is 1+ protein, and 24-hour urine monitoring is initiated.

AZT-induced anemia

A 22-year-old HIV-positive woman who emigrated from Botswana 2 months ago presents to the emergency department complaining of worsening shortness of breath and fatigue. She contracted HIV 5 years ago and was started on highly active antiretroviral therapy (HAART) 3 weeks before leaving Botswana. She states that she has been very adherent with her HAART regimen of zidovudine (AZT), lamivudine (3TC), and abacavir and has not missed even one dose. Her CD4 count prior to initiating treatment was 250/mm3. On physical examination, the patient has a temperature of 36.6° C (98.5° F), heart rate of 116/min, blood pressure of 110/68 mm Hg, respiratory rate of 26/min, and percutaneous oxygen saturation level of 97% on room air. Her conjunctivae are noticeably pale, and her capillary refill time is delayed.

Borderline personality disorder

A 22-year-old college student is referred to the dean of students because he is continuously missing assignment deadlines and is doing poorly on his examinations. He denies that he needs help with these issues and blames his poor performance on the unreasonable demands of his professors. He explains that he is unable to complete examinations because they are too long, and that the portions he does finish are very well written and infallible in their correctness. He explains that he keeps to a very rigid study schedule and does not waste time with "frivolous" activities like spending time with friends. As evidence, he presents his personal organizer that is impressive with the details of his schedule and long lists of things to do. When it is suggested that he join a study group, he adamantly refuses, stating that his classmates are inferior and would have nothing to contribute to his learning. He says that if the other students were more like him, they would get more done, but as it is, they are just lazy and unfocused. Sensing a deeper psychological root to his student's problems, the dean refers him to the student counseling center but strongly doubts he will keep the appointment

Obsessive-compulsive personality disorder

A 22-year-old college student is referred to the dean of students because he is continuously missing assignment deadlines and is doing poorly on his examinations. He denies that he needs help with these issues and blames his poor performance on the unreasonable demands of his professors. He explains that he is unable to complete examinations because they are too long, and that the portions he does finish are very well written and infallible in their correctness. He explains that he keeps to a very rigid study schedule and does not waste time with "frivolous" activities like spending time with friends. As evidence, he presents his personal organizer that is impressive with the details of his schedule and long lists of things to do. When it is suggested that he join a study group, he adamantly refuses, stating that his classmates are inferior and would have nothing to contribute to his learning. He says that if the other students were more like him, they would get more done, but as it is, they are just lazy and unfocused. Sensing a deeper psychological root to his student's problems, the dean refers him to the student counseling center but strongly doubts he will keep the appointment.

Polycystic ovarian syndrome

A 22-year-old nulligravid woman presents to her gynecologist because of irregular, widely spaced menses. Menarche was at age 14, but she has rarely had regular cycles. For the past year, she has had only three complete menses, once going 6 months between periods. She is sexually active and uses condoms for contraception. Upon physical examination, she has a temperature of 37° C (98.6° F), heart rate of 80/min, and blood pressure of 140/85 mm Hg. She is 165 cm (5′4′′) tall and weighs 83 kg (190 lb). She is overweight, with acne and a few dark hairs on her upper lip and chin. Speculum and bimanual examination reveal normal external and internal genitalia without tenderness or masses.

Pelvic fracture

A 22-year-old woman is brought to the emergency department following a motor vehicle collision in which she was an unrestrained driver. Paramedics report she was driving a four-door sedan that was "T-boned" on the driver's side. She denied any allergies or pertinent medical history before becoming unconscious at the scene. Physical exam at that time showed a mechanically unstable pelvic girdle and a systolic blood pressure of 80 mm Hg.

Endocarditis

A 22-year-old woman presents to her physician with complaints of fatigue, shortness of breath, and loss of appetite. Her symptoms started 2 weeks ago and have progressively worsened. She has had a fever for the past 3 days and has been having night sweats. Her past medical history is unremarkable except for a wisdom tooth extraction approximately 2 months before she came to the clinic. She denies any recent travel, and she has no pets or sick contacts. On physical examination, she has a temperature of 38.6° C (101.4° F), heart rate of 112/min, respiratory rate of 18/min, and blood pressure of 110/85 mm Hg. She has a 4/6 holosystolic murmur that radiates to the left axilla. Skin examination reveals scattered petechiae on her extremities; nonblanching, linear, reddish-brown lesions under her nail beds; and nonpainful erythematous, macular, blanching lesions on her palms and soles.

Cervicitis

A 22-year-old woman presents to the gynecologist's office complaining of pain with sexual intercourse. She states that the pain began 1 week prior but has continued to worsen. In addition to the dyspareunia, she complains of vaginal itching. She is in a steady relationship, although she does admit to having intercourse with more than one partner in the past month. She does not use condoms but does take an oral contraceptive pill. On physical examination, she is a well-appearing young woman. She is afebrile, with blood pressure of 120/80 mm Hg and heart rate of 75/min. She is nontender to palpation throughout her abdomen. On pelvic examination, a mucopurulent discharge is noted. Visualization of the cervix reveals a red, inflamed cervix. The cervix is extremely tender when swabbed and when moved on bimanual examination.

Chancroid

A 22-year-old woman presents to the health clinic complaining of fever and malaise. Upon further questioning she admits to a foul vaginal discharge, vulvar pain, and pain with urination. She recently returned home from a study abroad program in Southeast Asia and admits to being sexually active with another student in her program. Her temperature is 38.6° C (101.5° F). There is significant tender left-sided lymphadenopathy in the inguinal region. Examination of the external genitalia reveals three painful, well-demarcated soft ulcers on the labia majora and minora. The ulcers have ragged edges and necrotic bases. Pelvic examination reveals a foul-smelling purulent discharge.

Takayasu arteritis

A 23-year-old Asian-American woman presents to her primary care physician with cold hands and increasingly frequent episodes of headaches and lightheadedness. She reports that the coldness in her hands is associated with numbness, tingling, and loss of sensation in her arms. Two days ago, while reading a book at her desk, she reported seeing flashing lights followed by a loss of vision that lasted for about 15 seconds. She denies head trauma, fever, night sweats, chills, or weight loss. She is not taking any medications except for an occasional acetaminophen for her headaches. On physical exam, her temperature is 39° C (100.5° F), pulse is 65/min, blood pressure is 140/90 mm Hg, and respiratory rate is 12/min. She has carotid bruits and faint pulses in her arms bilaterally. Her hands are cold, with cyanotic nail beds. Her lungs are clear, and her heart has a regular rate and rhythm. Abdominal examination is unremarkable.

Preterm premature rupture of membranes (PPROM)

A 23-year-old G2P1 woman at 28 weeks' gestation presents to the emergency department complaining of clear fluid on her underwear that has collected for the past 4 hours. She has had all appropriate prenatal care and is in good health other than continuing to smoke a half-pack of cigarettes daily. She denies fever and all constitutional symptoms of infection and states that when she woke this morning she could feel the baby moving. Her past medical history is unremarkable. Social history is significant in that she is currently unemployed and recently began dating a man who has moved in with her. On physical examination, her lungs are clear to auscultation, and she has no costovertebral tenderness. She has mild discomfort with lower abdominal palpation. Vital signs are 37.1° C (98.8° F), pulse 99/min, and blood pressure 145/88 mm Hg. Fetal heart tones have normal range and variability.

Cardiac tamponade

A 23-year-old man is brought by ambulance to the emergency department after being stabbed in the chest during a fight. The initial history discloses he has no allergies, takes no medications, has no significant past medical history, and last ate about 3 hours ago. He complains of severe pain in his chest and of difficulty breathing. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 85/50 mm Hg during expiration and 60/palpable during inspiration, pulse rate of 120/min, respiratory rate of 20/min, and oxygen saturation of 96% on room air. Physical examination shows a well-developed, well-nourished man with tattered and blood-stained clothing, and no evidence of other penetrating or blunt trauma including head trauma. His HEENT examination is unremarkable. His neck examination shows a jugular venous pressure of about 15 cm H2O; he has a midline trachea, no subcutaneous crepitus, and no obvious neck wounds. His chest is clear to auscultation and he has good breath sounds bilaterally. A 2-cm linear wound is present about 2 cm to the left of his sternum at the level of the nipple. His heart sounds are distant and tachycardic but have a regular rhythm. His abdominal, extremity, and neurologic examinations are unremarkable. X-ray of the chest shows clear lung fields, no pneumothorax, no pleural effusion, and a moderately enlarged heart.

Testicular cancer

A 23-year-old man presents to his primary care physician with an enlarged right scrotum. He first noticed a "fullness" in his scrotum 2 months ago when he sprained his hamstring playing soccer in an outdoor league; he was reluctant to seek medical help until now because of embarrassment. He has no significant past medical history and denies pain in the area. On examination, the patient is somewhat anxious appearing but alert and oriented and in no apparent distress. His pulse is 60/min, blood pressure is 120/72 mm Hg, and respiratory rate is 12/min. His heart, lung, and abdominal exams are all within normal limits. The patient has a firm nontender mobile mass in his right scrotum that does not transilluminate. There is no palpable inguinal adenopathy. No abnormalities are found on rectal examination.

Hodgkin's lymphoma

A 23-year-old man visits his primary physician after 1 month of night sweats. He says that for the past 6 weeks he has had general malaise, which he attributes to the stress of his new job as an investment banker and his crumbling relationship with his girlfriend. He has lost about 4.5 kg (10 1b) during this time. He has been healthy in the past and is conscientious about eating a balanced diet and exercising daily. His family history is unremarkable. He does not smoke, drinks one to two beers per week, and denies intravenous drug use. He denies international travel and says he had a negative purified protein derivative (PPD) test before starting his new job. On examination, his temperature is 38.1° C (100.5° F), blood pressure is 120/65 mm Hg, heart rate is 80/ min, and respiratory rate is 16/min. His examination is within normal limits, with the exception of a palpable cervical lymph node, which is firm, painless, and approximately 2 cm in diameter. Results of excisional biopsy are shown in Figure 7-6.

Systemic lupus erythematosus

A 23-year-old woman presents to her primary care physician with complaints of malaise, fever of 10 days' duration, and swelling in her ankles and knees. She also has been having chest pain, which is particularly painful on inspiration and expiration. On questioning, the young woman states that she has always been healthy. She has not had any recent sick contacts and has been in a monogamous relationship for the past 3 years. Of note, her mother has Raynaud's disease. On examination, the patient is found to have no skin lesions or muscle tenderness. Her temperature is 38.1° C (100.6° F). She has a pleural friction rub and significant effusions around her ankles, knees, and hands bilaterally. She also has palpable cervical and inguinal lymph nodes. Radiography of her knees shows significant soft tissue swelling. Relevant laboratory findings are as follows:

Ectopic pregnancy

A 24-year-old G0 woman comes to the emergency department (ED) complaining of left lower abdominal pain and intermittent vaginal bleeding. The patient reports being sexually active with her husband and states that she only intermittently uses contraception. She denies any medical problem but does state that she had a chlamydial infection 7 years ago. Her last menstrual period was 6 weeks ago. On physical examination, the patient is in mild discomfort, with a heart rate of 98/min and a blood pressure of 130/85 mm Hg. Pelvic examination is remarkable for cervical motion tenderness and a closed cervical os. Her β-human chorionic gonadotropin (β-hCG) level is 2000 mIU/mL, and a transvaginal ultrasound is shown in Figure 11-1.

Kaposi's sarcoma

A 24-year-old new patient presents to a local clinic for evaluation of a dark spot on the roof of her mouth. She first noticed the discoloration while she was brushing her teeth, but she does not remember exactly when it first appeared. It does not itch nor cause her any pain or trouble eating. Her family history is unremarkable; however, she has been working as a sex worker since the age of 18 and does not routinely use a condom for protection. The patient appears comfortable, with a heart rate of 90/min, respirations of 12/min, and temperature of 37.0o C (98.5o F). Her physical examination is normal except for a 2 × 2-cm, violaceous, slightly raised plaque on her rear right palate.

Factitious disorders - Munchausen's syndrome

A 24-year-old nursing student presents to the emergency department (ED) after a syncopal episode. She was studying with a friend but took a break to go to the bathroom; when she returned, she complained of light-headedness and was diaphoretic. The friend states she then slumped over on the desk, unresponsive, so he called 911. Fingerstick blood glucose en route was 24 mg/dL, and she was revived with glucose. She describes multiple similar episodes, for which she has undergone an extensive workup without diagnosis. She is reluctant to give the names of any of her former providers. Physical examination is within normal limits. A C-peptide level is low.

Obesity effects on health

A 24-year-old white woman presents to her family physician for an annual examination. The patient has always been somewhat overweight, but her weight has increased significantly since her last visit. She is 163 cm (5'3") tall and weighs 91 kg (200 lb). The patient does not express concern about her weight gain. She states that she enjoys eating "good food and lots of it" and that she has little desire to exercise. She works in customer relations and spends most of her day sitting at a desk answering phone calls.

Congenital rubella - TORCH infections

A 25-year-old G1 woman delivers a baby girl at 37 weeks' gestation. The baby has a purpuric rash covering her entire body, a weak cry, and abnormally small eyes. On further examination, she is tachycardic with a machine-like murmur. Her ophthalmologic exam is notable for leukocoria and microopthalmia. Standard postpartum hearing tests are notable for bilateral sensorineural hearing loss. Her mother is a recent immigrant from Guatemala. She reports having had a brief illness during her first trimester with a low-grade fever, lymphadenopathy, and a maculopapular rash that began on the face and spread to the rest of her body before resolving spontaneously.

Compartment syndrome

A 25-year-old man involved in a motor vehicle accident is brought by ambulance to the nearest emergency department for evaluation of multiple cuts, bruises, and a swollen and extremely painful leg. On physical examination, his left leg is slightly cool and is swollen and tense relative to his right leg. He describes feeling "pins and needles" in his toes; he also has extreme difficulty dorsiflexing his left ankle. Dorsalis pedis and posterior tibial pulses are weak. Relevant findings include a temperature of 37° C (99.7° F), a blood pressure of 140/90 mm Hg, and a lateral compartment pressure of 60 mm Hg on compartment manometry of his left leg.

Orbital fracture

A 25-year-old man is brought to the emergency department by ambulance after a motor vehicle collision. The paramedics report that his vehicle, which was not equipped with airbags, hit a telephone pole at 35 mph. His temperature is 37.0° C (98.6° F), heart rate is 91/min, respiratory rate is 13/min, and blood pressure is 116/78 mm Hg. He is alert and oriented to person and place, but does not recall the date or any of the events leading up to the accident. He also reports that he feels very dizzy whenever he looks up at the ceiling. Examination of the head and neck reveals slight enophthalmos of the left orbit with infraorbital and upper lip anesthesia.

Tension pneumothorax

A 25-year-old man is brought to the emergency department following a stab wound to the right back. He complains of difficulty breathing and severe pain on his right side. His vital signs on arriving are a blood pressure of 140/80 mm Hg, heart rate of 100/min, and respiratory rate of 25/min with oxygen saturation of 90% by pulse oximetry. While undergoing an x-ray of the chest, he becomes agitated and develops severe respiratory distress. Vital signs are now blood pressure of 80/60 mm Hg, heart rate of 125/min, respiratory rate of 40/min, and oxygen saturation of 75% by pulse oximetry. Chest examination reveals an absence of breath sounds and hyper-resonance over the right lung field. Neck examination reveals distended neck veins and leftward tracheal deviation.

Traumatic urethral injury

A 25-year-old man was the unrestrained driver of a motorcycle involved in a high-speed collision with a tree. The paramedics noted him at the scene to have a pulse of 120/min, blood pressure of 96/56 mm Hg, respiratory rate of 14/min, and Glasgow Coma Scale (GCS) of 10. The paramedics placed two large-bore peripheral intravenous lines and administered 2 liters of intravenous fluids during transportation to the nearest level-one trauma center. His vital signs on arrival at the emergency department are temperature 36.5o C (97.7o F), pulse 110/min, blood pressure 90/70 mm Hg, respiratory rate 14/min, and GCS 10. Multiple lacerations and abrasions are present on the face and upper and lower extremities. The heart, lung, and abdominal findings are all within normal limits. The bony pelvis is somewhat unstable and appears to have a fracture of the right pubic ramus. Marked scrotal swelling is noted. Peripheral pulses are present in all extremities. A digital rectal examination (DRE) reveals a high-riding prostate. As a nurse is about to insert the Foley catheter, she notes blood at the penile meatus.

Inflammatory bowel disease

A 25-year-old woman presents to her primary care physician for recurrent abdominal pain. She describes having daily episodes of crampy, lower abdominal pain and diarrhea for the past 6 months. Her diarrhea has occasionally been bloody, and she has experienced an unintentional weight loss of 4.5 kg (10 lb) over the past 3 months. She adds that she had a subjective fever several nights last week. Physical examination reveals a temperature of 37.8°C (100.1°F), pulse of 96/min, and blood pressure of 108/66 mm Hg. She appears thin but is in no acute distress. An abdominal examination reveals diffuse tenderness, and a rectal examination is significant for frank blood.

Cocaine dependence

A 26-year-old G7P3 woman at 34 weeks' gestation presents to the emergency department because she feels she is beginning to experience contractions and does not have an outpatient obstetrician. On examination, her pupils are dilated and she appears agitated and nervous. She then changes her mind and says she does not want further evaluation because it has been too long since her last "smoke." She is adamant about needing to leave right away. Upon further questioning, she states that if she does not get to smoke soon, she will become very sleepy and depressed and will have intense food cravings. She has been in inpatient drug rehabilitation twice but always relapses back to her drug of choice. She is currently living at a halfway house, is on welfare, and does not have custody of any of her three children. "They will probably take this one away from me, too," she adds as she begins to cry. She says she used to be able to get high for $10 per day, but now it costs up to $100 per day. She affords her habit by trading drugs and money for sex; she cannot recall if she has been tested for HIV or other sexually transmitted diseases.

Bacterial vaginosis

A 26-year-old engaged woman presents with the complaint of a foul-smelling vaginal discharge. She denies any vulvar pruritus or dyspareunia, although she has noticed the presence of a thin, grayish discharge. Physical examination reveals an afebrile, well- appearing, slightly anxious young woman with a blood pressure of 125/85 mm Hg and heart rate of 80/min. A pelvic examination shows watery, grayish discharge with a vaginal pH > 4.5. Mixing the discharge with potassium hydroxide produces a fishy odor. Results of a wet prep for microscopic evaluation are shown in Figure 12-1.

Post-traumatic stress disorder

A 26-year-old man presents to a psychiatrist at the Veteran's Administration Behavioral Health Outpatient Clinic 2 years after being discharged from the Army. While enlisted, he served two tours overseas and saw active combat in the Persian Gulf region. He witnessed three fellow soldiers killed by a roadside bomb and states that he cannot get these and other disturbing images out of his head. He tells the psychiatrist that, since he returned home, "Things just have not been the same." He says he does not sleep much because of nightmares during which combat scenes are replayed. He also finds himself flinching each time he hears helicopters flying overhead. He refuses to watch the nightly newscasts that cover the war and will not read newspaper stories about it. He says he has not been able to "let down his guard," even with his wife. Their relationship has been strained by his emotional distance and his frequent angry outbursts. Since his discharge he has held four jobs, none longer than 5 months, and he is currently unemployed. On mental status examination, his appearance, behavior, and speech are normal. He does have an exaggerated startle response when his cellular phone rings during the interview. He describes his mood as "depressed," and his affect is congruently dysphoric. His thought process is linear and logical, and he denies auditory or visual hallucinations. He also denies homicidal or suicidal ideations.

Developmental dysplasia of the hip

A 26-year-old woman gives birth to her first child at the local hospital. The mother's pregnancy was uncomplicated, but the delivery was complicated by breech presentation. On successful delivery of a female infant, the pediatrician performed a full newborn examination. Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. All appropriate reflexes were present, and examination of the head, back, heart, lungs, and abdomen was normal. On examination of the hips, flexion and adduction of the hips produces an audible "clunk" and dislocation of the right hip. On flexion and abduction, the right hip relocates in the acetabulum.

Idiopathic thrombocytopenic purpura

A 26-year-old woman loses consciousness in her front yard and is rushed to the emergency department (ED) by her husband. He is concerned that she hit her head on the driveway when she fell, but she is conscious, alert, and oriented soon after arrival in the ED. Her neurological examination is normal, and imaging studies are negative for intracranial hemorrhage. While in the evaluation room, she says she may have cut her mouth when she fell. Upon closer inspection, the blood in her mouth is discovered to be gingival in origin, and she is also noted to have epistaxis and nonpalpable purpura on her arms and legs. When asked about other abnormal bleeding, the patient notes that her menses have been heavier than normal for the past 4 months and that she had noticed the purpura on her limbs approximately 1 month ago but thought it was "winter skin." Relevant laboratory results include:

Endometritis

A 27-year-old G2P1 woman is 2 days postpartum after a cesarean delivery of a 2.8-kg (6 lb 4 oz) boy. The patient's pregnancy was complicated by preterm premature rupture of membranes (PPROM) at 32 weeks, for which she was hospitalized. Fetal heart tracings were reassuring throughout the patient's hospitalization, and she began labor spontaneously at 34 weeks and 4 days. A cesarean section was performed due to nonreassuring heart tracings after 10 hours of labor. The patient complains of worsening abdominal pain and general malaise. On physical examination, she has a temperature of 38.9° C (102.1° F), a heart rate of 120/min, uterine tenderness, and foul-smelling lochia.

Acid reflux

A 27-year-old G2P1 woman who is 20 weeks pregnant presents to her obstetrician's office complaining of persistent coughing and chest discomfort for the past 2 weeks. She states that her coughing is intermittent and worse after eating. She experiences chest discomfort only when lying flat on her back and describes the discomfort as a sense of "fullness" with "occasional burning." She has not been ill recently, has had no sick contacts, and denies sore throat, rhinitis, dyspnea, chest pain, chest tightness, or palpitations. She has no history of any medical problems and has had an uncomplicated pregnancy, except for some nausea and vomiting during her first trimester. She is up to date on all of her prenatal tests. On physical examination, the patient has a heart rate of 85/min, a blood pressure of 125/75 mm Hg, a respiratory rate of 10 breaths per minute, and a temperature of 37.2° C (99.0° F). Head, ears, eyes, nose, and throat (HEENT) examination reveals no facial fullness or sinus tenderness. Her oropharynx is clear. The patient's lungs are clear to auscultation bilaterally, and her heart has a regular rate and rhythm. She has no lower-extremity edema, and her pulses are 2+ and symmetric in all four extremities.

Pyelonephritis

A 27-year-old G4P1 woman at 30 weeks', 6 days' gestation presents to the emergency department complaining of headache, fever, chills, and dysuria that have been worsening over the past 2 days. Two days ago, her temperature was 37.8° C (100.1° F), but it has steadily increased since, and the last time she checked, her temperature was 38.8° C (101.8° F). She denies blurry vision, abdominal pain, or dizziness. She is unsure if she has had any recent vaginal discharge, but she has noticed mild and intermittent spotting over the past several weeks. She additionally complains of urinary frequency, but she states that ever since she began her second trimester, she has had to urinate frequently, so she did not think that this recent worsening was abnormal. On physical examination, the patient's temperature is 38.4° C (101.1° F), her heart rate is 108/min, and her blood pressure is 155/96 mm Hg. Her abdomen is soft, with no suprapubic tenderness. She has mild pain at the costovertebral angles bilaterally. Laboratory values reveal the following:

Generalized tonic-clonic seizures

A 27-year-old man is having breakfast with his wife when suddenly he arches his back, turns his head to the side, shrieks loudly, and falls to the ground. His arms and legs remain extended for approximately 30 seconds, after which his arms and legs begin to flex and extend rhythmically for the next 2 minutes. The patient's wife calls 911, and on arrival the paramedics find the patient lying on the floor. He appears stuporous but can respond to vocal commands. He has bitten his tongue badly, and is soiled from having lost control of bowel and bladder functions. The patient is confused and appears to have no knowledge of what has happened to him. The paramedics transfer the patient to the ambulance and bring him to the emergency department for further evaluation.

Ankylosing spondylitis

A 27-year-old man presents to an orthopedic surgeon complaining of back pain and stiffness that has progressively worsened over the past 3 years. Initially, the pain was mild and intermittent, but currently it is 6/10 even at rest. The patient is occasionally awakened from sleep by the pain. The stiffness is worst in the morning and improves somewhat with exercise. On examination, the patient has a marked loss of lateral flexion of the lumbar spine and point tenderness over the sacroiliac joints. Radiographs of the patient's lumbar spine are significant for mild erosion and sclerosis of the subchondral bone within the sacroiliac joint. An x-ray of the patient's spine is shown in Figure 9-1. Relevant laboratory findings are a WBC count of 7200/mm3 and erythrocyte sedimentation rate of 113 mm/hr; results for rheumatoid factor are negative, but results for HLA-B27 are positive.

