Step 2 CK - First Aid Cases

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.

Confidentiality and disclosure

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.

GERD

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.

MRSA abscess

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.

Molluscum contagiosum

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.

Myasthenia gravis

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.

Wilson's 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:

Alpha-Thalassemia (Hemoglobin H disease)

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.

Breast cancer screening

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.

AZT-induced anemia

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.

Abdominal aortic aneurysm

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.

Acanthosis nigricans

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.

Achalasia

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.

Acne vulgaris

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.

Acute intermittent porphyria (AIP)

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.

Acromegaly

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.

Acute lymphoblastic leukemia (ALL)

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.

Acute cardiogenic pulmonary edema

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.

Acute cholecystitis

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.

Acute coronary syndrome

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.

Acute myelogenous leukemia (AML)

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.

Acute myocardial infarction

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.

Acute pancreatitis

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: WBC count: 11,000/mm3 Absolute neutrophil count: 620/mm3 Total eosinophil count: 475/μL Serum Na+: 125 mEq/L Serum K+: 5.9 mEq/L Serum glucose: 64 mg/dL (fasting)

Adrenal insufficiency (Addison's disease)

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.

Amyloidosis

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.

Amyotrophic lateral sclerosis (ALS)

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.

Ankylosing spondylitis

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.

Aortic dissection

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.

Aortic regurgitation

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.

Aortic stenosis

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.

Atopic dermatitis (Eczema)

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.

Atrial fibrillation

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:

Bacterial meningitis

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.

Basal cell carcinoma

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.

Benign positional paroxysmal vertigo (BPPV)

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.

Bias and confounding

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.

Bioterrorism

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.

Bullous pemphigoid

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).

Carcinoid syndrome

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.

Cardiac tamponade

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.

Carpel tunnel syndrome

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.

Celiac disease

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.

Chronic lymphocytic leukemia (CLL)

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.

Closed-angle glaucoma

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.

Cohort study

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.

Colorectal cancer

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.

Compartment syndrome

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.

Congestive heart failure

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.

Cushing's syndrome

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.

Deep venous thrombosis

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.

Dementia

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:

Dermatomyositis

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: Serum sodium concentration : 156 mEq/L Plasma osmolality : 320 mOsm/kg Urine osmolality : 65 mOsm/kg

Diabetes insipidus

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: Plasma glucose of 280 mg/dL.

Diabetes mellitus, type 1

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: Serum Na+: 143 mg/dL Serum Cl−: 101 mg/dL Serum glucose: 550 mg/dL Serum bicarbonate: 6 mEq/L Serum pH: 7.2 Serum ketones: positive

Diabetic ketoacidosis (DKA)

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.

Diastolic heart failure

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.

Dilated cardiomyopathy

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.

Disseminated gonococcal infection (DGI)

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.

Diverticulitis

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.

Duchenne muscular dystrophy

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.

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

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.

Endocarditis

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:

Epidural abscess

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.

Epidural hematoma

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.

Esophageal carcinoma

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.

Essential hypertension

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.

Factor V Leiden

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.

Fanconi's anemia

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.

Fibromyalgia

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.

Generalized tonic-clonic seizures

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.

Glioblastoma multiforme (GBM)

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.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency

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.

Gout

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.

Guillain-Barre syndrome

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).

Hairy cell leukemia

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.

Health care screening

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:

Hemochromatosis

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.

Hemophilia

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.

Herniated lumbar disk

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.

Herpes simplex virus

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.

Hiatal hernia

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.

Hidradenitis suppurativa

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: TSH: 0.5 μU/mL Total triiodothyronine (T3): 300 ng/dL Total thyroxine (T4): 25 μg/dL TSH-R antibodies: positive

Hyperthyroidism (Graves' disease)

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:

Histoplasmosis

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.

Hodgkin's lymphoma

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.

Huntington's disease

A 17-year-old cross-country runner presents to his primary care physician complaining of occasional chest pain (CP) 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.

Hypertrophic obstructive cardiomyopathy

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.

