Exam Master 1001-1288
A healthy couple presents for an evaluation before traveling to the Dominican Republic; they leave in 1 month and will stay for 4 weeks. The CDC lists the Dominican Republic as a malaria-endemic area, but it is not considered to have a resistant strain of Plasmodium falciparum.
"You should both take chloroquine weekly starting 1 week before travel."
A 60-year-old man presents with difficulty initiating voiding, incomplete emptying, and increasing urinary frequency over the past few months. He has no history of stones, cancer, surgery, diabetes, or AIDS; he takes no medications. His physical exam shows a temperature of 98.6°F, a blood pressure of 128/78 mm Hg, suprapubic fullness, an enlarged prostate, and no peripheral edema. The remainder of his exam is normal. He has been referred to urology.
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A 17-year-old boy presents with a 5-day history of intermittent fever, joint pain, and redness and swelling of the joints. The patient gives a history of pain in the right knee and ankle. 3 days ago, he had pain and swelling in his left knee, but now it has improved. On examination, temperature is 102°F, pulse is 108/min, RR is 20/min, and BP is 110/80 mm Hg. The patient's right knee is swollen, tender, and warm. There is a limitation of range of motion due to pain. The right ankle appears swollen and warm. Other system exams are normal. Lab tests are ordered; during the follow-up exam, you note elevated erythrocyte sedimentation rate (ESR) and rising ASO titers.
5 years
A 5-year-old boy presents with his mother with a history of fever, hemorrhages, and repeated bacterial infections. On exam, lymphadenopathy and hepatosplenomegaly are present. Blood work shows a white blood cell count of 50,000/µL.
Acute lymphocytic leukemia
A 5-year-old girl is brought to her pediatrician by her mother. Her mother notes that the patient has been bruising easily for the last few weeks, but she does not recall any major injury. The patient began feeling tired around this time as well. The mother initially thought she had the flu, but she brought the patient in when it became apparent she was not improving. On examination, the patient is pale and appears fatigued. Her skin has multiple areas of bruising and petechiae. She is febrile. A CBC/Diff is significant for the following:
Acute lymphocytic leukemia
A 13-year-old girl presents to the emergency department with febrile episodes (Tmax 102°F), joint aches in her knees and wrists, chest pain, and a raised red rash. She denies sexual activity or intravenous drug use. Vital signs are BP 90/60 mm Hg, HR 115/min, T 101°F, RR 25/min. Physical exam is remarkable for diffuse scattered ring-shaped macules on her extremities, a III/VI systolic ejection murmur, and guarded passive range of motion in wrists and knees bilaterally with no apparent swelling. Laboratory findings: WBC 16,000 mcL, Hematocrit 35%, Platelets 350,000 mcL, ESR 65 mm/h, positive antistreptolysin O titer.
Acute rheumatic fever
A 16-year-old African American girl with hemoglobin S disease has experienced several complications, including multiple acute splenic sequestration crises that resulted in a splenectomy when she was 14. She no longer receives antibiotic prophylaxis. Her last polyvalent pneumococcal vaccine was 2 years ago. She presents to the emergency department with a 2-day history of fever up to 104.3°F without localizing symptoms. She notes malaise, abdominal discomfort, and one episode of vomiting. Examination reveals a temperature of 103.2°F; pulse 110; blood pressure 116/76 mm Hg; and respirations 21. Hydration is normal, and no localizing findings are present.
Admit patient, obtain cultures, and begin IV ceftriaxone and vancomycin.
You have been asked to do a house call on an 88-year-old woman who is bed-bound and lives at home with her private home health aide. She has had no medical follow-up for the past year. Approximately 3 weeks ago, she appeared to be having "headaches." 2 weeks ago, she developed a rash on the left of her forehead that developed into "little blisters that popped and crusted over." She has a history of coronary artery disease and was diagnosed with "senile dementia" 6 years ago. The home health aide says she is occasionally combative and resistant to care. On exam, she is awake and mumbles several words but is not responsive to verbal commands. BP is 118/68 mm Hg, P 84/min R 20/min. Skin exam reveals clusters of vesicles with crusts on her left forehead. There are no other significant lesions noted on the body.
Aluminum acetate solution
A 41-year-old woman is found to have anemia with Hb of 10 g/dL on a routine physical exam and labs. Patient has a history of hypercholesterolemia, depression, and rheumatoid arthritis. She is on a low cholesterol diet, escitalopram (Lexapro) 10 mg daily, and diclofenac 50 mg twice daily. Physical examination was essentially unremarkable except for mild arthritic changes at the proximal interphalangeal joints of both hands. Further labs reveal normal MCV and MCHC on peripheral smear. Serum iron and TIBC levels are low, percentage saturation with iron is normal, and ferritin level is moderately high.