Trichomonas

A 27-year-old woman in her first trimester of pregnancy complains of intense vaginal itching with a profuse greenish discharge. She also notes a foul odor to the discharge. She states that she is in a monogamous relationship with her boyfriend of 6 months. They initially used condoms during intercourse, but they have not used any form of contraception for the past 2 months. On physical examination, the patient is afebrile, with blood pressure of 125/80 mm Hg and heart rate of 85/min. The pelvic examination reveals a malodorous, frothy greenish-gray discharge with inflammation of the cervix and vaginal mucosa. Punctate hemorrhages are visible on the cervix. The vaginal pH is > 4.5, and motile organisms are seen on a wet prep of the vaginal discharge (as seen in Figure 12-3).

Migraine headache

A 27-year-old woman presents to her primary care physician complaining of recurrent headaches that started in puberty, but have recently become more frequent, now occurring approximately three times a month. She describes the pain as throbbing, focused over the left temple, and accompanied by nausea, occasional vomiting, and sensitivity to bright lights and loud noises. Upon further questioning, she admits to seeing flashing lights in her right lower visual field approximately 1 hour before the headache begins. Physical examination reveals a temperature of 37°C (98.6°F), a heart rate of 80/min, a respiratory rate of 12/min, and a blood pressure of 120/80 mm Hg. A neurologic examination shows no focal deficits.

Meconium aspiration syndrome

A 28-year-old G1 at 42 weeks' gestation is admitted to labor and delivery to undergo scheduled induction. Her prenatal care has been routine, regular, and uncomplicated. Her last obstetric ultrasound was at 36 weeks' gestation, which revealed a healthy male fetus. After several hours of labor, contractions are 4 minutes apart. Electronic fetal monitoring demonstrates repetitive late decelerations and minimal beat-to-beat variability, and an emergency cesarean section is performed. When membranes are ruptured, amniotic fluid appears brownish-green and has no odor. The infant has long, thin limbs with decreased fat on his body. He has peeling, brown-stained skin, long fingernails, and decreased vernix. His lips appear bluish, and he has subxiphoid and abdominal retractions with inspiration. Auscultation reveals rales bilaterally. Apgars are 4 and 3 at 1 and 5 minutes, respectively. Relevant findings on arterial blood gas are pH 7.25, PCO2 45, HCO3 20, and PO2 62.

Preterm labor

A 28-year-old G1 woman at 30 weeks' estimated gestation presents to her obstetrician complaining of painful contractions occurring every 8 minutes for the past 2 hours. She has received appropriate prenatal care with no complications to date. She denies changes in vaginal discharge or leakage of fluid. She reports feeling tired with significant back pain, but when asked to clarify, she states that she has felt this way for the last few months. On review of symptoms, she denies headache, vision changes, shortness of breath, or burning with urination. She has costovertebral tenderness bilaterally, and the remainder of the exam including vitals is normal. Relevant laboratory values include WBC 8000/mm3; urinalysis is normal.

Perineal laceration

A 28-year-old G1P1 woman at 39 weeks' gestation presents to the emergency department complaining of severe, regular uterine contractions. On cervical examination, she is 5 cm dilated and is promptly admitted to the labor and delivery unit. The patient reports no complications with her pregnancy and has no medical problems. After almost 22 hours of active laboring, the patient delivers a 3.6-kg (8-lb) healthy baby girl. The placenta is delivered without difficulty, but the patient continues to bleed. Vaginal examination reveals the patient has extensive perineal lacerations.

Normal labor

A 28-year-old G3P2 woman presents to the labor and delivery triage unit at 39 weeks' gestation complaining of regular uterine contractions at intervals of 5-15 minutes. The patient's pregnancy was complicated by preterm labor at 31 weeks' gestation. Sterile speculum examination at that time was negative and revealed no pooling in the vaginal vault, a negative Nitrazine blue test, and a negative fern test. Her cervix was dilated to 2 cm and the patient was given two doses of betamethasone and 24 hours of intravenous magnesium sulfate. She was discharged on bed rest and had no further complications. On physical examination now, the patient is afebrile with a blood pressure of 115/70 mm Hg. Her cervix is dilated to 4.5 cm and 25% effaced.

Paroxysmal supraventricular tachycardia

A 28-year-old previously healthy female is brought to the emergency department by her boyfriend because of palpitations. Her boyfriend states that they had just left a bar when she began having a "fluttering" sensation in her chest. She quickly became short of breath and light-headed. Physical examination reveals an oral temperature of 37.0° C (98.6° F), a pulse rate of 193/min, a respiratory rate of 20/min, and a blood pressure of 96/46 mm Hg. Examination of the lungs is unremarkable, and a cardiac examination is significant only for tachycardia. Her electrocardiogram is shown in Figure 17-3.

Deep vein thrombosis

A 28-year-old woman is brought to the emergency department by her husband after she developed a high fever. She delivered a baby boy by cesarean section 5 days ago and then was discharged 3 days after delivery. Several hours ago, she began feeling flushed and her thermometer showed a fever of 38.2° C (100.8° F). Physical examination reveals an oral temperature of 38.7° C (101.7° F), a pulse of 105/min, and a blood pressure of 124/82 mm Hg. Abdominal examination is significant for a nontender abdomen with a normally healing cesarean section scar. Examination of the lower extremities reveals mild left lower-extremity edema with some pain on palpation without palpable cords.

Contraception

A 28-year-old woman presents to her gynecologist to discuss changing her contraceptive method. She has been using condoms with her partner, but they are monogamous and she would like to try something else. She has never been pregnant, but she thinks that she will one day want to have a child. She has never smoked. On physical examination, her heart rate is 80/min and her blood pressure is 130/80 mm Hg. A pelvic examination is unremarkable.

Sarcoidosis

A 29-year-old African-American woman presents to her primary care physician with a 6-month history of dyspnea on exertion, chronic dry cough, mild chest pain, malaise, and fatigue. Her temperature is 38.0° C (100.4° F), heart rate is 80/min, and respiratory rate is 20/min. Chest examination is notable for faint wheezes only. On eye examination, bilateral erythema at the scleral-corneal border is noted. Laboratory results are notable for a hemoglobin of 13 g/dL, a serum calcium of 12 mg/dL, and an elevated serum angiotensin-converting enzyme (ACE). Erythrocyte sedimentation rate (ESR) is elevated at 80 mm/hr. Results of pulmonary function tests (PFTs) are as follows:

Mastitis

A 29-year-old G1P1 woman presents to her obstetrician for her postpartum checkup 4 weeks after an uncomplicated delivery of a term male. She has been breast-feeding her son without difficulty until several days ago, when she noticed that her left nipple became dry and irritated, and the surrounding skin started to crack. Since then, her left breast has become increasingly sensitive, but she has continued to breast-feed despite the discomfort. Vital signs are notable for a temperature of 38° C (100.4° F). Physical examination reveals an erythematous left breast that is warm and tender to light touch. No pus can be expressed from the left nipple.

Nutrition in pregnancy

A 29-year-old G2P1 woman presents to her obstetrician's office at 10 weeks' gestation for her screening visit. She reports no complaints and states that she has been feeling well. Her past medical history is significant for a seizure disorder that began when she was a teenager. Her seizures have been well controlled with valproic acid, and she was able to discontinue her medication during her previous pregnancy without incident. Since discovering she was pregnant again, she self-discontinued her medication and has had no seizure activity. She is concerned about maintaining an adequate nutritional intake during her current pregnancy.

Hydrops fetalis

A 29-year-old G2P2 woman presents to the emergency department in labor and gives birth at 39 weeks' gestation to a baby girl who has difficulty breathing and appears grossly edematous and lethargic. She had received all appropriate prenatal care until 23 weeks, but she has not seen a doctor since then due to loss of health insurance. The infant is intubated and taken to the neonatal intensive care unit (NICU). She is tachycardic with muffled heart sounds, and she has a distended abdomen. She is hypotensive and difficult to arouse. Ultrasound examination reveals a pericardial effusion and ascites. Despite all resuscitative efforts, the infant dies after 4 hours of life.

Endometriosis

A 29-year-old nulligravid woman presents to her gynecologist complaining of pelvic pain, dyspareunia, and heavy cramping and back pain during her menses. On physical examination, she has a heart rate of 75/min and blood pressure of 125/80 mm Hg. Pelvic examination reveals a normal cervix, with tenderness of the posterior fornix on bimanual examination. No masses are palpated. Gonorrhea and chlamydia cultures are negative, as is a pregnancy test.

Cushing's syndrome

A 29-year-old woman presents to her gynecologist for her annual examination. She has been having irregular menstrual cycles for the past 2 years; the intervals between her periods have extended as long as 3 or 4 months. She denies painful cramps but notes that the periods are heavier than before the irregularity began. She and her husband have been trying to conceive for the past year but have not been successful. She denies pain during intercourse. She notes that she has been gaining weight for the past year, estimating that she is nearly 9.1 kg (20 lb) heavier than she was at her last annual checkup. Upon examination, she is 160 cm (5′3′′) tall and weighs 77 kg (170 lb). Her face is round and flushed, and her weight is concentrated around her abdomen; her arms and legs are comparatively thinner. Her breast and pelvic examinations are unremarkable, with the exception of thick, reddish-purple streaks around her breasts.

Irritable bowel syndrome

A 29-year-old woman presents to her primary care physician for repeated episodes of abdominal pain. She reports that, although she has had these episodes since college, the pains have become significantly worse since her divorce 1 year ago. Her abdominal pain is usually focused around her umbilicus, and she describes it as "crampy." She reports that the episodes of pain are exacerbated by eating and are relieved only by a bowel movement. She also frequently feels bloated. Her recent bowel movements have been loose and watery, with intervening episodes of constipation. She adds that although the abdominal pain is not present at night, she is also having difficulty sleeping. She denies any fevers or weight loss. Physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 69/min, and blood pressure of 118/76 mm Hg. An abdominal examination is remarkable only for diffuse mild abdominal tenderness.

MEN-1

A 29-year-old woman presents to her primary care physician with left-sided pain that has waxed and waned in severity over several hours. The pain started in her left flank but is now most intense in her left labial region. Her gynecologic history is notable for 12 months of amenorrhea. She is not pregnant but does report irregular milky discharge from both breasts for many months. Last week, she was diagnosed with peptic ulcer disease and given a prescription for omeprazole, which she has been taking as directed. Upon examination, the patient is clearly in distress. She cannot lie flat on the examination table and initially refuses to let the physician palpate her abdomen. Her blood pressure is 110/70 mm Hg, heart rate is 120/min, and respiratory rate is 19/min. Her examination is notable only for some left lower quadrant tenderness. Bowel sounds are normal. Relevant laboratory results include:

MEN-2a

A 29-year-old woman presents with a 1- week history of a neck mass. She noticed the mass while showering one day and is very concerned because her mother and grandfather both died of thyroid cancer at an early age. She denies any history of neck radiation or heat or cold intolerance. On examination, her temperature is 37.0°C (98.6°F), pulse is 85/min, and blood pressure is 136/90 mm Hg. She has a firm, non-tender 3-cm neck nodule located anteriorly just to the left of midline, immediately beneath the thyroid cartilage. The nodule rises when the patient swallows. There is palpable cervical adenopathy bilaterally. Relevant laboratory findings are as follows:

Primary sclerosing cholangitis

A 29-year-old-man presents to his gastroenterologist with jaundice, fatigue, fever, pruritus, and abdominal pain. He also notes pale-colored stools. His past medical history is significant for ulcerative colitis. He denies any fever, rashes, or recent illness but has been feeling fatigued for the past 3 weeks. He has been in a monogamous relationship with his wife for the past four year and has no history of sexually transmitted diseases. He works at a fast-food chain and tested negative for hepatitis A, B, and C at the company's last annual screening. Physical exam is notable for splenomegaly, hepatomegaly, and upper right quadrant tenderness. The patient has no rashes. His lungs are clear, and his heart has a regular rate and normal rhythm. Relevant laboratory findings are as follows:

Physiologic jaundice

A 3-day-old boy is brought to the pediatrician by his mother, who is worried that her son is turning progressively yellow. He was born by spontaneous vaginal delivery at 36 weeks' gestation to a 25-year-old G1P1; she had good prenatal care, and there were no complications with the pregnancy. He was discharged from the newborn nursery at 30 hours. He is breast-feeding and stooling well. On examination, he is a well-appearing infant with marked jaundice over his face and torso. Serum studies reveal total bilirubin of 13 mg/dL with conjugated bilirubin < 0.3 mg/dL.

Wilms' tumor (Nephroblastoma)

A 3-year-old boy is brought to his pediatrician because his mother noticed a "tennis- ball" sized mass in the lower-right side of his abdomen while giving him a bath. He is otherwise healthy, and his past medical history is unremarkable. On examination, he has a temperature of 36.5° C (97.7° F), heart rate of 120/min, respiratory rate of 18/min, and blood pressure of 98/65 mm Hg. He has a nontender 4 × 4-cm smooth, firm mass in the right lower quadrant and mild abdominal distention. The remainder of his examination is normal.

Chronic granulomatous disease

A 3-year-old boy with a history of recurrent infections is brought to the emergency department by his parents for left arm pain. The patient had fallen while climbing a tree 2 weeks ago and, 2 days prior to admission, had developed fever and left arm swelling. A radiograph of the left arm reveals an osteolytic lesion with periosteal reaction, consistent with osteomyelitis of the left ulna. Past medical history is significant for recurrent perianal abscesses since birth and repeated episodes of oral thrush, lymphadenitis, and bacterial enterocolitis. He was hospitalized at 14 months of age for osteomyelitis of the left proximal tibia caused by Serratia marcescens that responded well to antibiotic treatment. Family history is unremarkable, and there is no history of genetic disease.

Alpha-Thalassemia (Hemoglobin H disease)

A 3-year-old girl is brought to the emergency department after being found unconscious in her bed. She is cyanotic, her respiratory rate is 4/min, and her pulse is faint and thready. Her mother is frantic and unable to provide a history. She does state that her daughter has "a bad blood disease," which has necessitated numerous transfusions, particularly after a round of antibiotic treatment. Despite heroic measures, the child does not survive. A peripheral smear shows severe microcytic, hypochromic anemia with target cells and poikilocytosis. Emergency laboratory results revealed the following:

Renal artery stenosis

A 30-year-old Caucasian woman with a history of hyperlipidemia presents for evaluation of persistent hypertension. She was diagnosed with high blood pressure 18 months ago and was started on metoprolol, which did not significantly lower her pressures. A few months later, hydrochlorothiazide was added to her regimen, also with limited results. One week ago, she was started on captopril. She denies any symptoms from her hypertension, including palpitations, episodes of unexpected sweating, and headaches. She has no family history of hypertension and does not use oral contraceptives. She has smoked one pack of cigarettes per day for the past 10 years, does not use alcohol, and lives a sedentary lifestyle but denies alcohol use. Today, on examination, her pulse is 80/min; blood pressure is 152/90 mm Hg and relatively equal in all extremities. She has a normal, healthy body habitus. Her heart, lung, and abdominal examinations are all within normal limits. Her thyroid stimulating hormone (TSH) level is 2.9. The results of her two most recent basic metabolic panels are as follows:

Endometriosis

A 30-year-old G0 woman with a past medical history significant for dysmenorrhea presents to the infertility clinic with her husband for a follow-up visit. The couple has been trying to get pregnant for the past 3 years but has not had any success. A semen analysis and a hysterosalpingogram, as well as estrogen, progesterone, and follicle- stimulating hormone blood levels were all normal. A recent pelvic ultrasound revealed a 3-cm well-circumscribed mass on the patient's left ovary. Her last menstrual period was 3 weeks ago. The couple presents now to discuss the possibility of a diagnostic laparoscopy.

Internuclear ophthalmoplegia

A 30-year-old man presents to the ophthalmology clinic with "double vision." He states that when he gazes to the right, he sees two images side by side. This does not occur when he looks to the left. Past medical history is significant for depression, for which he takes amitriptyline. He denies ocular pain, recent viral illness, or tick bites. He does not smoke, drink alcohol, or use intravenous drugs. Visual field testing reveals an adduction deficit in the left eye. Extreme right lateral gaze causes horizontal nystagmus in the abducting right eye and recreates the painless horizontal diplopia the patient has been experiencing. Conjugate eye movements are observed in all other directions. Accommodation and convergence are normal.

Myasthenia gravis

A 30-year-old woman presents to her primary care physician complaining of double vision and fatigue. Her symptoms are absent in the morning but become progressively worse by the end of the day. Physical examination reveals a heart rate of 90/min and a blood pressure of 115/75 mm Hg. Ophthalmologic examination is remarkable for symmetric ptosis and intact pupillary responses bilaterally. Weakness of the muscles of the hand is evident bilaterally, but only after multiple contractions. Sensory exam is completely normal and deep tendon reflexes are intact.

Uterine atony

A 30-year-old woman with type 1 diabetes mellitus delivers a 4.3 kg (9 lb 8 oz) baby boy at 39 weeks' gestation. The first stage of labor progressed without incident, but the second stage was markedly prolonged. The patient received epidural anesthesia, which controlled her pain well. Immediately after the delivery of an intact placenta, the patient continues to bleed vaginally. Vital signs are significant for a blood pressure of 120/70 mm Hg and a heart rate of 79/min. The patient is alert and conversant. Bimanual examination reveals a soft, enlarged, boggy uterus.

Prenatal screening

A 31-year-old G3P2 woman presents to her obstetrician at 16 weeks' gestation. Both of her previous pregnancies were uncomplicated and resulted in normal spontaneous vaginal deliveries. The patient has no known medical problems and complains only of occasional morning sickness with nausea and vomiting. As part of her routine prenatal laboratory tests, the patient agrees to a triple screen test, which reveals a decreased maternal serum α-fetoprotein (MSAFP) level, elevated β-human chorionic gonadotropin (β-hCG), and a normal estradiol level.

Schizoid personality disorder

A 31-year-old man has decided to seek treatment from a psychiatrist through his employee assistance program because he feels that his drinking is jeopardizing his work and that he might be fired if he does not quit. He states that his job as a computer programmer is "okay" because he can keep to himself and not be bothered by his coworkers. During the interview, he reveals that he lives alone and has never had a girlfriend. He states that he does not miss having sex and that masturbation and computer pornography satisfy his sexual needs. He speaks to his brother frequently but has not seen other members of his family in quite some time; he shows little interest or affection in describing his relationship with them. He says that most nights he stays home surfing the Internet, playing computer games, or watching TV, and drinking up to a 12-pack of beer per night. He also smokes marijuana 4-5 times per week. On a mental status examination, he appears detached and aloof toward the psychiatrist. He reports his mood as "a little depressed"; his affect is congruent, and his range is flat. No other disorders are noted on examination.

Fetal monitoring

A 31-year-old obese G4P3 woman with a history of gestational diabetes in two of her previous pregnancies is in active labor at 41 weeks' gestation. She had an uncomplicated pregnancy and a negative glucose tolerance test. The patient's membranes spontaneously ruptured 2 hours ago, and she is currently experiencing regular contractions every 2-3 minutes. The patient's vital signs are within normal limits, and her pain is adequately controlled with an epidural. The fetal heart tracing is illustrated in Figure 11-2.

Deep venous thrombosis

A 31-year-old woman develops pain and swelling in her right calf on postoperative day 3 after an uncomplicated cesarean section for placenta previa. She denies any other complaints, including shortness of breath or heart palpitations. Her pain is relatively well controlled, and she has been using her incentive spirometer regularly. On physical examination, the patient is afebrile, heart rate is 88/min, and blood pressure is 125/75 mm Hg. Her right calf is tender, warm to the touch, and noticeably larger than the left calf.

Multiple sclerosis

A 31-year-old woman is referred to a neurologist for evaluation of multiple neurologic complaints. She recalls a specific episode 3 years ago of mild weakness in her right leg, which seemed to resolve over time. Last month, she developed incoordination of her left leg and left hand, although these too seem to be improving. She feels that she has also become less steady on her feet over time. Though she always considered herself to be an energetic person, over the past year or two she has been constantly fatigued. She has also been having problems focusing her attention and feels that her thinking has slowed down in general. She has noticed that many of her symptoms sometimes get worse after a hot bath or after she has been to the gym. The patient recently was sick with the flu and is now suffering from a particularly bad flare of her symptoms. Although her flu symptoms have subsided, she is concerned by the fact that 2 days following the onset of her flu she developed blurry vision in the right eye and pain in the eye associated with eye movements. On examination the patient is found to be afebrile and has normal vital signs. Her visual acuity in the right eye is 20/80 compared to 20/20 in the left eye. WBC count, erythrocyte sedimentation rate, and C-reactive protein are all normal. Cerebrospinal fluid analysis reveals slightly elevated protein, with elevated immunoglobulin G and oligoclonal bands on further analysis. MRI of the brain is shown in Figure 10-2.

Pneumocystosis

A 31-year-old woman with no known past medical history presents to the emergency department in respiratory distress. She recently emigrated with her family from India and is unable to speak English. Through a translator, she describes increasing shortness of breath over the past 2 weeks with a nonproductive cough. On physical examination, she is a thin and ill-appearing woman in respiratory distress. She is notably using her accessory muscles to breathe. Vital signs include a temperature of 38.3° C (101.8° F), heart rate of 122/min, blood pressure of 122/66 mm Hg, respiratory rate of 34/min, and oxygen saturation of 84%. Auscultation of the lungs reveals bibasilar crackles with relatively clear middle and upper lung fields. Her oral cavity reveals a white film on her tongue and buccal mucosa.

Uterine fibroids

A 32-year-old African-American G0 woman presents to her gynecologist for her annual examination. She complains of increased fatigue over the past year and thinks her periods may be heavier than before. She also notes increasing dysmenorrhea. Menarche was at age 9, and she denies previous problems with her periods. She has generally been healthy and takes hydrochlorothiazide for high blood pressure. On physical examination, she appears pale and tired. Vital signs include heart rate of 105/min and blood pressure of 120/78 mm Hg. Cardiac, lung, and abdominal exams are within normal limits. On pelvic exam, there is no discharge or cervical motion tenderness. Her uterus feels enlarged to 12-week size and misshapen. Laboratory tests reveal a hemoglobin of 8.7 g/dL and hematocrit of 27%.

Pheochromocytoma

A 32-year-old man presents to his primary care physician after experiencing a severe headache for 1 week. He rates the pain as 8 out of 10 and says that it is nearly constant. He has taken 650 mg acetaminophen every 6 hours for the past 5 days but has not gained significant relief. He has been in generally good health for most of his life, but has lost 2.7 kg (6 lb) in the past month. He has also begun feeling extremely anxious and "shaky," which he attributes to job-related stress. However, he admits that the level of anxiety exceeds the gravity of his problems at work. He has stopped exercising because of abdominal pain that makes it difficult to lift weights; he cannot localize the pain, noting that his entire abdomen aches at times. He also notes that he sweats much more than he used to and cannot drink enough water to compensate. Upon examination, he is trembling as he sits on the examination table. His blood pressure is 220/160 mm Hg, heart rate 148/min, and respiratory rate 17/min. His abdomen is soft and non-tender; bowel sounds are normal. On two occasions during the visit, he experiences severe nausea but does not vomit.

Acanthosis nigricans

A 32-year-old obese woman presents to her primary care physician's office for a preemployment physical. She states that she is in good health, but she has noticed darkening areas around her axillae and under her breasts. She first noticed the dark areas a few years ago but has not paid much attention to them. Her family history is remarkable for obesity, heart disease, hypertension, and type 2 diabetes mellitus. On physical examination, the patient is a well-appearing but obese female. Her blood pressure is 135/85 mm Hg, and her heart rate is 80/min. Her body mass index (BMI) is 32 kg/m2. Examination of the skin shows prominent skin lines in the patient's axilla (Figure 2-1), posterior neck, and underneath her breasts. There are also dark, "dirty- appearing," velvety plaques in these regions.

Domestic violence

A 32-year-old pregnant woman with a history of drug abuse and depression presents to the emergency department for evaluation of a sprained wrist. On physical examination, several bruises in various stages of healing are noted on her torso and upper extremities. The cause of her injuries is unclear, because she initially says that she slipped and fell against a table; the appearance and distribution of her bruises are not consistent with her story. She seems uncomfortable when pressed further for clarification and changes the details several times.

Syphilis - Chancre sore

A 32-year-old woman presents to the city health clinic after she noticed an ulceration on her vulva. She first noticed the lesion about 1 week prior. She has a history of gonorrhea and is worried that this may be another sexually transmitted infection. She recently became sexually active with a new partner, and she denies using any form of protection. She denies any other symptoms. On examination of the external genitalia, a painless, ulcerated papule is observed in the vestibule of the vagina. The ulcer has a smooth, clean base with indurated borders. The remainder of the pelvic examination is unremarkable.