Hypercholesterolemia

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: Serum Na+: 152 mg/dL Serum K+: 3.2 mg/dL Serum Ca2+: 17.3 mg/dL Serum phosphate: 1.7 mg/dL Serum Cl-: 121 mg/dL

Hyperparathyroidism

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: Serum glucose: 100 mg/dL (nonfasting) Serum Na+: 147 mg/dL Serum K+: 2.5 mg/dL Serum pH: 7.55 Serum HCO -: 32 mg/dL 3 Serum osmolality: 275 mOsm/kg Urine osmolality: 530 mOsm/kg

Hypokalemia (Hyperaldosteronism)

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: Hemoglobin: 9.7 g/dL TSH: 14 μU/mL Total triiodothyronine (T3): 60 ng/dL Total thyroxine (T4): 3.2 μg/dL Thyroid peroxidase antibodies: positive

Hypothyroidism (Hashimoto's thyroiditis)

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:

Idiopathic thrombocytopenic purpura (ITP)

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:

Incidence and prevalence

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.

Infantile spasms (West syndrome)

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.

Infectious mononucleosis (Mono)

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.

Infective endocarditis

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.

Inflammatory bowel disease

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.

Influenza vaccine

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.

Informed consent

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.

Internuclear ophthalmoplegia

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.

Irritable bowel syndrome (IBS)

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:

Juvenile rheumatic arthritis

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.

Kaposi's sarcoma

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:

Liver cirrhosis

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.

Legg-Calve-Perthes disease

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.

Lichen planus

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.

Lyme disease

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.

Malaria

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.

Melanoma

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:

Metabolic syndrome

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:

Microcytic anemia

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.

Migraine headache

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.

Minors

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.

Mitral regurgitation

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:

Multiple endocrine neoplasia, type 2a (MEN-2a)

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:

Multiple endocrine neoplasia, type I (MEN-1)

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:

Multiple myeloma

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.

Multiple sclerosis (MS)

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%.

Positive predictive value (PPV) and (NPV)

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.

Myocardial infarction

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.

Necrotizing fasciitis

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.

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.

Neutropenic fever

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.

Obesity effects on health

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.

Onychomycosis

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.

Ophthalmia neonatorum (Neonatal conjunctivitis)

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:

Organ transplant rejection

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.

Osteoarthritis

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.

Osteomyelitis

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:

Osteoporosis

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.

Osteosarcoma

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:

Paget's disease of the bone (Osteitis deformans)

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.

Papillary muscle rupture

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.

Parkinson's disease

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.

Partial complex seizures

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.

Pemphigus

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.

Peptic ulcer disease (PUD)

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).

Pericarditis

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.

Peripheral vascular disease

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.

Pheochromocytoma

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.

Pityriasis rosea

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.

Pneumocystosis

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.

Polycythemia vera

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:

Polymyalgia rheumatica

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:

Primary sclerosing cholangitis

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.

Pseudomembranous colitis

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.

Psoriasis

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.

Randomized clinical trial

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.

Reliability and validity

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: Sodium: 140 mEq/L Potassium: 4.1 mEq/L Chloride: 98 mEq/L Bicarbonate: 23 mEq/L BUN: 22 mg/dL Creatinine: 1.8 mg/dL Glucose: 110 mg/dL A magnetic resonance angiogram (MRA) is ordered, and shown in Figure 1-4.

Renal artery stenosis

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:

Rheumatoid arthritis (RA)

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:

Rocky mountain spotted fever (RMSF)

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:

Scleroderma

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.

Second-degree heart block

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:

Sensitivity and specificity

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.

Septic arthritis

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:

Sickle cell anemia

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.

Slipped capital femoral epiphysis (SCFE)

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.

Small bowel obstruction

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.

Spontaneous bacterial peritonitis (SBP)

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.

Spinal stenosis

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.

Stevens-Johnson syndrome

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.

Stroke

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:

Subacute granulomatous thyroiditis (de Quervain's thyroiditis)

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.

Subarachnoid hemorrhage

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.

Subdural hematoma

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:

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

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:

Systemic lupus erythematosus (SLE)

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.

Takayasu 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:

Temporal arteritis (Giant cell arteritis)

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.

Tertiary syphilis - Tabes dorsalis

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.

Thrombophlebitis

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.

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

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.

Thyroid nodule

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.

Tuberous sclerosis

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.

UTI

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.

Varicella-Zoster virus

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:

Viral hepatitis

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.

Vitamin B12 (Cobalamin) deficiency - Subacute combined degeneration

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.

Von Willebrand's disease

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:

Warfarin-induced hemorrhage

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.

Wolf-Parkinson-White 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.

Zollinger-Ellison syndrome