Anemia of chronic disease
A 65-year-old woman presents after being on hemodialysis for the past 1.5 years for diabetic nephropathy. Despite stable subcutaneous erythropoietin and intravenous iron doses, her hemoglobin level has decreased from 12 g/dL to 10 g/dL over the past month. Oral lanthanum doses have been stabilized. Diabetes is treated with glyburide. She developed a foot ulcer 2 weeks ago and was treated with antibiotics. Additional tests include:
Anemia of chronic disease
A 20-month-old boy presents for a routine visit. He is eating well and drinking at least a bottle of cow's milk daily, which he has done since age 8 months. His history and physical are normal except for mild pallor. Urinalysis is normal.
Anisocytosis
A 24-year-old woman notices that she has a bruising tendency. She frequently has numerous small bruises and purple blotches on her skin. She hates having dental work because of the associated bleeding. On physical exam, you note that she has numerous petechiae. Her lab results are shown in the chart.
Antiplatelet IgG
During a routine X-ray examination for employment insurance purposes, the radiologist notices a rounded lesion in a pulmonary cavity on the right upper lobe of the pulmonary X-ray of a middle-aged man. The patient was treated for pulmonary cavitary tuberculosis (TB) 2 years ago; he has completed treatment, and he has not had any problems since.
Aspergilloma
A 28-year-old man presents with a 2-week history of a non-painful non-pruritic rash. He is negative for any other rashes, dysuria, urinary frequency, penile discharge, erectile dysfunction, diarrhea, constipation, change in stool, nausea, or vomiting. He does recall having had a penile "scab" approximately 4 weeks ago that healed; he never sought medical attention. He is not aware of having been exposed to anyone with any illnesses in the past few months. Social history is positive for unprotected anal sex with multiple male partners in the past 6 months, with the last sexual encounter occurring 4 days ago. He states that he has not engaged in any recreational drug use or cigarette smoking. Skin exam reveals a pink-red papulosquamous eruption with scattered discrete coppery papules on the palms of his hands.
Benzathine penicillin G 2.4 million units IM once
A 71-year-old Caucasian man has been "peeing red" for 3 days and presents after being urged by his spouse. He is not having pain with urination. Pertinent history includes a 100 pack-year smoking history, quitting 5 years ago after having a successful heart catheterization. He has a history of benign prostatic hyperplasia, for which he is taking tamsulosin 0.4 mg once daily. The patient denies any acute trauma, injury, urinary frequency, or urgency.
Bladder cancer
A nurse in your office may have been exposed to blood from a patient with AIDS. She was administering an antibiotic injection intramuscularly to an HIV-positive patient and accidentally sustained a needle prick injury. As part of her post-exposure prophylaxis therapy, you instruct her to begin daily tenofovir.
Blocks the viral enzyme in reverse transcriptase
A 23-year-old man presents with a 2-day history of burning urine. He also reports a slight purulent urethral discharge. He denies any fever, malaise, or chills. He smokes 1 pack of cigarettes daily and drinks socially; he has multiple sexual partners. On exam, his vitals are normal and lungs are clear; abdominal exam is unremarkable, without any renal angle or suprapubic tenderness, and external genitals reveal only slight urethral discharge. Labs show WBC of 6500/uL, and urinalysis has 5-10 WBC and 0 RBC. Gram stain of the urethral discharge shows neutrophils and intracellular gram-negative diplococci.
Ceftriaxone 250 mg IM plus azithromycin 1g PO each single dose
A 30-year-old woman presents because she recently had a PPD skin test; the transverse diameter of the induration was 14 mm. The patient denies ever having tuberculosis and she is asymptomatic now, but she expresses some anxiety about the result of the skin test. For the last 6 months, she has worked as a nurse for a long-term care facility. Her patient is a vent-dependent tetraplegic. On clinical examination, there are no abnormalities.
Chest X-ray
A 2-month-old girl presents with rapid breathing and a staccato cough, appearing otherwise well; she is afebrile. Physical examination detects fine rales over the lungs and a thickened red tympanic membrane. A chest X-ray shows bilateral patchy interstitial infiltrates. Laboratory studies indicate eosinophilia. Her mother received limited prenatal care.
Chlamydia trachomatis
A 58-year-old man presents with a 4-month history of worsening fatigue. Physical examination is remarkable for right-sided posterior cervical and anterior clavicular lymphadenopathy. He has splenomegaly. Lab results reveal a WBC count of 250,000/mm3 (normal: 5000-10,000 mm3) with 77% lymphocytes (normal: 20-40%). Peripheral smear demonstrates small-but-mature-appearing lymphocytes. A subsequent bone marrow biopsy reveals variably infiltrated small mature lymphocytes that stain for CD5 and CD19. Philadelphia chromosome is negative.