Fibrocystic breast disease

A 32-year-old woman presents with a chief complaint of bilateral breast pain, with greater pain in her right than left breast. The patient's maternal grandmother had breast cancer at age 60, but otherwise there is no family history of breast or ovarian cancer. On physical examination, the patient's breasts appear symmetric, without dimpling, rashes, or nipple inversion or discharge. Her breasts are tender to palpation bilaterally, and several 2-3-cm masses are palpated in her upper outer right breast. The masses are movable and round, with discrete borders and a "rubbery" feel. The patient reports that the pain increases toward the latter part of her menstrual cycle and that she is currently contraceptives.

Peptic ulcer disease

A 33-year-old lawyer presents to his primary care physician with burning epigastric pain that worsens when he is hungry and is relieved by food. He reports that the pain awakens him at night. Over the past month he has gained 6.8 kg (15 lb). He has smoked 2 packs of cigarettes per day for the past 10 years. Due to work-related stress, he often gets severe headaches for which he takes up to seven aspirin tablets per day. Aside from epigastric tenderness on palpation, his physical exam is unremarkable. Vital signs include a temperature of 37°C (98.6°F), pulse of 75/min, and blood pressure of 118/74 mm Hg.

Conn syndrome (Hyperaldosteronism)

A 33-year-old woman presents to her family physician for a follow-up visit. Two months ago, during a visit for a viral upper respiratory infection, her blood pressure had been 140/90 mm Hg. Her physician noted this and requested that she return for further evaluation when her infection resolved. The patient is in generally good health and denies medical problems. Today, her blood pressure is 190/100 mm Hg, heart rate is 80/min, and respiratory rate is 14/min. Her physical examination is otherwise unremarkable. Relevant laboratory values are as follows:

de Quervain's thyroiditis

A 33-year-old woman presents to her primary care physician with neck pain. The pain began 2 weeks ago, is constant and sharp, and radiates to her jaw and ears. Over the past few weeks, she has also been having occasional loose stools and experiencing fatigue, malaise, and myalgias. She has no history of medical problems but does report having a "cold" 4 weeks ago. On examination, her temperature is 37.9°C (100.2°F), pulse 96/min, and blood pressure 134/82 mm Hg. There is diffuse enlargement of the thyroid gland, which is exquisitely tender to even mild palpation. Relevant laboratory results include:

Acute interstitial nephritis

A 33-year-old woman presents to the emergency department with a three-day history of fever, malaise, and mild nausea. Over the past day, she has also noticed a new rash on her trunk and extremities. She denies any medical problems, except for a urinary tract infection (UTI) 1 week ago, for which she has been taking cephalexin. She is not on any other medications and denies alcohol use. On examination, her temperature is 39.0o C (102.2o F), pulse is 90/min, and blood pressure is 128/82 mm Hg. Findings from her heart and lung examinations are within normal limits, and her abdomen is soft, nontender, nondistended, and with normal bowel sounds present. Her laboratory results are as follows:

Disseminated intravascular coagulation

A 34-year-old G3P2 woman at 33 weeks' gestation with a history of hypertension presents to the emergency department complaining of severe pelvic pain and persistent vaginal bleeding. Transvaginal ultrasound reveals a large retroplacental clot. Vital signs are significant for a blood pressure of 170/90 mm Hg, and the fetal heart rate tracing is nonreassuring. The patient is diagnosed with a placental abruption and preeclampsia and undergoes an emergent cesarean section. Postoperatively, the patient is unable to be extubated. Physical examination is notable for petechiae on all four extremities. Relevant laboratory studies are as follows:

Sheehan's syndrome

A 34-year-old G3P3 woman is 20 days postpartum after a vaginal delivery that was complicated by a 1500-mL hemorrhage secondary to uterine atony. The patient did not respond to oxytocin or methylergonovine administration and experienced a 10-minute episode of sustained hypotension ranging from 62/30 to 71/25 mm Hg that required 10 units of packed RBCs. The patient was finally stabilized after emergent uterine artery embolization. On postpartum day 2, the patient was found to have a creatinine level of 1.8 mg/dL, which peaked at 3.5 mg/dL on postpartum day 7, and has since returned to baseline. The patient is currently feeling well but presents to her obstetrician complaining of an inability to lactate.

Hypothyroidism

A 34-year-old mother of two children presents to her primary care physician for a routine checkup. She has been feeling weak and tired for the past 3 months and notes constipation, with bowel movements approximately three times per week. She attributes the fatigue to the increase in menstrual flow and painful cramps she has observed for the past six cycles. For the past 2 months, she has also experienced a general lack of interest in her hobbies and finds it difficult to get out of bed each morning to care for her children. On physical examination, she appears to be shivering slightly. She weighs 11.3 kg (25 lb) more than she did at her last visit 12 months ago. Her blood pressure is 125/75 mm Hg, pulse is 55/min, and respirations are 12/min. A 5-cm, nontender neck mass is palpable, and her skin is dry and cold. Delayed relaxation of deep tendon reflexes is also noted. Her physician orders blood tests that reveal the following:

Vulvovaginal candidiasis

A 35-year-old G1P1 woman presents to her gynecologist complaining of vaginal itching, discomfort, and discharge of a white "creamy" consistency. Her last menstrual period was 3 weeks ago, and she does not report any new sexual partners. She uses an intrauterine device (IUD) for contraception. Her temperature is 37.0° C (98.6° F), heart rate is 80/min, and blood pressure is 125/80 mm Hg. Speculum examination reveals erythematous and slightly edematous external genitalia. The vaginal walls are coated with a thick, white discharge, but the cervix appears normal, and the IUD string is visible from the os. A sample is taken, two slides are made, and the pH is determined to be 4.0. The saline-prepared slide shows only epithelial and inflammatory cells, while the potassium hydroxide-treated slide shows pseudohyphae and budding yeasts. There was no odor noted upon treatment with potassium hydroxide.

Secondary amenorrhea

A 35-year-old G2P1 woman presents to her gynecologist claiming absence of menstruation for the past 4 consecutive months, except for occasional spotting. Her gynecologic history is notable for an incomplete miscarriage and therapeutic dilation and curettage (D&C) approximately 6 months ago, along with the birth of a child within the past year. She is currently not taking oral contraceptive pills (OCPs) and indicates that her periods have previously followed a regular cycle. She has a body mass index (BMI) of 24, her pulse is 84/min, and blood pressure is 120/75 mm Hg. On gynecologic exam, the physician notes that the patient expresses discomfort; the patient indicates that she has noticed her vagina is drier than normal and that this has inhibited her sexual activity. The physician does not note any other gynecologic abnormalities on exam.

Abortion

A 35-year-old G3P3 woman presents to the office complaining of breast tenderness, bloating, and mild nausea. Her last menstrual period was 6 weeks ago. She is married and has three children under 5 years of age. She uses oral contraceptive pills for birth control. On physical examination, she is afebrile, with a heart rate of 90/min and blood pressure of 140/80 mm Hg. Pelvic examination reveals a normal cervix with a bluish tint. Results of a urine pregnancy test are positive. Transvaginal ultrasound reveals a 6-week-sized gestational sac with detectable fetal heartbeat. The patient is visibly distressed upon hearing about the pregnancy, which she says was unplanned. She says she is overwhelmed with taking care of her three children and does not think she can support another child, financially or emotionally. She says she has considered working with an adoption center, but she was on bed rest for 6 weeks during her last pregnancy and is afraid of the risks and difficulties of carrying this pregnancy to term. She asks for information about abortion.

Essential hypertension

A 35-year-old black man with no significant past medical history presents to the outpatient clinic for a follow-up examination 4 weeks after he was noted to have a blood pressure of 150/80 mm Hg on a routine health maintenance examination. He has no complaints, takes no medications, and does not smoke or use alcohol or other drugs. His family history is significant for a father with high blood pressure and a maternal grandmother who died of breast cancer. His blood pressure on this visit is 150/90 mm Hg.

Opioid withdrawal

A 35-year-old homeless man is admitted to the medical ward for treatment of an acute asthma exacerbation. He has a medical history significant for chronic severe asthma with multiple hospital admissions, as well as tobacco use, heroin abuse, hypertension, and chronic, untreated tinea corporis infection. He is on his third day of supportive treatment with nebulized albuterol, metered-dose inhaled fluticasone, and an oral prednisone taper when he develops nausea, vomiting, and nonbloody diarrhea. He denies chest pain, palpitations, shortness of breath, dizziness, abdominal pain, fevers, or chills. His vital signs are within normal limits, and he has teary eyes with dilated pupils; he is yawning and sneezing intermittently.

Abdominal trauma

A 35-year-old man is brought by ambulance to the trauma bay of the emergency department. The paramedic team reports that he appears to have been shot in the abdomen and had an unknown amount of blood loss at the scene. No other history surrounding the incident is known. His initial trauma survey reveals a temperature of 37.5° C (99.5° F), blood pressure of 90/60 mm Hg, a pulse rate of 110/min, a respiratory rate of 18/min, and an oxygen saturation of 98% on room air.

Herniated lumbar disk

A 35-year-old man is referred to an orthopedic surgeon for severe back pain radiating to his left leg. He has not been able to play in his weekly basketball game since the pain began 5 weeks ago. During the past 2 weeks, he says the pain has increased in severity and he can only sit for 20 minutes before the shooting pain becomes intolerable. The patient claims that he has had back pain before, but it has never been this severe and has always been well controlled with over-the-counter nonsteroidal anti-inflammatory medications (NSAIDs). Currently, he reports getting no relief from NSAIDs. The pain has begun to affect his ability to sleep, as he wakes up in pain every 1-2 hours. He denies any recent back injury, infection, weight loss, or changes in appetite. The patient appears to have an athletic build and stands throughout the office visit. On physical exam, raising the patient's left leg 30 degrees above the horizontal plane reproduces the pain; this does not occur with his right leg. The patient has no focal lower extremity weakness, but he does have an absent Achilles tendon reflex on the left. An MRI of the lower spine is shown in Figure 9-2.

Tuberculosis

A 35-year-old man is sent to the emergency department by a homeless shelter caseworker after he is seen coughing up blood. He has been living on the streets for the past 6 months following his release from a 3-year incarceration. He complains of night sweats and fevers. On physical examination, his temperature is 38.5° C (101.3° F) with a heart rate of 90/min, a respiratory rate of 15/min, and a blood pressure of 120/80 mm Hg. His physical exam is notable for cachexia. Both lung fields are clear to auscultation. His chest x-ray film is shown in Figure 15-5, and two of three sputum samples are positive for acid-fast bacilli.

Emphysema

A 35-year-old man presents to his primary care physician with shortness of breath, which has been worsening over the past few months. Always fairly active, he was unable to play tennis this past weekend. He notes a mild cough but denies chest pain with exertion, fevers, chills, or night sweats. He has no known sick contacts and has not traveled anywhere recently. He smoked for a few years in his 20s but does not currently smoke, has never used illicit drugs, and drinks alcohol socially. He has no significant past medical history except persistently elevated transaminases of unknown etiology. On physical examination, vital signs are within normal limits. The chest wall is tympanitic, and breath sounds are decreased in both bases. Basic labs and pulmonary function tests (PFTs) are as follows:

Rheumatoid arthritis

A 35-year-old woman presents to her primary care physician with a 6-week history of hand stiffness, swelling, and pain. The stiffness is worst in the morning, taking up to an hour to become "more manageable." Upon further questioning, the patient admits that she has been having some pain in her knees as well over the past 6 months but thought that it was related to inactivity. The patient denies any fevers, rashes, or recent illness. She is currently in a stable relationship, and both she and her partner were recently tested and found to be negative for sexually transmitted diseases. She denies any decreased sensation or color changes in her fingers during exposure to the cold. The patient notes that her grandmother had "arthritis" but does not recall the details. Her physical examination is significant for mild swelling and tenderness over the metacarpophalangeal (MCP) joints of both hands. Her knees also have slight warmth and small effusions bilaterally but no point tenderness or loss of range of motion. The patient has no rashes or mouth ulcers. Her lungs are clear, and her heart has a regular rate and rhythm. Relevant laboratory findings are as follows:

Stevens-Johnson syndrome

A 35-year-old woman presents to the emergency department complaining of flulike symptoms, sores in her mouth, and a rash on her chest and arms. She also complains of painful skin. She denies any drug allergies, but she does report recently starting a new anti-seizure mediation for her epilepsy. On physical examination, the patient is febrile, with blood pressure of 125/85 mm Hg and pulse of 100/min. A symmetric eruption of targetoid patches, many with central vesicles, is present over the chest, arms, and face.

Placenta previa

A 36-year-old G5P4 woman at 27 weeks' gestation presents to her obstetrician complaining of vaginal bleeding. She states that the bleeding began 2 days ago as mild, pinkish spotting but has recently worsened. She denies any abdominal or pelvic pain with the bleeding and states that she has not experienced any recent trauma. She has no medical problems except for a history of preeclampsia in a previous pregnancy, which necessitated an emergent cesarean section. Vital signs are notable for a temperature of 37.3° C (99.2° F), a heart rate of 90/min, and a blood pressure of 105/70 mm Hg. Physical examination is notable for a gravid uterus with sizes equal to dates, and a cervical exam was not performed.

Rapidly progressive glomerulonephritis

A 36-year-old woman presents to the emergency department with a 2-week history of nonproductive cough, fatigue, and swelling in her legs. She reports that over the past 3 days she has not been urinating as frequently as she normally does and that her urine is darker than usual. Review of symptoms and past and family histories are otherwise unremarkable. A routine employment physical 1 year ago showed a blood pressure of 115/75 mm Hg and a normal urinalysis. Current physical examination reveals hypertension (165/95 mm Hg) and peripheral edema, but otherwise is normal. Laboratory testing reveals a serum creatinine level of 2.5 mg/dL. Urinalysis reveals a specific gravity of 1.022, 4+ blood, 2+ protein, many RBCs, occasional WBCs, and pigmented and RBC casts. She is admitted to the hospital for further workup; the following day, her creatinine is 3.2 mg/dL.

Gestational diabetes

A 37-year-old G4P3 obese woman at 26 weeks' gestation presents to her obstetrician for a routine prenatal visit. She states that diabetes runs in her family. She has no significant past medical history and denies gestational diabetes in her previous pregnancies. She was screened at 10 weeks in this pregnancy and has been receiving routine prenatal care at regular intervals. The results of a 3-hour glucose tolerance test (GTT) are as follows:

Hyperosmolar hyperglycemic state

A 37-year-old hypertensive obese man with a 1 week history of productive cough, fever, and chills becomes progressively more obtunded and on day 7 is brought to the emergency department, where he has a generalized tonic-clonic seizure. Physical examination reveals a blood pressure of 90/60 mm Hg, heart rate of 100/min, and temperature of 37.9° C (100.2° F). He responds to his name but is lethargic, has decreased skin turgor, no axillary sweat, no peripheral edema, and no focal neurologic signs. There is dullness to percussion and decreased lungs sounds in the right lower lobe of his lungs. Relevant laboratory findings are as follows:

Idiopathic pulmonary arterial hypertension

A 37-year-old woman with no significant past medical history presents to her primary care physician complaining of dyspnea on exertion accompanied by mild chest pain. She recently fainted after walking up a flight of stairs. She is afebrile, with a heart rate of 90/min, respiratory rate of 12/min, blood pressure of 90/70 mm Hg, and oxygen saturation of 89% by pulse oximetry on room air. Cardiac examination is notable for a loud pulmonic component to the second heart sound and a systolic murmur best appreciated at the lower sternal border. Distended neck veins, hepatomegaly, and lower extremity edema are appreciated. Skin and musculoskeletal examinations are normal. X-ray of the chest reveals normal lung fields with cardiomegaly and enlarged pulmonary vessels. Pulmonary function tests (PFTs) reveal a diffusion capacity of 50%.

Informed consent

A 38-year-old man presents to an oncologist after being recently diagnosed with non- Hodgkin's lymphoma. The patient is the father of three young children and is notably distraught. He and his wife wish for "everything possible to be done." The physician begins to obtain informed consent for a specific treatment regimen.

Hidradenitis suppurativa

A 38-year-old woman presents to her primary care physician with a complaint of pain and bumps in both of her armpits. The bumps have come and gone over the past several months and are red, warm, and painful to the touch. She has also noticed intermittent drainage and has tried applying several over-the-counter creams and baby powder to the area, without improvement. On physical examination, she is an obese woman with a body mass index of 35 kg/m2 and is profusely sweating, with stains on her shirt about her axillae. Her exam is otherwise normal except for multiple raised, hard nodules in her axillae bilaterally that cause the patient considerable pain and drain a thick yellow liquid when pressed.

Toxic shock syndrome

A 38-year-old woman presents to the emergency department with nausea, vomiting, fever, and chills. A few days prior to the onset of these symptoms, she developed a rash over most of her body that resembles a sunburn. She has no prior medical history. She is currently menstruating and regularly uses "super-absorbent" tampons. She reports that she has not been changing her tampons as frequently since her pharmacy was out of her usual brand. On examination, her temperature is 39.0° C (102.2° F), blood pressure is 90/60 mm Hg, heart rate is 110/min, and oxygen saturation is 96%. She appears visibly ill. A diffuse macular erythematous rash is present over most of her body, and her conjunctivae appear injected. Relevant laboratory findings include a WBC count of 18,000/mm3, hemoglobin of 11.0 g/dL, and a platelet count of 90,000/mm3.

Achalasia

A 39-year-old G2P2 woman presents to her primary care physician with a sensation of undigested food in the back of her throat and chest pain following meals. She reports difficulty swallowing solids and liquids that started during her last pregnancy but has continued over the past year following delivery. On multiple occasions, she has found undigested food on her pillow in the morning. She reports losing 1.8 kg (12 lb) over the past 2 months due to the discomfort she feels after eating. She has been taking famotidine and omeprazole for her symptoms but reports no relief. Her physical exam is normal. Her abdomen is nontender, nondistended, and soft, with normal bowel sounds.

Hyperthyroidism

A 39-year-old woman is seen in the emergency department after having fainted while exercising with her husband. She notes that, despite having maintained the same exercise regimen for the past few years and increasing her caloric intake, she has lost about 6.8 kg (15 lb) over the past 2 months. Furthermore, she sweats much more than she used to, even when not exercising. Her bowel movements have become more frequent, and her menstrual cycles are more irregular. Her blood pressure is 130/80 mm Hg, pulse is 112/min, and respiratory rate is 16/min. She finds it difficult to sit still during the physical examination. Her skin is moist and warm. She has mild proptosis bilaterally. The rest of her examination is unremarkable. Laboratory tests reveal the following:

Ventricular septal defect (VSD)

A 4-month-old boy is brought to his pediatrician because of an increased difficulty in breathing and poor weight gain. His mother notes that he often perspires and appears dusky during feeds. His past medical history is significant for a suspected pneumonia at 2 months of age that resolved with antibiotic therapy. He was born full term without complications. His physical examination is remarkable for a 4/6 blowing holosystolic murmur in the left lower sternal border as well as a diastolic rumble heard at the apex.

Infantile spasms (West syndrome)

A 4-month-old boy is brought to the emergency department (ED) by his parents following a seizure. He was lying in his crib when his head, trunk, arms, and legs began symmetrically jerking; his parents estimate that the seizure lasted 2 minutes. He began seizing again in the car on the way to the ED. He has been healthy since birth and has met all his developmental milestones. On physical examination, the baby appears postictal. There are no obvious neurologic findings. An interictal electroencephalogram (EEG) displays hypsarrhythmia.

Hirschsprung disease

A 4-month-old girl with a history of chronic constipation and failure to thrive is brought to the emergency department with a 2-day history of fever to 39.1° C (102.3° F), bilious vomiting, and decreased oral intake. Her parents deny any change in her bowel habits from her usual 1-2 stools per week. Her only medication is docusate sodium for chronic constipation since 2 months of age. On examination, she has a temperature of 38.6° C (101.4° F), heart rate of 144/min, and blood pressure of 95/63 mm Hg. Her height, weight, and head circumference are all below the 5th percentile. Physical examination is significant for a thin and tired-appearing infant. Her abdomen is soft and distended with distant bowel sounds. There is palpable stool in the lower left quadrant. Rectal examination is significant for a small ampulla that is empty of stool. A radiograph of the abdomen is performed and shows dilated loops of bowel with an absence of rectal air.

Duchenne muscular dystrophy

A 4-year-old boy is brought to his pediatrician because he has been having difficulty in preschool with both learning and play activity. In the first 2 years of life, the patient successfully reached many developmental milestones including holding his head up, rolling over, sitting, and standing at the appropriate ages. However, he did not begin to walk until 16 months. By age 2, he was walking with a lordotic posture. The patient had been doing fairly well prior to beginning preschool, but over the past 5 months both the patient's parents and teacher have noticed that he seems to be regressing. In particular, he does not seem to be able to run around with the other kids in his class and has difficulty rising from a seated position. His physical exam is notable for 3/5 strength in the proximal muscles of both the upper and lower extremities. The patient's gastrocnemius muscles appear disproportionately large bilaterally. When lying prone and asked to raise himself to a standing position, the patient has great difficulty and needs to push off with his arms, and then push against his knees and thighs in order to stand. Laboratory examination is significant for an elevated serum creatine kinase level of 27,000 IU/L.

Molluscum contagiosum

A 4-year-old boy is brought to the pediatrician's office by his mother for "bumps" on the child's abdomen that have been present for over a month. The mother reports first noticing the lesions shortly after the child started attending day care. She has tried a variety of topical over-the-counter medications, but nothing has helped. She is concerned because the lesions seem to be increasing in number and spreading across the child's abdomen. The child is otherwise healthy. On physical examination, the child is well appearing. Multiple 2- to 5-mm dome-shaped, shiny papules, most with a central umbilication are observed on the child's abdomen (Figure 2-4). Two similar lesions are also observed around the child's left eye.

Animal bite

A 4-year-old boy presents to the emergency department being carried by his mother. His mother reports that approximately 1 hour ago the child was "playing" with the family dog by pulling its tail and flicking its ears while it was eating. Consequently, the dog bit the child on the hand deep enough to draw blood. She decided to bring the child into the hospital because, despite her best efforts to alleviate his pain, her son continues to cry. His vital signs are normal, and on physical exam, he appears healthy yet extremely agitated and inconsolable. His right hand is erythematous and swollen about the proximal metacarpal phalangeal joints of the second, third, and fourth digits.

Juvenile rheumatic arthritis

A 4-year-old girl is brought to her pediatrician by her parents because they are concerned about her right knee. For the past several months, the patient's right knee has been swollen and she often limps. Her parents note that sometimes she does not want to walk in the morning, but seems fine later in the day. The patient's past medical history is unremarkable. On physical examine, there appears to be a large effusion of the right knee but no erythema, increased warmth, or tenderness to palpation or range of motion testing. The right knee has a passive range of motion of 15-120 degrees. Relevant laboratory findings are as follows:

Acute lymphoblastic leukemia (ALL)

A 4-year-old girl presents to her pediatrician with a 2-week history of cough, nasal congestion, and fatigue. Her mother has brought her in three times in the past month for unremitting cold symptoms; each time, the child has been diagnosed with a viral upper respiratory infection and advised on symptomatic care. She has been sleeping more than usual for the past few days, and she awoke this morning with a new rash. On physical examination, she has a temperature of 37.2° C (99.0° F) and pulse of 140/min. She appears pale, with scattered petechiae across her lower legs, hepatosplenomegaly, and cervical lymphadenopathy.

MRSA

A 4-year-old girl presents to her pediatrician with pain and swelling of her right thigh. Her parents note that she has been playing outside frequently and suffered a questionable spider bite several days ago. The child has had increasing pain and discomfort since that time and now is not as active as usual. Over the last day, she has not been eating well, has had a fever up to 38.6° C (101.4° F), and is fussy and irritable. Her past medical history is significant only for a prior soft tissue infection at 2 years of age. Her mother thinks some of the other children at daycare may have had similar skin infections. On physical examination, her temperature is 38.9°C (102.1° F), blood pressure is 95/69 mm Hg, and heart rate is 115/min. The patient also has a 4 × 5-cm fluctuant mass on her medial right thigh with overlying erythema, which is obviously painful to touch.

Small bowel obstruction

A 47-year-old man presents to the emergency department with colicky abdominal pain that has lasted 5 hours. He reports two episodes of feculent vomiting and a bowel movement 10 hours ago. Physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 92/min, and blood pressure of 134/90 mm Hg. Abdominal examination reveals a mildly distended abdomen with well-healed surgical scars and diffuse tenderness. High-pitched, hyperactive bowel sounds are noted. No hernias are appreciated, and rectal examination is unremarkable. An abdominal film is shown in Figure 6-4.

Spontaneous bacterial peritonitis

A 47-year-old man presents to the emergency department with mild abdominal pain that he has had for the past 24 hours. He has noticed an increase in his abdominal girth and has been feeling intermittently confused. He adds that last year another physician told him that his "liver was bad." Physical examination reveals a temperature of 38.2°C (100.8°F), pulse of 104/min, and blood pressure of 136/74 mm Hg. He is alert and oriented to person and place. He is unable to provide the correct date. An abdominal examination reveals a distended, nontender abdomen with shifting dullness. Neurological examination reveals asterixis.

Suicidal ideation

A 47-year-old man was diagnosed with AIDS 3 years ago. Shortly after his diagnosis, he informed his partner of 8 years over the phone; she subsequently hung up on him and refused to speak with him again. Since then, he has become progressively more socially isolated from his friends and family and has started drinking heavily. The pain from his peripheral neuropathy is a source of constant agony. On several occasions he has expressed a desire to die to his physician, and against the doctor's pleas he has stopped taking his antiretroviral medications. He refuses to seek help from a psychiatrist who could treat his depression and help him to cope with his illness. He views his illness as a punishment beyond help. He feels useless and sees no good in trying to delay the inevitable.

Paraneoplastic syndrome

A 48-year-old man presents to the emergency department with a 2-day history of confusion and weakness. He has been complaining of back pain for the past 2 months and has lost 9.1 kg (20 lb) over the past 6 months. He takes acetaminophen and ibuprofen occasionally for his back pain. His past medical history is unremarkable. On physical examination, the patient looks older than his stated age; his blood pressure is 110/80 mm Hg while supine and 90/60 mm Hg when standing, and his heart rate increases from 90/min to 112/min, respectively. The rest of his examination is unremarkable except for mild muscular weakness. Relevant laboratory findings are as follows:

Metabolic syndrome

A 49-year-old man presents to his primary care physician for a work-related physical examination. He is in generally good health, though he admits to being in worse physical shape than he was 5 years ago. He attributes this to a career change that has him working at a desk instead of on his feet all day. He has tried repeatedly to start a new exercise regimen over the past year but generally only manages to exercise three times each month. He eats three meals a day but admits to a love of junk food. He drinks alcohol daily, typically one or two beers with dinner. He smoked one pack of cigarettes a day for 20 years before quitting last year. His blood pressure is 160/95 mm Hg, pulse is 90/min, and respiratory rate is 16/min. He is 168 cm (5′6′′) tall and weighs 90.7 kg (200 lb). His last full checkup was nearly 3 years earlier, so his physician recommends a full panel of blood work. Relevant results are as follows:

Congenital heart disease - Tetrology of Fallot

A 5-month-old boy is brought to the emergency department for cyanosis. The child was born full term and was noted to be mildly cyanotic at birth. The cyanosis resolved after 20 minutes, and he was discharged home after 3 days. His parents note that he occasionally has episodes of irritability, crying, hyperventilation, and breathlessness that are usually self-limiting and are followed in most cases by a period of sleep. His mother also notes that he has occasional difficulty breathing while breast-feeding. On the morning of admission, his parents noticed that his lips and fingertips turned blue while he was crying. On physical examination, the patient is sleeping comfortably with no signs of respiratory distress. His heart rate is 130/min, respiratory rate is 24/min, blood pressure is 95/65 mm Hg, and oxygen saturation is 92% on room air. Subtle cyanosis of his mucous membranes is present. Cardiac examination reveals a normal S1 and a single S2. A 4/6 systolic ejection murmur is heard loudest at the left upper sternal border. His lungs are clear to auscultation bilaterally. The remainder of the physical examination is unremarkable.

Henoch-Schonlein Purpura

A 5-year-old girl is brought to her pediatrician with a rash on her legs, abdominal pain, and arthralgias. Two weeks ago, the patient had an upper respiratory infection. Three days prior to this visit, the patient complained of abdominal pain and was taken to a local emergency department. Abdominal radiograph and obstruction series were normal and the patient was sent home. The morning of admission, her mother noticed "red bumps" on both of the patient's legs. The patient had no history of fever, diarrhea, or bloody stools. Her temperature is 37.5° C (99.5° F), heart rate is 115/min, respiratory rate is 22/min, and blood pressure is 95/70 mm Hg. Physical examination is significant for 2-5-mm erythematous, nonblanching papules on the lower extremities as well as a slightly swollen and tender right knee. The remainder of the examination is unremarkable. Relevant laboratory findings are as follows:

Amyotrophic lateral sclerosis

A 50-year-old left-hand-dominant man presents to his primary care physician with complaints of right hand weakness. He says 6 months ago he began dropping things with his right hand. In the subsequent months, his grip strength has weakened further and his handwriting has deteriorated. He has also noticed frequent twitching in the muscles of his right hand, forearm, and shoulder, and he has developed painful muscle cramps in his neck and back. He also reports occasional problems swallowing his food and says his speech seems "thicker." The patient reports no other significant past medical history and denies any lower extremity disturbances or sensory deficits. Vital signs are within normal limits. The patient's cranial nerve examination is significant for atrophy of the tongue, which also demonstrates fasciculations upon protrusion. On motor exam, the patient has significant thenar atrophy of the right hand, but not on the left. Right hand strength is 3/5, and left hand strength is 4/5. Triceps and biceps are 4+/5 bilaterally and deltoids are 5/5 bilaterally. Neuromuscular examination of the lower extremities is normal. Reflexes are 3+ in the upper extremities bilaterally and he also has a brisk jaw jerk reflex. Sensory examination is normal. The patient's gait is normal, and he exhibits no ataxia.

Health care screening

A 50-year-old man presents to his primary care physician for a physical examination. He has not seen a physician in over 20 years. He was given a membership to the local gym as a birthday present and feels that he should be medically evaluated before starting his workouts. He weighs 78 kg (172 lb) and is 183 cm (72 in) tall with a BMI of 24 kg/m2, blood pressure of 140/90 mm Hg, and heart rate of 86/min.

Obstructive sleep apnea

A 50-year-old man with a past medical history significant for type 2 diabetes mellitus presents to his primary care physician complaining of excessive daytime sleepiness. He claims that he gets 8 hours of sleep every night yet wakes up every morning with a headache and dry mouth. He finds himself to be lethargic and often falling asleep at work. His wife complains that he snores all night long. He is afebrile, with a heart rate of 90/min, respiratory rate of 12/min, and blood pressure of 150/90 mm Hg. He is 178 cm (5′10′′) tall and weighs 115 kg (253 lb). Head and neck examination is notable for a large, low-hanging soft palate, and a neck circumference of 43 cm (16.9 in). Heart, lung, and neurologic examinations are unremarkable. Hematology and electrolyte panels are normal.

Carpel tunnel syndrome

A 50-year-old seamstress presents to her primary care physician with numbness and pain in the thumb, index, and middle finger of her right hand. She reports occasionally being awakened from sleep by the pain, which is relieved by moving her fingers. She notes that the pain comes on when she is holding a piece of cloth for a prolonged period while sewing. She also notes that recently she has had difficulty unscrewing jar tops and holding onto a glass or tea cup after a long day at work. She denies any trauma to her right hand, pain in other joints, fevers, or chills. On physical exam, the paresthesia is reproducible by having her hold her wrist flexed at 90 degrees for 30 seconds. Tapping on her right wrist reproduces the pain.

Hepatitis

A 50-year-old surgeon presents to his primary care physician with a 2-3-week history of fatigue and right upper quadrant discomfort. During the past week, he has noticed yellowing of his eyes. He was previously healthy and has no chronic medical problems. Several months ago, while supervising a new intern on a trauma case he was accidentally stuck with a needle. He did not seek medical care at that time due to the patient's critical condition but thinks that the patient may have been a drug user. His physical exam is notable for jaundice, hepatomegaly, and right upper quadrant tenderness. His labs include: Bilirubin: 8.9 mg/dl

Acute respiratory distress syndrome

A 50-year-old woman is recovering in the surgical intensive care unit following emergency removal of a ruptured appendix. She was extubated on postoperative day 2 but has remained febrile with gram-negative bacteremia. She is receiving cefepime through a subclavian central venous catheter. Within the past 3 hours, she has become tachypneic and now requires oxygen via nasal cannula to keep her oxygen saturation level above 93%. The nurse notes that her temperature is 40.0° C (104.0° F), her heart rate is 100/min, her respiratory rate is now 30/min, her blood pressure is 90/50 mm Hg, and her oxygen saturation has dropped to 85%. The patient is complaining of difficulty breathing, and high-pitched rales are heard on lung auscultation. The patient is switched to 100% oxygen via nonrebreather mask, and an arterial blood gas analysis is performed with the following results: pH 7.30, CO2 50 mm Hg, PO2 55 mm Hg, HCO3, 18 mEq/L, and O2 saturation 85%. An x-ray film of the chest is shown in Figure 15-1. A Swan-Ganz catheter is placed, and the wedge pressure is recorded as 15 mm Hg.

Lung cancer

A 50-year-old woman presents for preoperative testing before elective cholecystectomy. Her medical history is significant for biliary colic, a 40-pack-year smoking history, and chronic bronchitis. She is afebrile with a respiratory rate of 12/min. A chest examination is notable for diffuse wheezing, but no lymphadenopathy, clubbing, or breast lumps are appreciated on physical exam. X-ray of the chest is remarkable for a 3.0-cm noncalcified nodule with irregular margins in the right middle lobe. An x-ray film taken 1 year ago does not show this lesion. A CT scan of the chest confirms the nodule, which enhances upon intravenous contrast administration. A tuberculin skin test is nonreactive.

Scleroderma

A 50-year-old woman presents to her primary care physician with cold and painful fingers. In addition to the pain, she has a lump on the dorsal aspect of her proximal carpophalangeal joint. Since her teenage years, she has always had difficulty keeping her hands warm and was diagnosed with Raynaud's phenomenon 5 years ago. Her past medical history is significant for acid reflux, dysphagia, and stomach ulcers. She also has a long history of joint pains, and was previously given a diagnosis of fibromyalgia. The appearance of the patient's hands is shown in Figure 9-5. Radiographs of the hands reveal no arthritic changes but demonstrate a large calcium deposit that corresponds to the lump felt by the patient. Relevant laboratory findings are as follows: WBC count: 11,000/mm3

Pulmonary embolus

A 50-year-old woman presents to the emergency department complaining of sudden- onset shortness of breath with pain on inspiration. She is 2 weeks status post total knee replacement and has been recovering without complication, although she has not gone to her prescribed physical therapy sessions. Her medications are oxycodone for pain management and hormone replacement therapy. Her temperature is 38.0° C (100.4° F), pulse is 120/min, respiratory rate is 30/min, blood pressure is 110/75 mm Hg, and oxygen saturation is 89% by pulse oximetry. X-ray of the chest is normal. An electrocardiogram shows sinus tachycardia with no other abnormalities.

Pemphigus vulgaris

A 52-year-old man presents to his primary care physician complaining of sores in his mouth, axillae, and on his chest. He states that the sores on his chest and axillae start as blisters but tend to break open when rubbed or if pressure is applied to them. The patient also reports recent weight loss and overall malaise. His oral intake has been limited by pain. On physical examination, the patient is tired appearing with scattered erosions over his axillae and trunk. There are also visible erosions in the oropharynx. No bullae are observed. When pressure is applied to the skin with a sliding motion, the skin rubs off.

Hemochromatosis

A 52-year-old man presents to his primary care physician for loss of libido that has persisted over the past 6 months. He was diagnosed with diabetes 1 year ago, and he has recently developed painful arthritis in his hands and fingers. Physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 83/min, and blood pressure of 132/90 mm Hg. An abdominal examination reveals splenomegaly, and a genital examination suggests testicular atrophy. Spider nevi are noted on his thorax. A cardiac examination is unremarkable. His complexion is an odd grayish-brown hue. He denies any alcohol consumption. Relevant lab findings are as follows:

Melanoma

A 52-year-old white man presents to the dermatologist after his wife noticed a dark, bleeding lesion on his back. The patient was unaware of the lesion until his wife pointed it out; she reports first noticing it a few months prior. The lesion has since changed shape, and she grew more concerned when she noticed it bleeding. The patient reports that he used to spend summers working as a lifeguard when he was much younger and rarely used sunblock. On physical examination, a 7-mm asymmetric macule with irregular borders and nonuniform color is observed on the right upper back.

Sensitivity and specificity

A 52-year-old woman presents to her primary care physician after suspicious microcalcifications were observed in her left breast tissue during a regular screening mammogram. She has been informed that a procedure will be necessary to make a definitive diagnosis, but she would like to undergo the least invasive procedure that will still yield a diagnosis. A friend of hers recently had a fine-needle aspiration biopsy (FNA) done, and the patient would like to know if this is a good diagnostic test. The results of a study comparing surgical excisional biopsy, the gold standard for obtaining a diagnosis, and FNA follow below:

Paget's disease

A 53-year-old man is brought to the emergency department after tripping over his cat in his living room. He is hard of hearing and shouts that he did not see the cat because he was forcing his baseball cap onto his head. He cannot put weight on his right leg and feels severe pain in his right thigh. The patient also notes that he has been experiencing pain in both legs for the past few months. The pain is throbbing and persists for a few hours, and then subsides. A heating pad helps to soothe the ache, but the patient has not used any medication for the pain. He is otherwise in good health and denies any history of hepatobiliary disease. Upon examination, his left leg and hip appear to have full range of motion. His right leg is limited on both abduction and adduction; medial rotation causes severe pain. X-ray of the hip reveals multiple spiral fractures of the right femoral diaphysis. Relevant laboratory values include the following:

Hairy cell leukemia

A 53-year-old man presents to his primary care physician complaining of weight loss and difficulty eating as much as he used to. He denies difficulty swallowing but reports that he feels full after much less food than previously. When questioned, he describes several months of fatigue that he attributed to the frequent colds he has had. He has no past medical history except hypertension, which is well-controlled on hydrochlorothiazide. On physical examination, he appears pale with multiple bruises over both legs. There is a palpable, nontender mass in his left upper quadrant on abdominal examination. The physician orders a complete blood count with peripheral smear, which is shown in Figure 7-5. The abnormal cells stain positive for tartrate-resistant acid phosphatase (TRAP).

Benign positional paroxysmal vertigo

A 53-year-old woman presents to her primary care physician complaining of severe nausea and "dizziness." The patient's symptoms began upon arising from bed. She states that "it feels like the world is spinning" around her and that she feels nauseous. Sitting still for a moment will cause the symptoms to abate, but upon moving the symptoms begin again. The patient has no significant past medical history and is an avid runner. She denies any history of smoking or alcohol use, and any recent illness or sick contacts. On examination, bringing the patient from a seated to a supine position and turning her head 45 degrees to the side reproduces her symptoms and causes upbeat torsional nystagmus 20 seconds after head movement. Vital signs are stable, and results of laboratory tests are within normal limits.

Confidentiality and disclosure

A 53-year-old woman with a known diagnosis of breast cancer presents to her primary care physician complaining of lower back pain. A bone scan reveals "hot spots" in the L3-5 region, and a CT scan of the lower back confirms metastases to the bone. The patient requests that her husband not be informed of these new findings, as she does not want him or any other members of her family to know the extent of her disease.

Dermatomyositis

A 54-year-old woman presents to her primary care physician with muscle weakness and a crusty, scaly rash on her knuckles and over her eyelids. For the past couple of months, she has had difficulty getting out of a chair but attributed it to aging. The rash developed 2 weeks after visiting a self-tanning salon and is extremely pruritic. She has tried taking antihistamines and applying moisturizer to the area but reports no relief. The itching is so severe that it often wakens her at night. She denies fevers, chills, or changes in detergents or creams. She is taking no medication except the antihistamine. On examination, she is afebrile with a heart rate of 70/min, blood pressure of 110/80 mm Hg, and a respiratory rate of 13/min. Notable findings include prominent violaceous papules over the metacarpophalangeal joints of her hands and over her upper eyelids and a rash with a shawl-like distribution over her anterior neck, upper chest, and back. Relevant labs are as follows:

Myocardial infarction

A 55-year-old homeless man presents to the emergency department complaining of chest pain, profuse sweating, and shortness of breath. ECG demonstrates ST elevation in leads V4-5 and elevation in troponin I. The man consents to cardiac catheterization but tells the attending cardiologist that he will not be able to take medicine after leaving because he has no money or insurance. Forty minutes later, he is taken to the catheterization lab, where a 70% occlusion of the LAD is evident and a stent is placed.

Pericarditis

A 55-year-old man comes to the emergency department complaining of sharp chest pain progressively worsened over the past day. He localizes the pain to the middle of his chest and describes it as a "9 out of 10" sharp pain that is worse with deep inspiration and lying flat; sitting forward seems to reduce the pain temporarily. He denies any medical history and takes no medications. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/90 mm Hg, pulse rate of 95/min, respiratory rate of 12/min, and oxygen saturation of 99% on room air. His physical examination shows no jugular venous distention; clear lung fields; regular heart rate and rhythm without murmurs, rubs, or gallops; and no tenderness to chest palpation. His abdominal, extremity, musculoskeletal, and neurologic examinations are normal. X-ray of the chest reveals clear lungs with a normal-sized heart and mediastinum. An ECG shows diffuse ST-segment elevation with upward concavity and "reciprocal" PR-segment changes (PR depression in leads with ST elevation, and vice versa).

Cardiac arrest

A 55-year-old man was walking through the hospital when he fell to the ground suddenly. It is confirmed at the scene that he is unresponsive, not breathing, and does not have a palpable heartbeat or pulse.

Nephrolithiasis

A 55-year-old man with a past medical history of hypertension and congestive heart failure presents to the emergency department with a 1-day history of right flank pain, nausea, and vomiting. The pain was initially mild a few hours ago but progressed gradually over the course of 30 minutes to severe pain, followed by nausea and vomiting several times. The pain now radiates to his right testicle. He denies any history of recent trauma. On examination, his temperature is 36.7° C (98.0° F), pulse is 90/min, blood pressure is 140/72 mm Hg, and respiratory rate is 14/min. He is lying in bed, doubled over in pain. Auscultation of his heart reveals a normal S1 and S2 with an S3 gallop and no murmurs or rubs. He has faint crackles in the bases of both lungs. His abdomen is soft, nondistended, and somewhat tender in the right flank area, without guarding or rebound tenderness and with normal bowel sounds present. No abdominal or flank masses are appreciated. He has pitting edema to the ankles bilaterally. In the hour since coming to the hospital, he has put out 50 cc of pinkish urine. His medications include metoprolol, furosemide, captopril, amlodipine, and aspirin.

Erectile dysfunction

A 55-year-old man with past medical history significant for hypertension presents to his primary care physician with the chief complaint of sexual problems. He reports gradual loss of the ability to have erections over the past year, including nocturnal and morning erections. He reports being depressed because of the resulting loss of intimacy with his wife, to whom he has been married for 30 years. He denies serious marital problems. He denies any other medical problems including problems voiding, but does report intermittent leg pain with exertion. He has not had any surgeries aside from a tonsillectomy at age 12 and denies any genitourinary trauma. His medications include amlodipine and aspirin. He has smoked one pack of cigarettes per day for the past 40 years but denies use of alcohol or illicit drugs. On examination, his pulse is 80/min, and blood pressure is 138/88 mm Hg. His visual fields are intact. His heart, lung, and abdominal examinations are within normal limits. He has normal radial pulses and weak femoral, popliteal, and dorsalis pedis pulses bilaterally. His testicles are somewhat asymmetric but normal in size. His cremasteric reflex is intact bilaterally. Examination of the penis reveals no abnormalities in the shaft, no signs of balanitis in the glans, and no phimosis. A digital rectal examination reveals a normal-sized prostate and normal rectal tone.

Ovarian cancer

A 55-year-old postmenopausal G1P1 woman presents to her primary care physician complaining of fatigue, abdominal discomfort, and bloating. She has mild nausea and anorexia, but no vomiting. On physical examination, she has a temperature of 38° C (100.4° F), heart rate of 85/min, respiratory rate of 18/min, and blood pressure of 130/80 mm Hg. Abdominal examination reveals distention, shifting dullness, a fluid wave, and slight tenderness to palpation with no masses. Head and neck, cardiovascular, chest, and musculoskeletal examinations are all unremarkable. Pelvic examination reveals normal external genitalia and cervix, but a fixed, nodular mass is palpated on the left adnexa. A transvaginal ultrasound reveals a 5-cm mass with cystic and solid elements on the left ovary and fluid in the cul-de-sac. No abnormalities are appreciated on the right ovary. CA-125 level is 150 U, while complete blood count and electrolyte panel are within normal limits.

Breast cancer

A 55-year-old postmenopausal woman presents to her primary care physician for an annual physical examination. She has no complaints and feels healthy. On physical examination, she is afebrile (37.0° C [98.6° F]), with a heart rate of 80/min and blood pressure of 140/85 mm Hg. During the breast examination, a small, hard, fixed nodule is palpated in the upper outer quadrant of the left breast. The skin on the breast is without abnormality, there is no nipple discharge, and no abnormal lymph nodes are palpated. She is sent for a diagnostic mammogram, which reveals a 3-cm nodule with microcalcifications. A core-needle biopsy is scheduled, and the pathology report is read as "invasive ductal carcinoma without clear margins, estrogen receptor positive (ER+), HER2/neu receptor negative."

Lichen planus

A 55-year-old woman with a history of hepatitis C infection presents to her primary care physician's office complaining of vulvar itching. On further questioning, she mentions that she has noticed lesions on both wrists. They are also pruritic but not as bothersome as the vulvar itching. On physical examination, sharply defined, flat-topped, polygonal, violaceous papules are observed on the flexor surface of the wrists. The surfaces of the lesions are shiny with fine white lines. Similar lesions are also seen on the vulva. Examination of the buccal mucosa reveals a white, lacelike pattern. A representative image of the wrist lesion is shown in Figure 2-3.

Acute tubular necrosis

A 55-year-old, 70-kg man injured in a motor vehicle collision (MVC) presents to the emergency department somnolent, with multiple bruises and a large abdominal laceration. At the time of the MVC, he was not wearing a seat belt and was catapulted through the windshield of his car. His temperature is 36.7o C (98.1o F) heart rate is 135/min, blood pressure is 40 mm Hg over palpable, respiratory rate is 24/min, and oxygen saturation is 99% on a nonrebreather mask with an FIO2 of 80%. On physical exam, the patient has dry mucous membranes, sunken eyes, and doughy skin. An abdominal CT reveals multiple broken ribs, a large liver laceration, and free fluid in the peritoneal cavity. His urine output has been 5 cc/hr since coming to the hospital. His urine sediment shows reveals muddy brown granular and epithelial cell casts and free epithelial cells.

Mesothelioma

A 56-year-old construction worker presents with increasing difficulty catching his breath and chest pain. Upon further questioning, he has had chest pain and trouble breathing for months. The pain is right-sided, sharp, worse with deep breathing, and nonradiating. In addition to his presenting symptoms, the patient's wife notes he is increasingly fatigued and has lost 4.6 kg (10 lb) over the last 2 months. The patient denies productive cough or recent infections. He has been in construction for most of his life, working for a company that remodels old buildings. He endorses a 35-pack-year smoking history. On physical examination, he is in mild respiratory distress, and there is dullness to percussion over his right lung base as well as decreased breath sounds. Serum chemistries, complete blood counts, and electrocardiogram are all within normal limits. A chest x-ray demonstrates a pleural-based mass and effusion in the right lower lung.

Subarachnoid hemorrhage

A 56-year-old man is brought to the emergency department (ED) by a coworker after suffering from severe headache, nausea, and vomiting over the past 2 hours. The patient was sitting at his desk when he suddenly developed a knifelike headache that he states is "10 out of 10" in intensity. He has never had a headache like this before. Shortly after headache onset, the patient became nauseous and vomited a few times before insisting that he be brought to the ED. On presentation to the ED, the patient is increasingly drowsy and is having difficulty answering questions. He denies any recent illness, head trauma, or history of migraine. He smokes one pack of cigarettes per day but denies any alcohol or intravenous drug abuse. His temperature is 37°C (98.6°F), heart rate is 86/min, respiratory rate is 14/min, and blood pressure is 126/60 mm Hg. The patient has no back or neck pain. WBC, blood chemistry, and coagulation laboratory values are all within normal limits. His neurologic examination is notable for a sluggishly responsive pupil on the right.

Basal cell carcinoma

A 56-year-old man presents to his dermatologist for evaluation of a lesion on his nose (Figure 2-2). He has had other similar lesions on his face that were treated with surgical excision. He is of Irish descent and has a long history of sun exposure from working as a farmer. On physical examination, the patient has clear evidence of sun damage and looks much older than his stated age. There are well-healed surgical scars on his forehead, nose, and left cheek. An erythematous, smooth papule with a translucent surface is observed on the left side of the patient's nose.

Polycystic kidney disease

A 56-year-old man presents to the emergency department following an episode of hematuria. He reports continuous bilateral flank pain and progressive worsening of fatigue, malaise, and nausea for the past several months, but he is uninsured and has not been able to seek medical care. When questioned, he states that he has been urinating less than previously. He believes his father suffered from something similar but is unclear on the details. His temperature is 36.9° C (98.4° F), heart rate is 88/min, and blood pressure is 168/99 mm Hg. There are bilateral masses palpated on abdominal exam. Laboratory findings:

Syncope

A 56-year-old woman presents to the emergency department following a syncopal episode. She was working in her garden and had just stood up from a flowerbed when she began feeling light-headed. She remembers her vision going gray before she lost consciousness and fell to the ground. She does not know how long she was out but was oriented when she awoke. She denies loss of bowel or bladder continence. On physical examination, she is alert, oriented, and interactive. Her vital signs include a temperature of 37.1° C (98.8° F), heart rate of 95/min, blood pressure of 113/68 mm Hg, and respiratory rate of 12/min. Her heart has a normal rate and regular rhythm without murmurs, rubs, or gallops. There are no abnormalities on neurological examination.

Papillary muscle rupture

A 57-year-old investment banker presents to the emergency department with crushing sub-sternal chest pain radiating to his left jaw. A 12-lead ECG demonstrates tall R waves in V1-V3 and a normal axis; troponin levels were elevated. No murmur was appreciated on initial examination. He is given morphine, aspirin, nitrates, and Plavix and is placed on supplemental oxygen. He is then taken to the catheterization lab, where a drug- eluting stent is placed. After 4 days, he is feeling well and walking in the hospital hall with a medical student checking his pulse oximeter. After 2 minutes, the patient begins sweating and states that he does not feel well. He promptly loses consciousness and falls to the floor. The medical student calls for help, places the patient back on oxygen, checks the patient's blood pressure and auscultates the patient's chest. He hears a blowing holo-systolic murmur that radiates throughout the precordium and rales as the patient breathes.

Alcohol withdrawal

A 57-year-old man comes to the emergency department because of palpitations. He reports that he was in his usual state of health until his daughter came for a visit yesterday. About 6 hours after she arrived, he states that he began to feel a bit shaky. His symptoms worsened overnight, and this morning he was so tremulous that he could barely sign his own name. He also began experiencing severe anxiety and the sensation that "my heart was jumping around in my chest." He subsequently took a cab to the emergency department for evaluation. He adds, "My daughter probably thinks I'm with the boys at the bar, but I don't drink a drop when she's visiting." Physical examination reveals an oral temperature of 37.5° C (99.6° F), an irregular pulse of 151/min, and a blood pressure of 132/78 mm Hg. He appears agitated and tremulous, with skin that is noticeably clammy. An electrocardiogram is consistent with atrial fibrillation. A blood alcohol test is negative.

Acute myelogenous leukemia (AML)

A 57-year-old man is referred to a hematologist for a detailed workup of severe anemia. His hemoglobin level is 8.2 mg/dL, but testing reveals no evidence of occult bleeding. For the past several weeks, he has noticed blood on his toothbrush nearly every day and complains that he bruises more easily than before. He has become increasingly fatigued and has cut back on his hours at the waste management company he owns because he often becomes short of breath with mild exertion. In addition, he complains that "I always have a cold; I can't get rid of it." In addition to the low hemoglobin, relevant laboratory results include a WBC count of 3200/mm3, reticulocyte count of 0.8%, and platelet count of 30,000/mm3. His peripheral smear shows myeloblasts and markedly decreased granulocytes.

Necrotizing fasciitis

A 58-year-old diabetic man presents to his primary care physician complaining of low- grade fever and severe right leg pain. He had sustained a small laceration to his calf while playing tennis with friends the day before. His pain began several hours after his injury, with localized redness and swelling. The pain worsened to the point where he had difficulty walking. On physical examination, he is ill-appearing and diaphoretic. His temperature is 38.9°C (102.1°F), heart rate is 115/min, blood pressure is 98/60 mm Hg, and respiratory rate is 29/min. On physical examination, his right leg is erythematous with a bluish hue, cold, swollen, and very painful to palpation.

Hiatal hernia

A 58-year-old man presents to his primary care physician for an employment physical examination. His physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 85/min, and blood pressure of 138/94 mm Hg. Abdominal and chest examinations are unremarkable. An x-ray of the chest required for his employment physical is shown in Figure 6-3.

Organ transplant rejection

A 58-year-old man presents to his primary physician with complaints of back pain and problems urinating. His past medical history is significant for a cadaveric kidney transplant 2 months ago. The surgery was successful, and he did not experience any immediate postoperative complications. For the past week, he has been having right lower back pain and malaise. He has noticed a significant decrease in his need to urinate as well as the volume of urine he can produce. He denies any burning on urination. On further questioning, he admits he has not been taking his medications regularly; he estimates he remembers to take his medications three to four times per week. Upon examination, he has a temperature of 38.3° C (101.0° F), blood pressure of 160/98 mm Hg, heart rate of 83/min, and respiratory rate of 18/min. His back is very tender, particularly over the right lumbar paraspinal region. When asked to provide a urine sample, the patient returns with only 20 mL of urine. Relevant laboratory results are as follows:

Polycythemia vera

A 58-year-old man presents to the emergency department complaining, "I can't stop itching all over, and my eyes are blurry." He successfully installed a new showerhead in his bathroom this weekend and took a long, hot shower to test it. A few minutes after the shower, his hands began to itch, and the sensation soon spread to his trunk and his limbs. He used the same soap he has used for the past few years and has lived in his current house for nearly three decades. He regularly completes small home improvement projects around the home but has never experienced these symptoms in the past; he denies any allergies. Upon examination, he is fidgeting and uncomfortable. He repeatedly scratches his arms, legs, and abdomen, and tries to reach his back. His face is very red and warm to the touch. His temperature is 38.3° C (101° F), blood pressure is 140/80 mm Hg, heart rate is 92/min, and respiratory rate is 16/min. He complains of a dull, throbbing headache that he rates 5/10 on the pain scale. His examination is remarkable for a palpable spleen and excoriated skin on his arms, legs, and abdomen. Relevant laboratory results include a hemoglobin of 20.5 mg/dL, a hematocrit of 62%, and an erythrocyte sedimentation rate of 2 mm/hr.

UTI

A 59-year-old man with known benign prostatic hyperplasia (BPH) and a history of nephrolithiasis presents to the emergency department with a 3-day history of fever and flank pain. He always has trouble emptying his bladder but notes that he has had more than his usual urgency and frequency over the past several days. Two days ago he began to have nausea, and he has not been able to keep anything down for the last 24 hours. He takes prazosin and some blood pressure medication, but cannot recall the name of the medication. On physical examination, he has a temperature of 38.5° C (101.3° F), heart rate of 89/min, and respiratory rate of 14/min. Chest exam is unremarkable. His abdomen is soft and nondistended, though he has some discomfort with suprapubic palpation. When his right flank is percussed, he almost jumps off the bed in pain. A CT scan is performed and is shown in Figure 8-2.

Necrotizing enterocolitis

A 6-day-old girl born at 35 weeks' gestation is being evaluated because of a 24-hour history of abdominal distention, decreased feeding, and vomiting. She was delivered by induced vaginal delivery to a 26-year-old G2P2 mother with preeclampsia. She was stabilized in the neonatal intensive care unit and had been doing well with no signs of respiratory distress. Over the past day, she has gradually become more irritable and has been vomiting her formula. The last stool she passed was guaiac positive. The nurse also describes one episode where she appeared to stop breathing. On examination, she appears lethargic and is lying still. Her temperature is 37.8° C (100.1° F), heart rate is 145/min, blood pressure is 91/60 mm Hg, and respiratory rate is 20/min. Birth weight was 1139 g (2 lb 8 oz), and her current weight is 1077 g (2 lb 6 oz). Her abdomen is distended and tender to palpation with decreased bowel sounds. Pulmonary and cardiac exams are within normal limits. X-ray of the abdomen reveals distended loops of bowel with pneumatosis intestinalis.

Pyloric stenosis

A 6-week-old boy is referred to the emergency department by his pediatrician for dehydration and vomiting. The infant had been feeding well until 3 weeks prior to admission when he began having nonbloody and nonbilious vomiting after most feeds. In the week prior to admission, the vomiting had increased in frequency and force, becoming projectile and occurring after every feed. Review of systems is significant for increased sleepiness in the past 2 days, decreased urine output, and less frequent bowel movements. His mother denies any diarrhea, hematochezia, or fever. On examination, the child has normal vital signs, with height at the 50th percentile and weight at the 30th percentile. Physical examination is significant for a sunken anterior fontanelle. Relevant laboratory findings are as follows:

Malaria

A 6-year-old boy presents to his pediatrician with high fevers, chills, and sweats that he has experienced since returning from a family trip to India. His parents say he has had no energy since their return, has complained of stomach and muscle aches, and has been unable to tolerate any food. He did not receive any prophylactic medications during their trip. On physical examination, he is clinging to his mother and appears uncomfortable. Vital signs include a temperature of 40.1° C (104.1° F), heart rate of 157/min, blood pressure of 88/65 mm Hg, and respiratory rate of 16/min. His abdomen is soft with marked splenomegaly. There is no lymphadenopathy, nuchal rigidity, or rash.

Fanconi's anemia

A 6-year-old girl is brought to the pediatrician by her parents 1 week after her adoption. She has had a progressively severe cold for the past week and developed a cough productive of yellow sputum yesterday. She was seen at the community clinic 3 days ago (when she had a fever of 37.7° C [99.8° F]) and was given antibiotics. Today, her fever is 39.4° C (102.9° F). She is tachycardic at 125/min, respiratory rate is 16/min, and blood pressure is 100/58 mm Hg. She is curled up on the examination table and appears pale and lethargic. During his examination, the pediatrician notes that the patient's thumbs are proportionately smaller than her other fingers and that she has a number of hyperpigmented lesions on her skin that are 4-8 cm in diameter. He suspects that the patient has an inherited disorder.

Rocky mountain spotted fever

A 6-year-old girl presents to the emergency department (ED) with a 6-day history of fever, malaise, irritability, diffuse myalgias, abdominal pain, nausea, and vomiting. She had been seen in the ED 4 days prior to admission for fever, abdominal pain, nausea, and vomiting and was diagnosed with viral gastroenteritis. In the past 4 days, she has developed a rash that started on her wrists and ankles and spread toward her trunk. She has a temperature of 39.3° C (102.7° F), heart rate of 130/min, respiratory rate of 16/min, and blood pressure of 87/45 mm Hg. Physical examination is significant for hepatosplenomegaly and an erythematous papular rash with scattered petechiae on the trunk, arms, legs, palms, and soles. The patient lives with her parents, two siblings, and three dogs. The family had recently traveled to North Carolina and gone bird watching in the woods. Relevant laboratory findings are as follows:

Idiopathic pulmonary fibrosis

A 60-year-old lawyer presents to his primary care physician complaining of worsening shortness of breath and chronic dry cough. His past medical history is significant for well-controlled hypertension. He does not smoke. His temperature is 37.0° C (98.6° F), pulse 80/min, respiratory rate at rest 20/min, and blood pressure 130/80 mm Hg. Chest examination reveals fine, bibasilar "Velcro" crackles without wheezes. Joints are not swollen or tender, although clubbing of the digits is noted. Full hematology, electrolyte, serology, and liver function panels are normal. A CT of the chest is shown below (Figure 15-2). Results of pulmonary function tests (PFTs) are as follows:

Myocardial infarction

A 60-year-old man is brought to the emergency department with severe chest pain. He says it began about an hour ago while he was climbing stairs and has persisted, despite resting. He describes it as "tightness" in the center of his chest. He has been short of breath, nauseated, and sweating since the pain began. On questioning, he reports a history of similar pain brought on by exertion, but it usually resolves with rest. He also has a history of diabetes mellitus type 2, hypertension, and a 30-pack-year smoking history. His father and cousin both died of heart attacks in their seventies. He takes metformin, hydrochlorothiazide, and a multivitamin. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 150/90 mm Hg, pulse rate of 100/min, respiratory rate of 15/min, and oxygen saturation of 99% on room air. Results of physical examination are unremarkable. X-ray of the chest reveals clear lungs with a normal-sized heart and mediastinum. An ECG is shown in Figure 1-5.

Warfarin-induced hemorrhage

A 60-year-old man presents to the emergency department complaining of a persistent nosebleed. His nose began bleeding spontaneously about 3 hours ago, and he has not been able to get it to stop despite direct pressure and ice packs. He denies trauma, blood disorders, cancer, or a family history of hematologic or oncologic problems. He has gastroesophageal reflux disease (GERD), for which he recently increased his dose of cimetidine, and atrial fibrillation, for which he takes metoprolol and warfarin. His temperature is 37.0° C (98.6° F), blood pressure is 120/80 mm Hg, heart rate is 90/min, and respiratory rate is 10/min. Physical examination is notable for crusted blood around his left nasal ala and slowly oozing bright red blood from his left nostril. He also has small conjunctival hemorrhages and a large bruise on his knee. The remainder of his physical examination is unremarkable, including a regular heart rate and rhythm and normal chest, abdominal, and neurologic examinations. Laboratory tests show:

Chronic lymphocytic leukemia (CLL)

A 60-year-old white man presents to his family physician for a full physical examination. His last doctor's visit was 2 years ago when he had the flu. He explains that his health has been "relatively okay" and that he has had many colds but no ongoing medical problems. Upon further probing, he admits that he has been increasingly tired for the past 6 months and that he has lost about 9 kg (20 lb) over the past 2 years. He insists that he is healthy and needed to lose the weight, but he denies any exercise regimen or specific dietary restrictions. His vital signs are within normal limits, and he appears comfortable. Upon examination, he has palpable lymph nodes in his neck and axillae. He denies any pain on palpation; the nodes range from 1.0 cm to 3.0 cm in diameter. His abdominal examination is significant for hepatosplenomegaly. His chemistry test values are within normal limits; his WBC count is 25,200/mm3 with 90% lymphocytes.

Renal artery stenosis

A 60-year-old white man with a history of coronary artery disease, peripheral vascular disease status post-femoral artery-posterior tibial artery bypass grafting, osteoarthritis, and a 3-year history of hypertension presents to the clinic for a routine blood pressure check. He has had no complaints since his last checkup 6 months ago. He is taking hydrochlorothiazide, metoprolol, lisinopril, diltiazem, pravastatin, and aspirin. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 160/95 mm Hg, pulse rate of 70/min, and respiratory rate of 10/min. His physical examination is notable for an abdominal bruit auscultated to the right of midline at the level of the umbilicus. Laboratory values are as follows:

Wernicke's encephalopathy

A 61-year-old man is brought to the emergency department by his daughter because of difficulty walking. His daughter reports that 2 days ago she noticed that his steps were very short and that he could not walk a distance of more than 5 feet without staggering. She assumed that her father's symptoms were the result of another drinking binge, but when they did not resolve with time, she decided to seek medical attention. Physical examination reveals an oral temperature of 37.0° C (98.6° F), a pulse rate of 84/min, and a blood pressure of 122/74 mm Hg. The patient appears distracted and is oriented to person only. Neurological examination reveals bilateral horizontal nystagmus on lateral gaze, diminished pain and vibratory sensation below the knee bilaterally, and a wide-based gait with slow, short-spaced steps. Blood alcohol concentration is 18 mg/dL. A cardiac examination is within normal limits.

Thrombophlebitis

A 61-year-old man with a past medical history significant for coronary artery disease underwent an open abdominal aortic aneurysm repair 2 days ago. The patient has been doing well, with systolic blood pressures ranging between 100 and 120 mm Hg and no evidence of cardiac ischemia detected by telemetry monitoring. He says he is feeling well except for his recent right thigh and knee pain. On physical examination, the right leg is swollen and slightly pale. It is painful to palpation and to full extension.

Nephrotic syndrome

A 62-year-old man develops sudden onset pain in his right foot. On further inspection, he notices that his foot is cold and blue, and he is taken to the emergency department. His past medical history is significant for osteoarthritis of his knees, which limits his mobility. He takes nonsteroidal anti-inflammatory drugs (NSAIDs), which help the pain. On physical examination, his blood pressure is 145/90 mm Hg, heart rate is 92/min, and temperature is 37° C (98.6° F). His right foot is cool and pulseless, and there is 2+ pitting edema to the knees bilaterally. Urinalysis reveals a specific gravity of 1.026, 1+ blood, 3+ protein, occasional RBCs, and occasional hyaline casts.

SIADH

A 62-year-old man is brought into the emergency department after experiencing a generalized tonic-clonic seizure. He was recently diagnosed with small cell carcinoma of the lung but is taking no medications and has not received chemotherapy. Physical examination reveals a patient in the postictal state. His blood pressure is 138/86 mm Hg, and heart rate is 76/min without orthostatic changes. He has no lower extremity edema. Relevant laboratory findings are as follows:

Aortic dissection

A 62-year-old man with a history of poorly controlled hypertension comes to the emergency department complaining of 1 hour of intense pain in his chest. He was climbing the stairs at home when he felt a sudden, sharp pain in the center of his chest, and felt light-headed. He still feels light-headed and reports that the pain is a "stabbing," 10 out of 10 pain that radiates throughout his chest. He denies any other medical history, but on further questioning reveals that he smokes one pack of cigarettes daily and takes his metoprolol only when he feels "sick" or has a headache. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 170/100 mm Hg, pulse rate of 85/min, and respiratory rate of 15/min. Physical examination shows a well- developed, well-nourished, uncomfortable man with slight diaphoresis. His HEENT and neck examinations are unremarkable. His lung fields are clear to auscultation and he has good breath sounds bilaterally. His heart has a regular rate and rhythm with a 2/6 diastolic murmur along the right sternal border. Examination of his extremities reveals an absent right radial pulse. His abdominal and neurologic examinations are unremarkable. X-ray of the chest shows clear lung fields and a widened mediastinum.

Stroke

A 62-year-old woman is brought to the emergency department (ED) by ambulance because she is experiencing weakness and language disturbances. She and her husband were having dinner when she suddenly stopped speaking, slumped to her right side, and slid to the floor. She was unable to get off of the floor because she could not move her right side. He also noted that that she neither spoke nor seemed to understand what he was saying. Approximately 45 minutes passed from the onset of symptoms to the time the patient was evaluated in the ED. Past medical history is significant for poorly controlled hypertension and stable angina. Her husband recalled that she had not taken her antihypertensive medication for several days. The patient smokes two packs of cigarettes per day. Family history is significant for hypertension and coronary artery disease. The patient's father died at age 58 of a heart attack. On physical examination, the patient is afebrile, has a blood pressure of 168/94 mm Hg, a heart rate of 70/min, and a respiratory rate of 18/min. Medications include a baby aspirin and atenolol. A mental status examination reveals the patient to be globally aphasic. She cannot produce fluent speech, follow commands, repeat phrases, or name objects. Her gaze is deviated to the left. She does not blink to visual threat on the right side, and cranial nerve examination reveals a right-sided central pattern of facial weakness. Strength is 0/5 in the right upper extremity and 5/5 on the left. Strength is 0/5 in the right lower extremity and 5/5 on the left. In response to noxious sensory stimulation, she does not move her right side, but readily moves her left side with good strength. Laboratory examination including complete blood count and blood chemistries are within normal limits.

Retinal detachment

A 63-year-old man presents to the clinic complaining of 4 days of "seeing spider webs" in his right eye. He senses clear-colored spidery patterns in his lower field of vision, only in his right eye. The sensation began upon awakening in the morning and has increased slightly over the past 4 days. He now feels that he has difficulty seeing the lower periphery with his right eye. In addition, he says his vision gets "darker" in that area after he is in a bright room. He denies headache, eye pain, eye discharge, or any other neurological symptoms. He denies recent eye trauma, although he did have a cataract removed 1 year ago. He is otherwise healthy, with no significant past medical history other than baseline myopia. On physical examination, his vital signs are within normal limits and he appears generally well. His head, eyes, ears, nose, and throat (HEENT) examination is remarkable for the use of corrective lenses and a slight lower hemispheric visual field defect in his right eye on visual field confrontation examination; otherwise, his exam is normal.

Pseudomembranous colitis

A 63-year-old woman who was recently hospitalized 3 weeks for pyelonephritis is brought to the emergency department by her daughter for new-onset diarrhea and fever. The woman appears weak and dehydrated. The daughter reports that her mother has been having continuous episodes of up to 6 loose watery stools for the past 3 days. Her medical history is significant for Parkinson's disease and hypothyroidism, which is well-controlled with levothyroxine. She is otherwise healthy. On physical exam, her temperature is 38.3°C (101°F), pulse is 125/min, blood pressure is 80/40 mm Hg, and respiratory rate is 22/min with 93% oxygen saturation on room air. On examination, she is lethargic but arousable, her neck veins are flat, and her lungs are clear to auscultation. She is tachycardic, but no gallops, murmurs, or clicks are heard. Her abdominal exam is notable for diffuse tenderness, guarding, and rebound tenderness. Lab findings include WBC count of 18,000/mm3 and a positive fecal leukocyte test.

Cardiogenic pulmonary edema

A 63-year-old woman with a history of diabetes mellitus and hypertension presents to the emergency department complaining that she feels short of breath. She reports that she began having difficulty breathing over the past week, which has progressed to the point that she can no longer walk up one flight of stairs without feeling short of breath. She was previously able to walk five blocks before becoming short of breath. She denies any history of heart or lung disease, cough or hemoptysis, chest pain, swelling of the extremities, or fever. She takes no medication. Vitals signs include a temperature of 37.0°C (98.6°F), blood pressure of 170/90 mm Hg, pulse rate of 95/min, respiratory rate of 22/min, and oxygen saturation of 92% on room air. Physical examination reveals that her lungs have crackles at the bases bilaterally, and her cardiac examination reveals a point of maximum impulse at the sixth intercostal space at the midaxillary line. There is no clubbing, cyanosis, or edema of the extremities. X-ray of the chest reveals perivascular haziness, interstitial edema, and an enlarged cardiac silhouette.

Alcohol withdrawal syndrome

A 64-year-old man is brought to the emergency department by ambulance after losing consciousness at a local bar. On arrival he is awake but intoxicated, and physical examination reveals a haggard-looking man with contusions on his left elbow and knee. His blood alcohol level is 307 mg/dL, and a urine toxicology screen excludes the presence of other substances. He tells the physician that he has been in and out of alcohol treatment facilities several times and once had a seizure when he tried to stop drinking. He is admitted to the hospital for observation. The next morning, a mental status examination reveals he is alert and oriented to person, place, and time. His speech is of normal rate and tone, and he is cooperative with the physician. He tells the examiner that the previous night he consumed 8-10 beers and several shots. His mood is depressed; his affect is congruent and dysphoric. Otherwise, no abnormalities are noted.

Dissociative fugue

A 64-year-old man presents to the emergency department disoriented and confused. Airport security brought him into the hospital after he repeatedly accosted strangers in the airport, asking them his name and expressing confusion as to why he was there. The patient's physical examination is within normal limits, except for minor bruising on his legs, which he says was a result of a fall earlier in the day. When asked his name, the man replies, "I don't know." Flight records indicate that the patient flew from a city hundreds of miles away approximately a day ago and also confirm his identity. When family members are contacted, they indicate that the patient's wife died about 2 weeks ago, and the patient has also had some ongoing financial problems. Family members have been unable to reach him for the past several days. They indicate that he is not on any medications and that, while he had grieved his wife's death, he had appeared to be recovering well the last time they saw him. Medical evaluation including routine laboratory studies and a head CT is unrevealing.

Renal tubular acidosis

A 64-year-old woman with a long history of diabetes mellitus and hypertension presents to her primary care physician for an annual checkup. Laboratory studies reveal a potassium level of 5.5 mEq/L. Repeat laboratory studies include serum electrolytes and an arterial blood gas. Relevant findings are as follows:

Parkinson's disease

A 65-year-old man presents to a neurologist complaining of a resting tremor. He is accompanied by his wife, who points out that her husband has been moving much more slowly, has not been sleeping well, and has been depressed and anxious. During the interview, the patient speaks in a low tone without facial expression, and his left hand has a resting tremor involving the fingers and wrist. Physical examination reveals a wide-based, shuffling gait without arm swing. Passive movement of the arms demonstrates uniform resistance to movement with a ratchet-like quality. His temperature is 37°C (98.6°F), heart rate is 90/min, and blood pressure is 140/85 mm Hg.

Varicella-Zoster virus

A 65-year-old man presents to his primary care physician complaining of severe pain on the left side of his trunk. In addition to the pain, he complains of a rash that extends from the right side of his midback to the right side of his abdomen. He reports feeling ill a few days prior to developing the rash. On physical examination, the patient appears uncomfortable and in pain. Examination of the skin reveals grouped vesicles on an erythematous base in a unilateral dermatomal distribution along the patient's trunk, as shown in Figure 2-7.

Peripheral vascular disease

A 65-year-old man presents to his primary care physician with the chief complaint of leg pain. He notes that his buttocks and thighs ache bilaterally, left worse than right, when he walks more than a few blocks; the pain resolves with rest. He denies any history of trauma or problems with his joints; his past medical history is significant for a 40-pack- year smoking history and an acute myocardial infarction (MI) at the age of 61 years. When questioned, he admits to impotence beginning a few months prior to his MI. On physical examination, he is seated comfortably on the table in no acute distress. His heart and lung exams are within normal limits. His radial pulses are 2+ and symmetric, but his femoral and dorsalis pedis pulses are diminished bilaterally. The skin on his legs is cool to the touch and appears shiny, with very little hair growth. There is no swelling or erythema of his hip or knee joints.

Osteoarthritis

A 65-year-old woman is referred to an orthopedic surgeon by her primary care physician for evaluation of right knee pain. Just 10 years ago, she was a competitive marathon runner, but over the past 5 years the aches and pains in her joints have gradually begun to limit her physical activity. The patient reports that she can walk only "about a half mile" before the pain in her knee forces her to stop and rest. On examination, her right knee has a moderate effusion but is not warm or erythematous. She has decreased range of motion in her right knee relative to her left. Radiographs of the right knee show osteophyte formation, subchondral bone cysts, and narrowing of the joint space. The patient's leukocyte count is 6000/mm3 and erythrocyte sedimentation rate is 8 mm/hr.

Influenza vaccine

A 65-year-old woman presents to her primary care physician for her yearly checkup. After the physician takes a detailed history of her chronic ailments, including emphysema and high blood pressure, she asks if the patient has received an influenza shot for the present year. The patient responds by saying, "Last year, the nursing home where I live made me get one, and it made me come down with the flu, so I don't want it." After educating the patient that the influenza vaccine is the single best way to protect against influenza, the patient agrees to receive one.

Temporal arteritis

A 65-year-old woman presents to her primary care physician with a severe headache that has persisted for 2 weeks despite therapy with ibuprofen. The headache is localized over the right temporal region. She is particularly worried since she rarely suffers from headaches. The patient also notes that she has been experiencing discomfort while attempting to eat over the past few days. She reports no history of trauma and denies fever, night sweats, or chills; weight loss; photophobia; and visual disturbances. She is taking no medication except for ibuprofen, which she has been taking for 1 year to treat what she describes as arthritis of the neck, shoulders, and elbows. The patient's temperature is 38° C (100.4° F), pulse is 90/min, blood pressure is 120/75 mm Hg, and respiratory rate is 12/min. On palpation of the patient's right temporal region, there is noticeable throbbing and tenderness but no signs of trauma to the head. Ophthalmologic examination reveals equally round and reactive pupils and no papilledema. Her chest is clear, and her heart has a normal rate and regular rhythm. Abdominal examination is unremarkable. Relevant labs include the following:

Osteoporosis

A 65-year-old woman presents with a history of low back pain. She began menopause at age 48 and did not receive hormone replacement therapy. Her mother had a hip fracture at age 71. She spends several hours each day outside gardening and consumes 1500 mg of calcium and 800 IU of Vitamin D each day. She denies any history of loose stools, weight loss, fever, chills, night sweats, or neurological problems. On examination, she is 1.5-m (4′11′′) tall and weighs 45 kg (100 lb). Lumbar-spine films reveal a new vertebral fracture at the L4 level and diffusely decreased radiodensity and loss of trabecular structure in her bones. Dual-energy x-ray absorptiometry of the hip reveals a bone mineral density T score of -1.5. Relevant laboratory results are as follows:

Bullous pemphigoid

A 66-year-old man presents to his primary care physician complaining of recurrent outbreaks of blisters all over his body. The blisters slowly increase in size and become tense and pruritic. When the blisters break open, clear fluid drains. Painful erosions develop after the blisters collapse. On physical examination, the patient has multiple blisters in different stages concentrated mostly on his upper arms and thighs. There are a few erythematous plaques, a number of large, tense bullae, and scattered deep erosions and crusts. Nikolsky's sign is negative. He does not have any lesions on the mucous membranes.

Esophageal cancer

A 66-year-old man presents to his primary care physician for difficulty swallowing. Approximately 8 months ago, he began exclusively eating soft foods because of the sensation of solid foods becoming "stuck" in his chest. He reports some anorexia and an unintentional weight loss of 11.3 kg (25 lb) over the past several months. He admits to smoking one pack of cigarettes daily for the past 35 years and drinking two beers a day since he was 18 years old. Physical examination reveals a temperature of 37.0°C (98.6°F), pulse of 86/min, and blood pressure of 136/86 mm Hg. He appears cachectic.

Polymyalgia rheumatica

A 66-year-old woman presents to the rheumatologist's office complaining of muscle aching, weakness in her upper arms and thighs, and severe fatigue. She also notes an unintentional weight loss of 2.3 kg (5 lb) over the past 6 months. The patient's symptoms are most severe in the morning and so debilitating that she can barely get dressed. The patient denies any history of trauma or arthritis. She also denies fevers, headache, and jaw claudication. On physical examination, the patient is tender to palpation along her shoulder girdle bilaterally as well as her trunk. The patient has a normal neuromuscular examination and no obvious signs of inflammation in any of her joints. Relevant laboratory findings are as follows:

Amyloidosis

A 67-year-old man presents to his primary care physician with one episode of syncope, fatigue, and weight loss for several months. He fainted earlier that morning and felt palpitations prior to passing out. He also complains of alternating constipation and diarrhea, tingling in his right hand, and difficulty forming words. On physical examination, his vital signs include a temperature of 37.2° C (99.0°F) and respiratory rate of 12/min. His seated blood pressure is 110/75 mm Hg with pulse of 75/min; after standing, blood pressure is 95/60 mm Hg with pulse of 104/min. Hepatomegaly, 1+ peripheral edema, and macroglossia are noted. An electrocardiogram demonstrates multiple premature ventricular contractions. Urinalysis reveals proteinuria, and urine protein electrophoresis reveals monoclonal kappa light chains.

Urinary incontinence - Urge incontinence

A 67-year-old woman is being seen by her primary care physician for her annual checkup. She denies any recent illness but states that she has been having a problem with very sudden, severe urges to go to the bathroom. If she cannot find a restroom quickly, she sometimes loses control of her bladder. She is becoming more and more nervous about going out in public. She denies dysuria or stool incontinence. She does not take any medications. On physical examination, she is comfortable, and her vital signs are within normal limits. Abdominal examination does not reveal any evidence of fecal impaction. Neurologically, she has good muscle tone, including the rectal sphincter. Urinalysis is negative for WBCs, bacteria, and leukocyte esterase.

End-of-life issues (Advance directs & Withdrawal of care)

A 67-year-old woman is unresponsive in the intensive care unit 2 weeks after sustaining anoxic injury to her brain. The patient has a known history of dilated cardiomyopathy with atrial fibrillation, for which she was closely monitored and taking several medications. Her husband found her unresponsive on the floor in their home upon returning from work 2 weeks ago. The patient has maintained a relatively normal cardiac rhythm since admission to the hospital but has evidence of severe cardiac compromise.

Septic arthritis

A 67-year-old woman with a past medical history significant for rheumatoid arthritis for 15 years presents to the emergency department complaining of a painful, swollen left knee that has been worsening over the past 3 days. She denies any recent trauma to the affected joint and states that she has been compliantly taking methotrexate for her rheumatoid arthritis for the past 5 years. She further denies any recent sexual activity other than with her husband of 41 years. On physical examination, her temperature is 38.5° C (101.3° F), heart rate is 90/min, and blood pressure is 110/74 mm Hg. Her knee is markedly warm, erythematous, swollen, and painful. A mild effusion is noted.

Tertiary syphilis - Tabes dorsalis

A 68-year-old African-American man presents to his physician with his daughter, who brought him in due to concerns about his ability to walk. He lives with her and her husband, and over the past 5 months they have noticed him falling and bumping into objects with increasing frequency. The patient complains of shooting pains down both his legs. On physical examination, his vital signs are normal, but he has decreased proprioception and vibratory sense in his lower extremities. He has a wide-based gait, extreme difficulty with heel-toe walking, and a positive Romberg test. He has absent deep tendon reflexes. With his eyes closed, he cannot tell whether his toe is moving up or down, but pain and temperature sensations are intact. His pupils are not reactive to light but do accommodate. There are several plaque-like growths on the inside of his mouth which have ulcerated but are not painful.

Benign prostatic hyperplasia

A 68-year-old man presents to the emergency department with severe lower abdominal pain. He has a constant desire to urinate but can produce only a small amount of urine. His past medical history is unremarkable, but he says he has experienced hesitancy before the onset of urination and decreased strength of his urinary stream for several months. Physical examination is significant for trace pedal edema, and his blood pressure is 140/86 mm Hg, with no orthostatic changes. He has marked tenderness in the suprapubic region and dullness to percussion to the level of the umbilicus. Rectal examination reveals a large, smooth, firm, midline mass located anteriorly. Laboratory tests show:

Fibromyalgia

A 68-year-old woman with a history of depression, anxiety, and irritable bowel syndrome presents to her primary care physician with muscle aches and weakness, joint pain, and fatigue. She reports continued fatigue despite sleeping 10 hours each night. The muscle ache is described as a tight, burning stiffness that spreads across the upper part of her back. The pain is worse in the morning but gradually improves throughout the day. She also reports occasional back pain that radiates down her buttocks to her legs. On examination, her blood pressure is 132/70 mm Hg, pulse is 73/min, and respiratory rate is 12/min. Motor examination of the lower and upper extremities reveals no weakness or decreased range of motion. Her joints are not warm or edematous. Her neurological exam is normal.

Multiple myeloma

A 69-year-old man presents to the community clinic complaining of pain in his right thigh for the past 2 months. He also reports fatigue for the past few weeks. The pain is constant and knifelike and is always midway between his hip and his knee; it does not radiate. He rates the pain 9/10 and says that he feels like it is deep in his bones. He denies any trauma to the area; femoral x-rays are negative for fracture. He says that sometimes he feels a similar pain in his ribs; x-ray of the chest is negative for rib fractures. About 3 months earlier, he suffered a severe bout of pneumonia and was successfully treated. His past medical history is significant only for essential hypertension, for which he is taking hydrochlorothiazide. He quit smoking 20 years ago but enjoys a glass of brandy after dinner every night. He denies any intravenous drug use. Relevant laboratory results are as follows:

Sepsis

A 69-year-old woman with a history of acute myeloblastic leukemia who is currently receiving high-dose chemotherapy is brought to the emergency department because she is breathing rapidly and lapsing in and out of consciousness. Her nurse reports that she has been doing well with her chemotherapeutic regimen and has been maintaining her weight with minimally decreased appetite and little nausea or vomiting. She has no other significant medical, surgical, or developmental history other than the placement of a tunneled central venous infusion port 1 week ago into her left subclavian vein. On physical examination, she is diaphoretic and appears disoriented to person, place, and time. Her temperature is 40° C (104° F), blood pressure is 70/50 mm Hg, pulse rate is 140/min, and respiratory rate is 30/min. Examination of her head and neck is unremarkable, with no erythema, masses, or discharge noted, and there is no photophobia or neck stiffness. Otherwise, the exam is normal.

Mitral regurgitation

A 69-year-old woman with a history of hypertension and rheumatic heart disease in childhood presents to the clinic complaining of worsening shortness of breath with exertion, fatigue, and occasional palpitations. On physical examination, she appears in no acute distress, and her vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 140/80 mm Hg, pulse rate of 80/min, respiratory rate of 12/min, and oxygen saturation of 99% on room air. Her physical examination is remarkable for mild crackles in both lung fields bilaterally, a laterally displaced point of maximum impulse, a diminished S1, and a 3/6 holo-systolic murmur heard best at the apex and radiating to the axilla. The murmur is reduced with Valsalva maneuver.

Meningitis

A 7-month-old boy presents to the emergency department with a history of lethargy. He was seen by his pediatrician 3 days ago with fever and symptoms of an ear infection. He was diagnosed with otitis media and treated with oral amoxicillin. The morning of admission, he became irritable and was less active than usual. He has vomited three times, and his urine output is noticeably decreased. He has no diarrhea. He has a temperature of 40.2° C (104.0° F), heart rate of 100/min, respiratory rate of 20/min, and blood pressure of 110/80 mm Hg. He is lethargic and arousable only to painful stimuli. Physical examination shows his anterior fontanelle is full and tense. His tympanic membranes are red and bulging. His pupils are reactive, but his eyes do not focus well on his parents. His heart, lungs, and abdomen are normal. His color and perfusion are good. He has no petechiae. He moves all his extremities weakly, and his deep tendon reflexes are hyperactive.

Crohn's disease

A 7-year-old boy is admitted to the hospital with abdominal pain and weight loss of 4.5 kg (10 lb) over the past 5 months. During this time, his parents have noticed a change in his bowel habits, from 4-5 stools per week to daily stools that are occasionally mixed with blood. The abdominal pain is intermittent and cramping. On examination, he is thin, tired, and pale. His heart and lung examinations are normal. His abdomen is soft, with mild tenderness to palpation in the right lower quadrant. Rectal examination reveals an anal skin tag and guiaic-positive stool. Laboratory findings are significant for hemoglobin of 7.3 g/dL and erythrocyte sedimentation rate (ESR) of 77 mm/hr.

Hemophilia

A 7-year-old boy is brought to the emergency department (ED) after falling on the playground and hurting his knee. He collided with a classmate while running across the schoolyard and fell on the pavement. No medical history is available; a teacher's aide accompanies the patient to the ED. She became concerned when his knee became terribly swollen and she was unable to stop the bleeding. Upon examination, the patient is extremely uncomfortable, his knee is warm and tender, and there is a large hematoma on the anterior aspect of the knee. The patient also has cuts on both elbows that continue to bleed, as well as a number of contusions elsewhere on his arms and legs. The rest of the examination is unremarkable, laboratory studies reveal a normal CBC, including a normal platelet count, a normal prothrombin time, and a markedly elevated partial thromboplastin time. X-rays of the leg are negative for fractures in the femur, tibia, and fibula.

Diabetes mellitus, type 1

A 7-year-old boy is brought to the pediatrician by his parents for new-onset bedwetting and weight loss. They state that he is eating and drinking more than usual but continues to lose weight. He has been using the bathroom more during the day in addition to his accidents at night. He has also complained of changes in his vision. On physical examination, the child is alert and oriented with stable vital signs; there are no abnormal physical findings. Laboratory tests:

Closed-angle glaucoma

A 70-year-old Asian woman presents to the emergency department complaining of extreme pain in her right eye and blurred vision. The pain began suddenly that morning and got progressively worse during her drive to the hospital; she vomited once and reports continued nausea. The blurred vision began with the pain and is in only her right eye. She is a retired radiologist with no significant past medical history. On physical examination, she is in severe discomfort, with her hand over her right eye. Her eye is hard and red; the pupil is 6 mm dilated and reacts poorly to light. Visual acuity is 20/200 in the right eye and 20/30 in the left. The remainder of her exam, including that of the left eye, is unremarkable.

Endometrial hyperplasia

A 70-year-old G3P3 woman complains of 2 months of painless intermittent vaginal spotting. She went through menopause at age 52 and was using hormone replacement therapy (HRT) until 3 years ago. Her past medical history is significant for type 2 diabetes. She is 170 cm (5′6′′) tall and weighs 82 kg (180 lb). On physical examination, she is afebrile, with heart rate of 75/min and blood pressure of 135/80 mm Hg. On speculum examination, the external genitalia are normal, while the vaginal walls are dry and atrophic. The cervix has no lesions, and a drop of blood is seen at the os. An intravaginal ultrasound is performed in the office, revealing a 7-mm endometrial stripe. A Pap smear and endometrial biopsy are done and results are sent to pathology.

Acute coronary syndrome

A 70-year-old man presents to the emergency department complaining of central chest pain that has been getting worse in the past 3 days, although he reports he is not in pain currently. He reports a history of "squeezing" pain in his chest for the past 5 years that occurs occasionally with physical exertion and resolves with rest; this pain has been occurring at rest for the past 3 days, is occurring more frequently (up to 6 times per day), and lasts a few minutes longer than usual. His medical history is significant for hypertension, hypercholesterolemia, a 40-pack-year smoking history, and a family history of heart disease. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 130/90 mm Hg, pulse rate of 80/min, respiratory rate of 12/min, and oxygen saturation of 99% on room air. His physical examination is remarkable for slightly decreased breath sounds bilaterally and a normal cardiac examination. X-ray of the chest reveals clear lungs with a normal-sized heart and mediastinum. An ECG is shown in Figure 1-1.

Congestive heart failure

A 70-year-old man presents to the emergency department complaining of increased shortness of breath with minimal exercise, cough, and fatigue. These symptoms began 2 weeks ago and have progressed gradually. He reports he used to feel this way "all the time" years ago but that this has not happened much since he began using his inhalers and his "water pill." He also has a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), diabetes mellitus, hypertension, and 30-pack-year of smoking. He denies swelling of the extremities, fever or chills, productive cough, chest pain, or palpitations. He cannot remember the names of his medications but says he has not missed any doses. When asked about his diet, he says he has been eating more hot soup since the weather has gotten colder. His temperature is 37.5°C (99.5°F), blood pressure is 135/90 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and oxygen saturation is 94% on room air. Examination of the neck reveals mild jugular venous distention. Examination of the lungs reveals loud crackles throughout the lung fields bilaterally. Examination of the heart reveals a laterally displaced point of maximum impulse with no murmurs, rubs, or gallops. There is mild clubbing of the extremities, as well as pitting edema of the lower extremities to the knee, bilaterally. His plasma brain natriuretic peptide level on rapid bedside assay is 500 pg/mL, and an x-ray of the chest reveals perivascular haziness, interstitial edema, and an enlarged cardiac silhouette.

Second-degree heart block

A 70-year-old man with a history of hypertension is brought to the emergency department by his wife after having a "fainting" spell 2 hours earlier. He denies any preceding light-headedness, nausea, diaphoresis, chest pain, palpitations, or confusion; his wife reports "he just collapsed and woke up 15 seconds later." She denies witnessing any convulsive movements or any postictal symptoms. He has a history significant only for hypertension that is controlled with metoprolol. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 125/70 mm Hg, pulse rate of 60/min, and respiratory rate of 10/min. His chest is clear, his heart examination reveals a regular rate and rhythm with no murmurs or gallops, he has normal bowel sounds, and has unremarkable extremity and neurologic examinations. An ECG taken on arrival is shown in Figure 1-7.

Acute respiratory failure

A 70-year-old man with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), myasthenia gravis, and chronic back pain is recovering after a motor vehicle accident. The patient fractured both tibiae and multiple ribs but escaped serious internal organ injury. His problem during this hospitalization has been pain control. He has recently been transitioned to oral oxycodone, but morphine injections are still needed for breakthrough pain. At the 4 A.M. vital sign check, the night nurse finds him unarousable. He has a respiratory rate of 5/min and an oxygen saturation of 80% by pulse oximetry. His heart rate is 80/min, and blood pressure is 130/80 mm Hg. He has pinpoint pupils, a normal cardiac exam, and clear lung fields. Arterial blood gas analysis shows a pH of 7.02, partial pressure of CO2 of 90 mm Hg, partial pressure of O2 of 45 mm Hg, and bicarbonate of 24 mEq/L. Administration of 100% oxygen by nonrebreather mask raises the oxygen saturation to 95%. Review of the medication log shows that the patient got two morphine injections in addition to his maximum oxycodone dosage.

Neutropenic fever

A 70-year-old woman who recently started chemotherapy for acute myeloid leukemia presents to the emergency department with fever of 1 day's duration. She is otherwise asymptomatic. She has a temperature of 38.7° C (102° F), heart rate of 88/min, respiratory rate of 12/min, and blood pressure of 110/80 mm Hg. Physical examination is unremarkable. Her indwelling vascular catheter site is without erythema or tenderness. A chest radiograph is normal. Relevant laboratory findings include a WBC count of 1.2/mm3, hemoglobin of 11.4 g/dL, platelet count of 150,000/mm3, and an absolute neutrophil count of 290/mL. RBC levels are within normal limits.

Spinal stenosis

A 72-year-old man presents to his primary care physician complaining of progressively worsening exercise intolerance. He states that he has always been active, but over the past 3 years he has been having more and more pain while walking. On walking four or five blocks, he begins to experience discomfort in his lower back as well as numbness and tingling that radiates down the back of his thighs and calves. The patient states that these symptoms persist until he sits down and rests for awhile. Past medical history is significant for hypertension for which he takes losartan. On examination, his blood pressure is 132/70 mm Hg, pulse is 73/min, and respiratory rate is 12/min. Motor examination of the lower extremities reveals no weakness, but the patient has decreased sensation to light touch in the S1 distribution, and his Achilles reflexes are diminished bilaterally. Posterior tibial and dorsalis pedis pulses are 2+, and a straight leg raise test (Lasègue's sign) is negative bilaterally.

Aortic stenosis

A 72-year-old man with a history of peripheral vascular disease presents to the clinic complaining of having shortness of breath for the past month. He had previously been able to climb two flights of steps with little difficulty, but now cannot climb one flight without severe shortness of breath. On further questioning, he reports occasional chest pain on heavy exertion, and says 1 week earlier he fainted after climbing the stairs from his basement. He denies a history of heart or lung problems, high cholesterol, diabetes, smoking, or family history of heart or lung disease. On physical examination, he appears in no acute distress, and his vital signs include a temperature of 37.0° C (98.6° F), blood pressure of 140/80 mm Hg, pulse rate of 80/min, respiratory rate of 12/min, and oxygen saturation of 99% on room air. There is a slow rise of the carotid upstroke, a sustained apical impulse, and a quiet S2, as well as a 3/6 harsh systolic ejection murmur heard best at the second intercostal space at the right sternal border.

Acute mesenteric ischemia

A 72-year-old woman with a history of atrial fibrillation and gout is brought to the emergency department with severe pain throughout her abdomen. She was watching television when the pain began very suddenly and quickly became the worst pain she has ever experienced. She also reports having the sudden urge to defecate after the onset of the pain. She describes the pain as "knifelike," and nothing improves or worsens the pain. She also denies radiation of the pain, chest pain, shortness of breath, blood in her stool, vomiting, or change in dietary habits. Her physical examination reveals a well-developed, well-nourished elderly woman writhing on the bed. She has a temperature of 37.5° C (99.5° F), blood pressure of 155/100 mm Hg, an irregular pulse rate of 90/min, a respiratory rate of 14/min, and an oxygen saturation of 98% on room air. Her physical examination is remarkable for an irregularly irregular heart rhythm, mild tenderness to palpation in the periumbilical region, and minimal bowel sounds, but no rebound, guarding, or flank tenderness. Her rectal exam is guaiac negative. Her pelvic examination is unremarkable.

Vitamin B12 (Cobalamin) deficiency - Subacute combined degeneration

A 75-year-old man presents to his neurologist with difficulty walking. His gait has become progressively more spastic and ataxic over the past several months, and he reports increased problems with fatigue and forgetfulness. He has lived in a residential facility for the past 5 years and complains that the food is terrible, so he has been eating very poorly. He is otherwise very healthy and takes no medications or supplements. On physical examination, his vital signs include a temperature of 36.3°C (97.4°F), pulse of 99/min, and blood pressure of 120/80 mm Hg. He is alert and oriented but scores 25/30 on the Mini Mental Status Examination (MMSE). Neurologic examination is significant for 4+/5 strength in the bilateral lower extremities, 5/5 in the bilateral upper extremities, a positive Romberg test, and increased muscle tone in the lower extremities. On sensory testing, there are notable deficits in fine discriminative touch, vibration and conscious proprioception but retained pain and temperature sensation in the lower extremities. The remainder of his examination is within normal limits. A complete blood count (CBC) reveals hemoglobin of 8.3 g/dL, hematocrit of 26%, and mean corpuscular volume (MCV) of 110 fl. Hypersegmented neutrophils are visible on peripheral smear.

COPD

A 75-year-old man presents to his primary care physician complaining of decreased exercise tolerance and shortness of breath. He has a 50-pack-year history of smoking cigarettes. On physical examination, he has a barrel-shaped chest, a heart rate of 75/min, and a respiratory rate of 20/min. Cardiac examination is normal with no jugular venous distention. Chest examination reveals diminished breath sounds bilaterally with faint expiratory wheezing. He has an oxygen saturation of 93% by pulse oximetry and an arterial blood gas analysis that reveals pH 7.37, PCO2 58 mm Hg, PO2 65 mm Hg, and HCO3 35 mEq/L. An x-ray film of the chest reveals hyperinflation and subpleural blebs. Results of pulmonary function tests (PFTs) are as follows:

Aortic regurgitation

A 75-year-old man with a history of Marfan's syndrome presents to his physician complaining of a 6-month history of shortness of breath. He says his exercise tolerance has gradually decreased from 10 blocks on level ground to about 1 block and is limited by shortness of breath. He also reports shortness of breath at night, as well as generalized fatigue, occasional palpitations, and feeling like his heart is "pounding," especially when he lies on his left side. On physical examination, he appears in no acute distress and is a tall, thin man with a marfanoid body habitus. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 160/50 mm Hg, pulse rate of 80/min, respiratory rate of 12/min, and oxygen saturation of 99% on room air. He has a laterally displaced point of maximum impulse; distant heart sounds; a high-pitched, blowing early diastolic murmur heard best at the left sternal border that is decreased by the Valsalva maneuver; clear lungs; and peripheral pulses with sharp upstrokes and downstrokes.

Atrial fibrillation

A 75-year-old man with a past medical history of diabetes mellitus and hypertension presents to the emergency department complaining of the sudden onset of shortness of breath accompanied by palpitations beginning 6 hours ago. The palpitations last for approximately 10 minutes at a time and recur at least once an hour. He admits to a 5-year history of intermittent similar symptoms. He denies chest pain, cough, or light- headedness. He takes no medications and does not smoke cigarettes, but admits to drinking six to eight beers per day over the past 3 days. Vital signs include a temperature of 37.2°C (98.9°F), blood pressure of 135/90 mm Hg, pulse rate of 130/min, and respiratory rate of 22/min. The patient is speaking in full sentences, has a midline trachea, and has no inspiratory rales, dullness to percussion, or increased tactile fremitus over the lung fields. His heart examination is notable for an irregularly irregular rhythm without murmurs; there is no chest wall tenderness. An ECG is shown in Figure 1-2.

Pleural effusion

A 75-year-old woman presents to the emergency department complaining of shortness of breath at rest. She has a history of non-small cell lung cancer treated 1 month ago with partial left lung resection. Her temperature is 38.0° C (100.4° F), pulse is 100/min, respiratory rate is 25/min, and blood pressure is 135/80 mm Hg. She is in mild respiratory distress, and chest examination reveals absent breath sounds and dullness to percussion at the base of the left lung field. Upright and lateral decubitus radiographs of the chest are shown in Figure 15-3. A left-sided thoracentesis yields 1 L of nonbloody, turbid fluid. The fluid is tested, and results are as follows:

Colorectal cancer

A 76-year-old man presents to his primary care physician with 2 months of abdominal pain. He reports bloating, diarrhea, fatigue, and an unintentional weight loss of 6.8 kg (15 lb). Vital signs include a temperature of 37.0°C (98.6°F), pulse of 75/min, and blood pressure of 118/74 mm Hg. Relevant laboratory findings include a hemoglobin level of 8.4 g/dL, a WBC count of 10.0/mm3, and a positive fecal occult blood test.

Endocarditis

A 77-year-old man is brought to the emergency department by his daughter after he developed weakness in his right upper extremity. She says that he has been sick for the past two weeks with fever, chills, and night sweats and that he has lost nearly 4.5 kg (10 lb) during that time. He had attributed these symptoms to the flu, but he could not move his left arm when he woke this morning. He denies other symptoms. On further questioning, his general health is good except for poorly controlled hypertension, and he underwent an aortic valve replacement 2 months ago. Physical examination is remarkable for upper left hemiplegia, the click of his prosthetic valve, and the image below on funduscopic exam. Vital signs include a temperature of 38.9°C (102.0 °F), blood pressure of 114/55 mm Hg, and pulse of 115/min.

Subdural hematoma

A 78-year-old woman is found by her son lying at the bottom of the stairs in their house where they live together. After calling for an ambulance, the patient is brought to the emergency department for further evaluation. The son is not sure how long his mother was at the bottom of the stairs, but suspects that she must have fallen while attempting to descend the stairs. He states that she does not smoke or drink, and that she is fairly healthy except for a history of hypertension, for which she takes atenolol, and hip arthritis, for which she takes ibuprofen. The patient is unresponsive except to painful stimuli. The right pupil is 4 mm and sluggishly reactive, and the left pupil is 3 mm and reactive to 2 mm. Painful stimulation of the right lower and upper extremities elicits movement, whereas painful stimulation of the left produces no response. A Babinski reflex test elicits downgoing toes on the right and upgoing toes on the left. Vital signs include a temperature of 37°C (98.4°F), heart rate of 90/min, respiratory rate of 16/min, and blood pressure of 135/75 mm Hg. CBC and blood chemistry values are within normal limits. The patient undergoes a noncontrast CT scan of the head, as shown in Figure 10-4.

Hypernatremia

A 79-year-old woman who resides in a nursing home is brought to the hospital because of decreased mental acuity. She had been doing well until she developed a fever associated with an upper respiratory infection. She ate poorly and over 3 days became less responsive. She had been treated with antibiotics but not intravenous fluids. Physical examination reveals an obtunded elderly woman with a blood pressure of 110/78 mm Hg supine, 108/80 mm Hg sitting up in bed, heart rate of 96/min, respiratory rate of 20/min, and temperature of 39.1° C (102.4° F). She has poor skin turgor, her chest is clear to auscultation bilaterally, and her heart rhythm is regular with no murmurs or gallops; she has no abdominal masses and no peripheral edema. Laboratory studies are as follows:

Respiratory syncytial virus

A 9-month-old boy presents to the emergency department in January with a 1-day history of fever and wheezing. Three days prior, he had developed nasal congestion and a mild cough. He was born prematurely at 36 weeks but is otherwise healthy.On examination, he has a temperature of 39.2° C (102.5° F), heart rate of 130/min, respiratory rate of 28/min, and oxygen saturation of 95% on room air. He is a well- nourished, acyanotic infant in moderate respiratory distress. He has clear rhinorrhea, no conjunctival injection, and moderate intercostal and subcostal retractions. Lung examination is significant for diffuse expiratory wheezing. No murmurs or gallops are heard on cardiac examination. The remainder of his examination is normal. An x-ray of the chest is notable for hyperinflation and peribronchial thickening.

Partial complex seizures

A 9-year-old boy is brought to the pediatrician's office because his parents have become concerned about his unusual behavior over the past 2 days. The patient's mother states that over the past 2 days her son has had several episodes of sudden alteration in behavior. He first complains of a rising feeling in his stomach and becomes fearful. He begins to have difficulty speaking, and then begins to stare and seems to lose awareness of what he is doing. He starts making strange lip-smacking movements, and assumes awkward postures with his right hand and arm. These episodes last about 30 seconds to 1 minute. As soon as an episode is over, the patient becomes tired and confused for a few minutes and does not seem to recall the event afterward. The patient is in good health, and all of his developmental milestones were normal. Obstetric history is unremarkable. He did, however, suffer from a prolonged episode of convulsions as a child in the setting of a febrile illness. On examination, the patient is well appearing. Height, weight, and head circumference are appropriate for his age. Physical examination reveals no rashes or other skin lesions. The patient is afebrile, and all vital signs are stable. Neurologic examination is normal, as is an MRI of the head. Electroencephalography (EEG) demonstrates left temporal slowing with occasional spikes and sharp waves.

Legg-Calve-Perthes disease

A 9-year-old boy is referred to a pediatric sports medicine physician due to a history of intermittent pain in his right hip. The pain began during a soccer game 6 months ago and has increased in severity over this time. Although he has tried activity restriction and crutches, the right hip continues to bother him, especially with any activity. He had an uncomplicated birth and a past medical history negative for trauma or significant illness. He has no family history of similar complaints or disability. On physical examination, the patient is a healthy well-nourished boy who is at the 50th percentile for both height and weight for his age. He is afebrile and has stable vital signs. He walks with an antalgic gait. There are no obvious deformities of either lower extremity. However, he has marked discomfort to palpation over the entire right hip region, and internal rotation and hip abduction cause significant pain. When compared with the opposite side, the right hip has decreased range of motion noted in abduction, internal rotation, and flexion. A full laboratory workup was within normal limits. An x-ray of the affected right hip demonstrates a "moth-eaten" radiolucency suggestive of osteopenia of the femoral epiphysis and neck with a shortened femoral epiphysis. A bone scan of the lower extremities demonstrates evidence of avascularity of the right femoral epiphysis.

Osteomyelitis

A 9-year-old boy presents to his pediatrician with right leg pain and intermittent fever of 5 days' duration. He complains of pain in his right leg that has gotten progressively worse, and he has been having an increasingly difficult time walking over the past 2 days. He fell off of his skateboard 7 days ago but has no other history of trauma. He has no previous medical problems. He denies recent weight loss, cough, diarrhea, or dysuria. On examination, his temperature is 39.4° C (102.9° F), heart rate is 110/min, respiratory rate is 16/min, and blood pressure is 95/50 mm Hg. He is alert and well appearing. Physical examination is significant for edema, warmth, and tenderness over his right proximal tibia. The remainder of his examination is unremarkable.

Abdominal aortic aneurysm

A 90-year-old man with a history of coronary artery disease, hypertension, and a 30-pack- year smoking history presents to the outpatient clinic for his annual checkup. He denies recent complaints, although reports that he has not been as "active" lately. He has a history of good adherence to health maintenance recommendations, and results of recent colonoscopy and prostate examination are negative. He takes aspirin, metoprolol, and an occasional multivitamin. He admits to having problems with smoking cessation. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 120/80 mm Hg, pulse rate of 60/min, and respiratory rate of 10/min. Physical examination shows a thin, elderly man with mottled skin. His head, ears, eyes, nose, and throat (HEENT); neck; chest; and cardiac examinations are unremarkable. His abdomen is non-tender and non-distended, but a pulsating mass is palpated approximately 2 cm superior to his umbilicus, 1 cm left of midline.

Congenital cytomegalovirus (CMV) infection - TORCH infections

A boy at 33 weeks' gestation is born via spontaneous vaginal delivery. Membranes are ruptured at the time of delivery with clear amniotic fluid. His mother did not seek prenatal care but denies any medical problems during the pregnancy. She denies tobacco, alcohol, and illicit drug use. At delivery, the infant is small, and his length and weight are < 25% for gestational age. His head is microcephalic. Ophthalmologic examination reveals chorioretinitis. He is pink, with good respiratory effort. His skin is mildly jaundiced with diffuse raised red/purple lesions and petechiae. His anterior fontanelle is soft but full. His sclerae are mildly icteric. His abdomen appears distended and protuberant, but it is soft and nontender. A firm liver edge is felt 4 cm below the right costal margin, and the spleen is felt 3 cm below the left costal margin. The remainder of the examination is unremarkable. Laboratory results are significant for a hemoglobin of 9 g/dL and a platelet count of 45 × 103/mm3 with an atypical lymphocytosis (10%). Direct serum bilirubin is elevated at 8 mg/100 mL. Three hours after birth, the infant develops generalized tonic-clonic seizures that stop after administration of 20 mg/kg of phenobarbital. Cranial ultrasound reveals periventricular calcifications.

Diabetes insipidus

A healthy 24-year-old woman was involved in an automobile accident, and sustained a fracture of her jaw, multiple facial bone fractures, and a brief loss of consciousness. In the emergency department, an intravenous infusion of 5% dextrose in 0.45% normal saline at 125 mL/hr was started. Twelve hours after admission to the hospital, she was awake and alert but had difficulty swallowing and talking because of her injuries, and she complained of extreme thirst. Her urine output was 500-600 mL/hr. Laboratory studies show:

Reliability and validity

A medical researcher has developed a tool to evaluate the effectiveness of new international health research training programs in encouraging medical students to pursue careers in international health. The evaluation is compared against currently measured external criteria such as length of training, quality of mentorship, length of time spent training abroad, foreign language training, productivity of research faculty, and student satisfaction; the endpoint evaluated is the number of students who, over time, incorporate international health into their career. The tool is administered to a select group of international health training programs for further evaluation.

Incidence and prevalence

A medical student conducts a study on gastrointestinal (GI) ulcers in a randomly chosen group of traders who work on the floor of the New York Stock Exchange. He enrolls a cohort of traders at the beginning of the fiscal year and will follow them for one year, contacting them each month to see if any of them has had any episodes of chronic epigastric pain that had brought them to see a physician for diagnostic workup. After one year, the cases of confirmed GI ulcer are tabulated and the results are shown below:

Developmental milestones

A mother brings her three children to their pediatrician's office for checkups. While in the waiting room, the oldest child hops around the room and then begins to play with blocks. She speaks clearly and can count 10 blocks. When another child comes over, they build a block tower together. The middle child is using the furniture for support as he explores the waiting room. He sees a red crayon and picks it up using his thumb and forefinger. He then waves bye-bye to a child who is leaving the office. The youngest child sits on her mother's lap and holds a toy. She babbles while her mother reads to her. When one of her siblings comes over, she smiles at them. When a nurse says hello, she does not smile immediately but she takes a toy from her. All three children are healthy and have no developmental issues.

Positive predictive value (PPV) and (NPV)

A new three-dimensional MRI imaging technique for the detection of renal artery stenosis has been developed. After positive results in small studies, it is being tested versus renal artery angiogram (the gold standard study for the diagnosis of renal artery stenosis) in 1000 women aged 35-55 years old with cardiac risk factors. The results are shown below. The prevalence of the disease being screened for in this population is 10%.

Omphalocele

A newborn infant boy is transferred to the neonatal intensive care unit because of a defect in his abdominal wall. He was born by repeat low-transverse cesarean section at term to a 34-year-old G4P4 mother who did not receive any prenatal care. She denies any problems with this pregnancy. On examination, there is a 6-cm sac protruding from the midline of the abdomen; bowel and liver can be seen within the sac. The infant is hemodynamically stable and not in acute distress.

Bias and confounding

A physician reading a weekly medical journal comes across the results of a case-control study designed to identify risk factors for cerebral vascular accidents (CVAs). The study reports a significant association between CVAs and the routine use of sleeping pills (odds ratio = 0.62, p ≤ 0.035). Before recommending that his patients stop using these to address insomnia, the physician decides to present the article for discussion at his monthly journal club to discuss the strengths and weaknesses of the study.

Croup - Laryngotracheobronchitis

A previously healthy 3-year-old boy presents to the emergency department with fever, stridor, and hoarseness. His mother reports that he has had a runny nose and mild cough for the past week. Overnight, she noted his cough had worsened and sounded "barking." On examination, he has a temperature of 38.2° C (100.8° F), heart rate of 95/min, respiratory rate of 20/min, and pulse oximetry of 97% on room air. Pulmonary exam is significant for tachypnea and inspiratory stridor; mild retractions and nasal flaring are noted. Cardiac exam is unremarkable. Anteroposterior x-ray of the neck demonstrates subglottic narrowing consistent with a "steeple sign."

Kawasaki disease

A previously healthy 5-year-old boy presents to the emergency department with a 6-day history of fever and rash. Four days prior to admission the patient developed a small papular rash all over his body, bilateral conjunctival injection without exudate, and a temperature of 38.7° C (101.7° F). He was seen by his pediatrician on day 3 of fever and was diagnosed with a viral syndrome. The rash disappeared by day 4, but his fever persisted. On examination, he has a temperature of 39.0° C (102.2° F), heart rate of 130/min, respiratory rate of 24/min, and blood pressure of 99/62 mm Hg. He is irritable and difficult to console. His sclerae are injected bilaterally, and his oropharynx is mildly erythematous. His lips are dry and cracked. A 1.5 × 2-cm lymph node is palpable on the left anterior cervical chain. His chest is clear to auscultation. He does not have a rash. Relevant laboratory findings are as follows:

Cohort study

A student working on her degree in public health plans to study the association between maternal vaginal infections during gestation and the development of schizophrenia in offspring. In preparation for her committee meeting, she must have a preliminary study design prepared. She has access to a large database of obstetric records with 30-year follow-up data on the mothers and offspring.

Huntington's disease

A woman brings her 50-year-old father to a neurologist after being referred by his psychiatrist. He is belligerent, making inappropriate comments, and occasionally experiencing auditory hallucinations. His behavioral problems developed a few years ago and were initially attributed to a substance abuse problem. However, a recent examination by his psychiatrist showed rhythmic, repetitive grimacing and blinking, with occasional rapid, jerky, dancelike movements of his right arm. The daughter says that she remembers her grandfather having similar symptoms and that he committed suicide when she was a child. Physical examination reveals a temperature of 37°C (98.6°F), a heart rate of 80/min, and a blood pressure of 145/90 mm Hg.

OBESE woman. BMI is 32. DIABETES MELLITUS type 2. DARK hyperpigmented lesions on POSTERIOR NECK, ARMPIT, UNDER BREAST, GROIN. dark "dirty-appearing" VELVETY plaques.

ACANTHOSIS NIGRICANS

ADOLESCENT. BUMPS on FOREHEAD, NOSE, CHEEKS; some BLACK, others WHITE with RED RING around them. PAINFUL when pressed.

ACNE VULGARIS

ITCHY RASH on ARMS, LEGS, CHEEKS. DRY SKIN. SCALY, CRUSTED, PINK lesions and EXCORIATIONS are on FLEXURAL surfaces.

ATOPIC DERMATITIS (eczema)

Von Willebrand's disease

An 18-year-old African-American woman presents to a gynecologist for her first visit. She is in generally good health but complains of menorrhagia since menarche. She notes that she bleeds profusely from cuts but that she can stop the bleeding with prolonged pressure. Her mother has the same problem, but her two brothers and her father seem to clot more quickly. Her maternal uncle died in a car accident as a teenager and was rumored to be a hemophiliac; two of her maternal aunts also have menorrhagia, but neither they nor her mother have had problems getting pregnant or any complications during pregnancy and delivery. The patient's prothrombin time is 13 seconds, and her partial thromboplastin time is 62 seconds.

Hydatidiform mole

An 18-year-old G1 woman at 16 weeks' gestation presents to her obstetrician for severe vomiting. She has difficulty even keeping fluids down and has been vomiting at least 10 times daily. The pregnancy has otherwise been uneventful. On physical examination, her vital signs include a temperature of 37.2° C (99.0° F), heart rate of 110/min, blood pressure of 100/58 mm Hg, and respiratory rate of 15/min. She appears dehydrated, with sunken eyes and tacky mucous membranes. Her uterus is measured at 20 weeks' size; no fetal heart tones can be heard. Transabdominal ultrasound reveals a "snowstorm" pattern.

Pityriasis rosea

An 18-year-old black man visits his primary care physician because of a rash he has noticed over the past few days that continues to spread. On further questioning, the man mentions he noticed a pinkish, oval area on his chest that first appeared 2 weeks prior. On physical examination, the patient is healthy and well appearing. Examination of his skin reveals a crop of small, oval macules with a peripheral rim of scale, scattered over the trunk in a "Christmas tree pattern." The area where the first patch appeared has an area of central clearing with a cigarette paper-like scale. The patient's rash is shown in Figure 2-5.

Epidural abscess

An 18-year-old man is brought to the emergency department (ED) by his mother for "increasing sleepiness." His mother relates that he has been having fevers over the past week up to 38.6°C (101.4°F), which were reduced with acetaminophen. The last two days he has had headaches, and this morning began experiencing significant nausea and vomiting. She attributed his symptoms to gastroenteritis until he began having trouble using his left arm and became progressively more somnolent. He has no sick contacts but did have an upper respiratory tract infection about 5 weeks ago. His past medical history is significant for mild asthma and frequent sinusitis. His sinusitis usually resolves with oxymetazoline and saline nasal sprays. Several times over the past few years he has required antibiotics for chronic sinusitis. On physical examination, the patient is able to answer some basic questions but has difficulty keeping his eyes open. His neck is supple. His neurologic exam demonstrates bilateral papilledema and 2/5 strength in his left arm and leg. Computed tomography (CT) scan of the head with contrast reveals a ring-enhancing lesion adjacent to the superior aspect of the right frontal and temporal bones, without evidence of a bony defect. Laboratory findings are as follows:

Herpes simplex virus

An 18-year-old man presents to his primary care physician for his annual checkup. Before leaving the office, he complains of a few bumps near his lips that cause him significant pain. He recalls a strange tingling and burning sensation near the left corner of his lips that occurred a week ago. A few days later, he saw a small group of bumps appear in the same area. Physical examination is normal except for small groups of 2-mm vesicles on an erythematous base around the left angle of his mouth.

Anorexia nervosa

An 18-year-old woman is being evaluated by her physician at the urging of her parents. Her mother says she is concerned about her daughter's dramatic weight loss over the past year. The patient states that her mother is worrying over nothing, and that she agreed to the doctor's appointment just to get her off her back. She reports that she feels just fine, has been sleeping well, although her mood is "a little depressed." She admits she has not had her period in several months. She says she eats when she is hungry but admits that she's not hungry very often. She also says she is unhappy with her current weight and would be happier if she just lost a few more pounds. She is an accomplished ballet dancer and often spends hours in the evening dancing at the studio. She describes her relationship with her mother as "very tense"; she feels like her mother is too controlling. On physical examination, the patient is 173 cm (5′8′′) tall; she weighs 46.7 kg (103 lb) and appears cachectic. Relevant laboratory findings reveal a WBC count of 4.5/mm3, hemoglobin of 9.8 g/dL, and a platelet count of 140/mm3.

Epidural hematoma

An 18-year-old woman is brought to the emergency department by ambulance after a motor vehicle accident. The patient was alert when the paramedics arrived at the scene, but her level of consciousness declined en route to the hospital. The patient told the paramedics she was unrestrained and had hit her windshield during the collision. On presentation the patient is drowsy but responsive to verbal commands. She complains of back and neck pain and a headache. There is a contusion and abrasion over her right temporal region; the remainder of her head, ear, eye, nose, and throat examination is normal. Neurological examination reveals no focal deficits, and cranial nerves II-XII are intact. Vital signs, a complete blood count, and blood chemistry test results are within normal limits. A lateral x-ray of the cervical spine reveals no abnormalities. Noncontrast CT scan of the head shows a small skull fracture in the temporal region and an underlying extra-axial lenticular hyperdensity.

Guillain-Barre syndrome

An 18-year-old woman presents to the emergency department complaining of leg weakness. One week ago the patient was ill with fever, nausea, and diarrhea, but the symptoms resolved 2 days prior to admission. The patient first noticed that something was wrong upon waking up this morning, when she nearly fell over after getting out of bed. She says she cannot walk without support and that as the day has progressed, her arms have also begun to feel weak. She has also developed pain in the lower back and legs as well as a bothersome tingling sensation in the feet. The patient denies any headache, blurred vision, tinnitus, or vertigo, but has had mild weakness in the face and has noticed that her speech is becoming more slurred. She is not experiencing any bowel or bladder incontinence. On presentation, the patient is a well-nourished teenager who appears nervous. Vital signs include a temperature of 37.0°C (98.6°F), a heart rate of 72/min, a respiratory rate of 22/min, and a blood pressure of 100/64 mm Hg. HEENT, heart, lung, and abdomen examinations are normal. Her cranial nerve examination demonstrates mild facial diplegia and dysarthria. She has 3/5 strength in the lower extremities bilaterally and 4/5 strength in the upper extremities. Deep tendon reflexes are absent throughout. Brachial, posterior tibial, and dorsalis pedis pulses are 2+ bilaterally. CBC, electrolytes, blood urea nitrogen, creatinine, glucose, calcium, and liver function tests are normal. Urine toxicology screen is negative. A lumbar puncture is performed; opening pressure is normal. CSF analysis shows a protein level of 146 mg/dL, glucose of 70 mg/dL, and no WBCs or RBCs. Gram stain demonstrates no WBCs and no organisms.

Intussusception

An 8-month-old boy with no significant past medical history presents to his pediatrician with irritability and one episode of stool mixed with blood and mucus. His mother notes that he began crying inconsolably for about 30 minutes after waking up early from his morning nap and then began acting like himself again. An hour later, he began crying again and was noted to be pulling his knees toward his abdomen. He continued to have episodes of irritability and crying that lasted approximately 20 minutes and occurred at 30-45-minute intervals. On examination, he is afebrile, and vital signs are within normal limits. He has normal rectal tone with Hemoccult-positive stool. Laboratory results are all unremarkable.

Child abuse (Non-accidental trauma)

An 8-month-old girl is brought to the emergency department by her grandmother for being "too sleepy." On the day of admission, the grandmother noted that she was difficult to arouse and had decreased oral intake. On examination, the child has a temperature of 37.5° C (99.5° F), a heart rate of 140/min, and a respiratory rate of 28/min. She is somnolent but withdraws all four extremities to painful stimuli. Physical examination is unremarkable except for a 2 × 2-cm hematoma on her right buttock. Relevant laboratory findings include a WBC count of 9000/mm3 (85% neutrophils), hemoglobin of 9.4 g/dL, and platelet count of 355,000/mm3. Lumbar puncture reveals a WBC count of 4/mm3, RBC count of 264/mm3, glucose of 82 mg/dL, and protein of 41 mg/dL. An x-ray of the chest reveals a fracture of the lateral aspect of the right first rib and a healing fracture of the right clavicle.

Tay-Sachs disease

An 8-month-old girl is brought to the hospital because of motor deterioration and convulsions. She was born at 38 weeks' gestation without complications. Her past medical history was unremarkable, and she had been meeting her developmental milestones normally until 2 weeks prior to admission, when her parents noted that she had lost the ability to sit unassisted. On the morning of admission she had a tonic-clonic seizure lasting 2 minutes. Physical examination is significant for generalized hypotonia and macrocephaly. She is also noted to have a dramatic startle reflex. Ophthalmic examination reveals a retinal cherry-red spot. She has no evidence of organomegaly.

ADHD

An 8-year-old boy is referred to his pediatrician at the recommendation of his teacher because of difficulties he has been having in school for the past year. According to the teacher, he is not completing assignments and often makes careless mistakes. He is easily distracted and must constantly be told to sit still and remain in his seat; he frequently is found staring out the window or talking to other students at their desks. She also says that he is very disruptive and blurts out answers to questions before she has completed them. He cannot seem to wait his turn in the cafeteria line and insists on playing games that others have not invited him to play. His parents describe him as a happy boy who enjoys playing with his brother and neighborhood friends. They have seen some of the same behaviors at home that are giving him trouble at school. They describe him as "constantly on the go" and describe the evenings as "a battle" to get him to finish his schoolwork or to clean his room, which is always a mess. He complains that he does not like school except for recess and physical education. Evaluation by the school counselor showed no evidence of a learning disorder.

Dementia

An 80-year-old woman is brought to her physician by her daughter for a medication check. During the visit, the patient has trouble answering questions about events that took place in the past month, and at one point stops to ask her daughter where she is. Her daughter comments that she has recently been disoriented in familiar environments, that she has trouble coming up with the names of people and objects, and that she recently forgot to turn off the stove at home, setting off the fire alarm. Her temperature is 36.5°C (97.7°F), with a heart rate of 90/min and a blood pressure of 130/80 mm Hg. Neurologic examination reveals no focal deficits, but she scores a 22/30 on the Mini-Mental State Examination, losing points because she is not oriented to the date or day of the week, is unable to recall words that she has been asked to remember after a brief delay, and is unable to copy a simple figure.

Diastolic heart failure

An 80-year-old woman with a history of chronic hypertension presents to the clinic for a routine examination. She notes that over the past couple of years she has had progressive mild shortness of breath on exertion and in the middle of the night, as well as mild foot swelling. She denies cough, chest pain, palpitations, light-headedness, or fatigue. She denies that it is very bothersome but would like to know if it is dangerous to her health. She has never been hospitalized, and denies any significant medical history other than high blood pressure, although she admits to being poorly adherent to her medications. She denies a smoking history and family history of similar problems. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 170/110 mm Hg, pulse rate of 80/min, and respiratory rate of 18/min. Physical examination reveals a lack of jugular venous distention and a laterally displaced point of maximum impulse, with no murmurs, rubs, or gallops, a clear lung exam, and 2+ pitting edema to mid-leg bilaterally. An ECG shows left atrial enlargement and left ventricular hypertrophy with repolarization abnormalities. Echocardiography shows an ejection fraction of 65% and a thickened left ventricular wall.

Depression

An 81-year-old man is brought to his geriatrician by his daughter because she is concerned about his recent behavior. She says he has been crying frequently and not eating well. The patient admits that he has been feeling despondent lately and has told his children he no longer wishes to be a burden to them and that they would be better off if he weren't around anymore. Prior to the past few weeks, he was still active and played poker regularly with other men in his retirement community. He says he "has not been up to it" for the past 2 weeks and finds himself sleeping throughout the day. The patient denies experiencing manic symptoms or auditory or visual hallucinations. The results of his physical examination are essentially normal, although he has lost 4.5 kg (10 lb) since his last visit and exhibits psychomotor slowing. His medications include an angiotensin-converting enzyme inhibitor and a thiazide diuretic, neither of which were prescribed recently.

Diverticulitis

An 83-year-old woman presents to the emergency department for abdominal pain. She was in her usual state of health until approximately 8 hours ago, when she began experiencing a crampy pain in the left lower quadrant of her abdomen. Since the onset of her symptoms, she has vomited twice and has not had a bowel movement. Physical examination reveals a temperature of 38.3°C (100.9°F), pulse of 109/min, and blood pressure of 122/70 mm Hg. Abdominal examination is significant for left lower quadrant tenderness with guarding. Rectal examination is notable for rectal tenderness. A complete blood count reveals a WBC count of 14.1/mm3, hemoglobin level of 13.1 g/dL, and platelet count of 200/mm3.

Onychomycosis

An 85-year-old man presents to his primary care physician with trouble walking. He states that over the past several weeks he has been having considerable pain around the toes of his right foot whenever he stands. This same pain makes it impossible for him to play in his daily racquetball matches with colleagues. Physical examination reveals a healthy-looking male who appears younger than his stated age. A powerful odor is present when he removes his athletic shoes. The rest of the exam is normal except for brown, thick, opacified nail plates on three of the five toes on his right foot that cause him pain when touched.

Deep venous thrombosis

An 85-year-old woman who underwent colon cancer surgery 2 months ago is brought to the clinic by her daughter because she has been complaining of painful swelling of her left leg. The patient says she has been feeling otherwise well except for a 2-week history of pain, swelling, and redness in her upper left calf. She denies any history of similar problems in the past and denies acute or repetitive trauma to the area; she says that, in fact, she has been avoiding exercise or walking unnecessarily since her surgery. She denies any other medical or surgical history and takes atenolol and aspirin daily. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 135/90 mm Hg, pulse rate of 60/min, and respiratory rate of 12/min. Her physical examination demonstrates no jugular venous distention; clear lung fields; a regular heart rate and rhythm without murmurs, rubs, or gallops; and a normal abdomen. Her left calf has pitting edema and is approximately 4 cm larger in circumference than the right calf. It is erythematous on the posterior aspect and tender to palpation. Neurologic and skin examinations are otherwise unremarkable.

Delirium

An 86-year-old woman is admitted to the intensive care unit after suffering a myocardial infarction. Despite her advanced age, she has no known previous medical history. Her son, who is her primary caregiver, is very concerned about her condition and insists on remaining at her bedside at all times. Shortly after midnight, she becomes agitated and removes her intravenous line. As the nursing staff attempts to replace the line and calm her, she begins screaming, "I have to clean the kitchen!" She does not appear to recognize her son. Physical examination reveals a temperature of 37.0° C (98.6° F), pulse of 101/min, and blood pressure of 132/84 mm Hg. Oxygen saturation is 98%, and blood glucose is 103 mg/dL.

Bioterrorism

An employee at a federal government building in Washington, D.C., begins to experience symptoms that include a fever of 38.3°C (101.0°F), chills, headache, backache, vomiting, and abdominal pain. Within 4 days, the symptoms are followed by the development of a rash characterized by deep-seated, firm or hard, round, well- circumscribed vesicles. The lesions on the patient's arms appear to be in the same stage of development as those on his abdomen. Further investigation reveals that a suspicious package arrived in the office of the employees 2 weeks before the symptoms began.

Randomized clinical trial

An international clinical research group would like to evaluate a new COX-2 inhibitor that aims to limit prostaglandin production in HIV+ women as a means of preventing the development of cervical cancer. The team wishes to enroll HIV+ women from sites around the world and randomize them into two groups. One group will receive the study drug, while the other group receives a nonactive pill that appears identical to the study drug. Neither the investigators nor the subjects will know who is in which group until the end of the study. The women will be followed for 5 years with regular cervical exams every 6 months, using the development of in-situ cervical cancer as the outcome measure.

Somatization disorder

At her initial office visit, a 29-year-old woman presented with a chief complaint of weakness and malaise of 3 years' duration. She states, "I've learned to live with weakness and tiredness all the time." These symptoms began shortly after she gave birth to her only child, and she thought it might be because of her difficult pregnancy, during which she experienced nausea and vomiting throughout the 9 months. Over the course of the next 3 years, she consulted many physicians with a variety of complaints: diffuse abdominal pain, trouble swallowing, constipation, headache, back pain, joint pain, and excessive menstrual bleeding. To evaluate the abdominal pain and constipation, she had a barium enema examination and upper gastrointestinal x-ray series. The test results were normal. On her most recent visit, she states she has been feeling a strange numbness and tingling in her left leg. Her past surgical history is significant for an appendectomy, cholecystectomy, and arthroscopic surgery on her right knee. She has been unable to work because of her symptoms and claims they have "ruined her life." The mental status examination is notable for the patient's anxious affect.

Autism

The parents of a 28-month-old boy present to their pediatrician expressing concern about his development. Until age 2, their son had met all his developmental milestones; he was able to follow simple directions, respond to his name, and speak 8-10 words. However, over the past 4 months, their son has progressively become more withdrawn. He rarely makes eye contact and does not respond to his parents' laughter or affectionate gestures. He does not play with other children his age and frequently rocks back and forth. Of most concern to his parents, he rarely speaks and often does not respond to his name. He does not compensate for his lack of speech through other communication, such as miming or gesturing.

Generalized anxiety disorder

A 42-year-old man presents to his primary care physician with a chief complaint of insomnia. He states he is able to fall asleep quickly but wakes up in the middle of the night and is unable to get back to sleep. He lies in bed worrying about his job as an accountant in a large firm, the health of his aging parents, the country's involvement in wars overseas, the encroachment of gangs in his city, and any number of seemingly random, unrelated topics. He complains of frequent tension headaches and does not feel like he is ever "really relaxed." He reports occasionally feeling short of breath and experiences heart palpitations. He is concerned because his restlessness is affecting his ability to concentrate at work, and they are heading into the busiest time of year. He says he has felt this way for most of his adult life but that his symptoms seem to be getting worse. The only thing that seems to help is if he has a few drinks after work, but he does not want to become dependent on alcohol to ease his nerves.

Pancreatitis

A 42-year-old man presents to the emergency department because of pain in his back and around his umbilicus. The pain began 2 days ago after a long night of drinking at his favorite bar. He admits to vomiting twice in the past several hours, with only slight relief of his pain. His temperature is 38.3°C (100.9°F), pulse is 114/min, and blood pressure is 92/62 mm Hg. On physical examination, he appears anxious and is leaning forward in bed with his knees bent. Abdominal examination is notable for epigastric tenderness. Relevant laboratory findings include a WBC count of 15.2/mm3, hemoglobin of 16.2 g/dL, and serum amylase of 950 U/L.

Cholecystitis

A 42-year-old obese woman presents to the emergency department with abdominal pain of several hours' duration. The pain began shortly after she ate a slice of pizza at her son's birthday party. She describes the pain as constant and localized to the upper right side of her abdomen. She admits to having previous episodes of similar pain but adds that these episodes spontaneously resolved within a few hours. Physical examination reveals a temperature of 38.3°C (100.9°F), pulse of 113/min, and blood pressure of 126/82 mm Hg. Abdominal examination is significant for right upper quadrant tenderness with a positive Murphy's sign. A complete blood count reveals a mild leukocytosis of 15.2/mm3. An abdominal ultrasound is shown in Figure 6-1.

Lyme disease

A 42-year-old woman presents to her physician with an erythematous annular patch with central clearing on her left forearm. The patient states that the rash began as a small red papule about 5 days ago and has grown progressively larger. She also complains of fatigue, headache, myalgias, and intermittent arthralgias that have lasted 2 weeks. She has remained afebrile, and her vital signs are stable. Physical examination is significant for a 9 × 9-cm erythematous patch on her left forearm that has concentric rings of redness and a clearing center. She also has cervical and axillary lymphadenopathy. The remainder of the examination is unremarkable. She has no recent travel history, no sick contacts, and keeps several dogs for hunting in the woods near her Connecticut home.

Carcinoid syndrome

A 42-year-old woman presents to her primary care physician with a chief complaint of flushing. These episodes arise suddenly and spontaneously, without any trigger she can identify. These episodes usually last about a minute. However, she describes one episode that continued for about 15 minutes. During these episodes, the skin on her chest and face becomes very red, with a mild burning feeling. Over the past few weeks, she has also had increasing problems with diarrhea and has had up to 20 watery, nonbloody stools per day, accompanied by intense abdominal cramping. She denies any health problems prior to these complaints, which began a few months ago. On physical examination, she appears comfortable with normal vital signs. Faint wheezes are heard on her lung exam. She has mildly hyperactive bowel sounds, but her abdomen is soft and nontender. A 24-hour urine collection is obtained and found to contain 274 mg of 5-hydroxyindoleacetic acid (5-HIAA; normal 2-8 mg/day).

Glucose-6-phosphate dehydrogenase deficiency

A 43-year-old African-American man is brought to the emergency department after losing consciousness during a barbecue. Earlier that morning when getting out of bed, he felt dizzy and had to steady himself against the doorframe of the bathroom. He is generally healthy, although he recently had a bad sinus infection for which he received trimethoprim-sulfamethoxazole 4 days ago from his primary physician. Upon examination, he is tachycardic and tachypneic. His sclerae are icteric, but the rest of his examination is unremarkable. He has never been anemic in the past, but at this time laboratory studies reveal a hemoglobin of 9.1 mg/dL, a normal white count, white cell differential and platelet count. The reticulocyte count is elevated. The bilirubin is elevated, and fractionation reveals that the bilirubin is predominantly indirect.

Carbon monoxide poisoning

A 43-year-old man is brought to the emergency department by his wife after she found him in their winter cabin confused and dizzy. He drove up to the mountains the day before to prepare the cabin for their winter vacation. When she arrived, he was staggering around the cabin and complaining about a bad headache. His wife adds that he must have worked very hard to prepare the house because the cabin floors were swept and the old kerosene heater was working well. Physical examination reveals a temperature of 37.0° C (98.6° F), a pulse rate of 86/min, blood pressure of 126/82 mm Hg, and pulse oximetry of 99% on room air. He is not oriented to place or time and has a ruddy complexion. Significant laboratory findings:

Hypocalcemia

A 43-year-old woman presents with a fractured rib. She has diffuse bone pain and difficulty combing her hair, rising from a chair, and climbing stairs. She states she has had foul-smelling, bulky stools and has lost about 4.5 kg (10 lb) over the past 6 months, though her appetite has been normal. She has high calcium intake and normal sun exposure. She takes a multivitamin daily. Physical examination shows a normal abdomen, proximal muscle weakness, and tenderness over the spine and ribs. She walks with a waddling gait. Neurologic examination is otherwise normal. Blood studies show normal electrolytes, renal function, and liver function. Other pertinent laboratory data are as follows: Calcium: 7.5 mg/dL

Wegener's granulomatosis

A 44-year-old man presents to the emergency department after coughing up blood intermittently for the last several days. He notes one prior episode of hemoptysis several months ago that resolved on its own. He generally dislikes going to the doctor because he has chronic sinusitis with intermittent bloody discharge, which never gets better "no matter what they try." He denies any other medical conditions but notes that he has felt fatigued over the last year. He has never smoked, has never been incarcerated, and has never traveled outside the United States. He reports subjective fevers and night sweats but has no sick contacts. On physical examination, his temperature is 38.2° C (100.8° F), pulse is 95/min, blood pressure is 135/80 mm Hg, respiratory rate is 18/min, and oxygen saturation is 95% on room air. Rhonchi are heard in the upper left lung field. Urine histoplasma antigen was negative, as was a sputum stain for acid-fast bacilli. A CT scan of the head revealed patchy mucosal and periosteal thickening without fluid levels. A CT scan of the head revealed multiple nodules, some with cavitation as well as ground-glass infiltrates.

Acid-base disorders

A 44-year-old man with a history of chronic alcoholism enters the emergency department obviously intoxicated. He complains of severe epigastric abdominal pain radiating to his back, nausea, vomiting, and dyspnea for the past 2 days. On examination, his temperature is 38.8o C (101.8o F), pulse is 115/min, blood pressure is 110/60 mm Hg, and respirations are 28/min and shallow. His abdomen is rigid with diffuse tenderness and hypoactive bowel sounds. Chest examination reveals dullness to percussion at the right base. Relevant laboratory findings are as follows:

Renal cell carcinoma

A 44-year-old man with no significant past medical history presents to his primary care physician with a 3-month history of left flank pain. The pain is dull in character, constant, and has become progressively worse over time. Over the past week, he has also noticed a pink hue to his urine. He denies any history of trauma in the past year. On examination, his temperature is 37.2° C (99.0° F), pulse is 88/min, and blood pressure is 110/74 mm Hg. His heart and lung examinations are within normal limits. A palpable mass is noted in his left abdominal/flank region. The mass is firm, nontender, and moves with respiration. The rest of the abdomen is soft, nontender, nondistended, and with normal bowel sounds. Fullness is also noted in his left scrotum when the patient is recumbent. The fullness permits light penetration on transillumination.

Menopause

A 44-year-old woman presents to her gynecologist complaining of menstrual irregularity. In the past year, she has missed four periods, and her menstrual flow has been lighter than usual. She has not noticed the presence of clots and denies spotting between periods or after intercourse. She reports frequent headaches, difficulties sleeping, and mood swings. She denies the presence of hot flashes, decrease in libido, or vaginal dryness. She does not take oral contraceptives (OCPs) and has never had gynecologic surgery. Physical examination reveals no abnormalities.

Thyroid nodule

A 44-year-old woman presents to her primary physician for her annual checkup. She is healthy and denies any medical problems. She has a blood pressure of 110/75 mm Hg, pulse 72/min, and respiratory rate 14/min. Her physical examination is remarkable only for a discrete, firm, non-tender mass, approximately 0.9 cm in diameter, palpable just lateral to the midline of the neck which rises when the patient swallows.

Cervical cancer

A 45-year-old G4P3 woman presents to her gynecologist complaining of a 3-month history of spotting and postcoital bleeding. She takes no medication and has not seen a doctor in 10 years. Her last Pap smear was 15 years ago; she thinks it was normal. On physical examination she is afebrile, with a heart rate of 80/min and blood pressure of 130/80 mm Hg. Speculum examination reveals normal external genitalia and normal vaginal mucosa, but the cervix has a 2-cm friable lesion protruding from the os. Bimanual examination reveals a retroverted uterus with no masses palpated.

Glioblastoma multiforme

A 45-year-old man is brought to the emergency department following a generalized convulsive episode witnessed by strangers. He was subsequently observed to be in a confused state, having lost continence of bowel and bladder. When the paramedics bring him to the hospital, he is more lucid but his language ability seems impaired. He states that he has noticed progressive difficulty comprehending conversations, and that he sometimes mispronounces words or uses the wrong words. He says he has also been suffering from general malaise and a dull headache. In the past several weeks he has had several episodes of "lost time" in which he loses awareness, followed by a transient disorientation; he has no memory of what occurs during these episodes. The patient denies any fever, chills, night sweats, or recent illness and has no relevant past medical history. He smokes half a pack of cigarettes per day and drinks socially on occasion. On examination, the patient is well appearing and in no acute distress. His vital signs are stable and his CBC and blood chemistry studies are unremarkable. HEENT, cranial nerve, and neurological examinations reveal no abnormalities or focal deficits. Results of T2- (Figure 10-1A) and enhanced T1-weighted (Figure 10-1B) MRI are shown.

Acromegaly

A 45-year-old man presents to his primary care physician accompanied by his wife complaining of recurrent headaches for the past 3 months. He has experienced at least two headaches a week and rates the pain 7-8 out of 10. The headaches occur at all times of the day. Sometimes the pain is accompanied by loss of peripheral vision; however, the patient notes that he has experienced vision loss in the absence of the headaches as well. This winter, he notes that neither his hat nor his gloves fit properly anymore. His wife mentions that he stopped wearing his wedding band last year because it began to cut off the blood supply. Vital signs include a blood pressure of 150/90 mm Hg, heart rate of 82/min, and respiratory rate of 14/min. His physical examination is remarkable only for the position of the point of maximal impulse, which is along the left mid-axillary line at the level of the sixth rib.

GERD

A 45-year-old man presents to his primary care physician for recurrent, burning chest pain after meals. His pain worsens when he reclines and improves with over-the-counter antacid tablets. He also reports a sour taste in his mouth and a persistent cough for the past 6 months. He has smoked two packs of cigarettes daily for the past 20 years. His temperature is 37.0°C (98.6°F), pulse is 91/min, and blood pressure is 142/90 mm Hg. He is 175 cm (69 in) tall and weighs 135 kg (298 lb). His physical examination is unremarkable.

Gout

A 45-year-old man presents to the emergency department complaining of pain and swelling of his great left toe. He reports being awoken from sleep by the pain, which is 9/10 in severity. In addition, his proximal medial foot is swollen and erythematous. The patient denies any history of trauma, recent illness, or intravenous drug abuse. The patient admits that he drinks alcohol heavily on occasion and had 10 or 15 beers 2 days ago while at a party. He is married and has been in a monogamous relationship with his wife for the past 20 years. His past medical history is significant only for mild hypertension, which is well controlled with hydrochlorothiazide. On examination, the patient is clearly in significant distress due to the pain. The patient's metatarsophalangeal joint appears warm, erythematous, edematous, and tender to palpation. The patient's temperature is 38.7° C (101.7° F), and his heart rate is 92/min. Joint fluid analysis reveals a WBC count of 80,000/mm3; results of culture are pending. A Gram stain of joint fluid is negative, but microscopic analysis reveals negatively birefringent needle-shaped crystals.

Acute kidney injury

A 45-year-old man with a history of a cerebrovascular accident and seizure disorder is found unresponsive in his home by his neighbor. On arrival to the emergency department, his blood pressure is 90/50 mm Hg, heart rate is 110/min, and temperature is 37.2° C (99.0° F). Lung and heart examinations are normal, and there is no lower extremity edema. A Foley catheter is placed, and 50 mL of brown urine is obtained. Pertinent laboratory data are the following:

Hyperkalemia

A 45-year-old man with a history of depression is brought to the emergency department a few hours after ingesting 50 of his wife's potassium supplement tablets in a suicide attempt (each tablet contains 8 mEq of potassium). His physical examination is normal except for mild hyporeflexia. Laboratory studies show a serum potassium concentration of 7.0 mEq/L.

Wolf-Parkinson-White syndrome

A 45-year-old man with no significant medical history is brought by his wife to the emergency department (ED) complaining of a fainting episode earlier that morning after breakfast. He reports no memory of the event; he says he was getting up from the table, and the "next thing he knew" he was lying on the kitchen floor. His wife reports he was unconscious for about 15 seconds. He denies other symptoms, including prodromal light-headedness, nausea, vision changes, diaphoresis, chest pain, shortness of breath, or vertigo. His wife denies witnessing any convulsive movements and denies any signs of confusion in her husband following the episode. The patient admits to recently increasing his caffeine intake to two cups of coffee per morning. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 120/80 mm Hg, pulse rate of 110/min, and respiratory rate of 10/min. His physical examination is notable for a regular tachycardia without murmurs, rubs, or gallops, and unremarkable HEENT, lung, and neurological examinations. His 12-lead ECG from the ED and from his outpatient clinic 2 weeks ago are shown as Figures 1-8 and 1-9, respectively.

Histoplasmosis

A 45-year-old woman from Cincinnati presents to her physician complaining of cough, dyspnea, fevers, and weight loss. She has been HIV positive for 20 years and has been using highly active antiretroviral therapy for the past decade. While previously adherent to her regimen, she has lost her health insurance and hasn't seen her regular physician. Her temperature is 39° C (102.2° F), heart rate is 90/min, and respiratory rate is 20/min. Physical exam is significant for diffuse rales, hepatosplenomegaly, and lymphadenopathy. X-ray of the chest reveals reticulonodular infiltrates with a few calcified granulomas. Laboratory studies are as follows:

Breast cancer screening

A 45-year-old woman presents to her primary care physician for her annual checkup. She has no current medical complaints, but she is concerned about her risk for breast cancer, as a good friend was recently diagnosed with the disease. The patient's family history is remarkable for breast cancer in her paternal aunt, who was diagnosed at age 66. There is no other family history of cancer.

Cirrhosis

A 46-year-old man presents to the emergency department for having three episodes of hematemesis during the past 3 hours. He admits to many years of alcohol and heroin abuse. Physical examination reveals a temperature of 37.8°C (100.1°F). He has a pulse of 102/min and blood pressure of 116/70 mm Hg while supine, and a pulse of 115/min and blood pressure of 90/56 mm Hg while upright. Abdominal examination reveals a distended abdomen with splenomegaly, caput medusae, and a fluid wave. He is anicteric, and spider angiomata are present on his thorax. Neurological examination is unremarkable. Relevant labs are as follows:

Dilated cardiomyopathy

A 46-year-old man with a history of chronic alcohol abuse presents to the clinic with a chief complaint of swelling in his feet and lower legs. He says the swelling started within the past year and has been persistent despite elevating his feet at night. He denies any significant medical history, takes no medications, and does not use tobacco. He reports 20 years of drinking six to eight beers daily and reports that he has tried to "cut down" his alcohol intake recently, but still drinks approximately four beers per night. On further questioning, he reveals that he has been feeling more fatigued than normal, and says he cannot walk as far as he used to without getting short of breath. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 125/70 mm Hg, pulse rate of 80/min, and respiratory rate of 14/min. Physical examination reveals distended jugular veins. His chest exam is clear, and his heart has a regular rate and rhythm with no murmurs or gallops. He has normal bowel sounds but has a protuberant abdomen with shifting dullness and a fluid wave. He has pitting edema to mid-calf bilaterally with good distal pulses. An x-ray of the chest is shown in Figure 1-3.