Chronic lymphocytic leukemia (CLL)
A 55-year-old man presents with a 1-week history of fatigue, night sweats, and abdominal fullness. On physical examination, you note a palpable spleen. You order a CBC; the results indicate a white blood count of 105,000 cells/mcL with a left shift of the myeloid series. The red blood cell count and morphology show anemia, and he has an elevated platelet count. To help confirm your suspicions, you order genetic studies, and the results come back with the BCR/ABL gene detected.
Chronic myelogenous leukemia
A 52-year-old man stepped on a piece of glassyesterday. On exam, his wound appears clean, and it is not infected. He has never had the primary series of tetanus immunization. The patient asks if he needs tetanus immunization.
Complete tetanus immunizations plus TIG
A 3-year-old boy is admitted to the emergency room in acute respiratory distress. The patient has a body temperature of 40°C, a respiratory rate of 70/min, and a pulse of 130/min. Auscultations of the lungs are unremarkable. An examination of the throat reveals an exudate in the posterior pharynx that is yellowish and membranous. Bleeding occurrs when it is scraped and removed. The parents of the child reveal that the child has no prior immunizations. A throat culture was ordered and worked up specifically for an organism that selectively grows on cystine tellurite agar.
Corynebacterium diphtheriae
A 15-year-old girl presents with a 2-day history of excessive vaginal discharge. She had unprotected sex with a boyfriend 4 days ago, and he later informed her that he has gonorrhea. On speculum exam, the girl is found to have a moderate amount of off-white and frothy vaginal secretions. The appearance of the cervix is normal. A cervical swab reveals copious gram-negative intracellular diplococci.
Counsel the patient about safer sex and treat.
A 17-year-old boy presents for a follow-up regarding fatigue and dizziness. After his initial presentation, he had some general blood work drawn, including a complete blood count (CBC) showing a low hemoglobin and hematocrit. MCV is low.
Craving to eat ice
Upon inspection of an 18-year-old man's scrotum, you note that the left side is underdeveloped and a testis is not palpable. There is no scrotal tenderness, swelling, or nodularity.
Cryptorchidism
A 46-year-old woman underwent elective cholecystectomy. The attending nurse noted mild bleeding at the site of IV line and the incision site during dressing. The patient also reported bleeding from the gums and nose. Coagulation profiles revealed prolongation of aPTT, PT, and TT; decreased fibrinogen level; and increased levels of fibrinogen degradation product (FDP). Platelet count was also decreased. The patient was not experiencing any bleeding disorder before her hospitalization.
Disseminated intravascular coagulation
A 48-year-old previously healthy African American woman was involved in a severe motor vehicle accident, sustaining multiple injuries. She was stabilized in the emergency department but is now bleeding extensively from her laceration sites, her IV catheter site, and from mucous membranes. Laboratory results show thrombocytopenia, fragmented red blood cells, and low fibrinogen levels.
Disseminated intravascular coagulation
A 22-year-old man presents to his physician with swollen lymph nodes in the right axilla. He notes that he develops pain in the area after drinking alcohol. He has been feeling fatigued for the last few weeks and has lost weight without trying. Examination confirms lymphadenopathy in the right axilla. Biopsy of the region shows the presence of Reed Sternberg cells.
Doxorubicin, bleomycin, vinblastine, and dacarbazine
Your patient is a 1-day-old "floppy baby"; he was born full term by normal vaginal delivery in the hospital. Birth weight was 2.4 kg; Apgar scores were 6 (1 min), 8 (5 min), and 8 (10 min). His mother had a normal pregnancy, except for an episode of a mononucleosis-like illness, but her heterophile antibodies were negative. On examination today, the patient is febrile, with a heart rate of 130/min, shallow breathing, and bilateral fine crepitations. You notice petechial purpura. He has hepatosplenomegaly and generalized lymphadenopathy (cervical, axillary, and inguinal). Neurological examination reveals hypotonia and bulging anterior fontanelles; there are no meningeal signs. Ophthalmological examination reveals multiple foci of chorioretinitis on both eyes. He is polypneic and hypoxic; nasal oxygen therapy and wide-spectrum antibiotic therapy is introduced (ampicillin, gentamycin, and cefotaxime). Labs are listed below.
Eating undercooked meat during the pregnancy
A 35-year-old woman presents with fatigue and yellowish coloration of her eyes and skin that started several weeks after non-eventful implantation of a prosthetic mechanical heart valve 6 weeks ago. She denies any history of similar episodes. She has a history of severe aortic stenosis. Other past medical history is non-contributory. Physical examination reveals the presence of regurgitant murmur and subicterus. Laboratory results: hemoglobin 7.0 g/dL, reticulocytes 21%, WBCs 11,500/µL, platelets 80,000/µL, undetected levels of haptoglobin. Lactate dehydrogenase (3100 U/L), direct bilirubin (2.1 mg/dL), and indirect bilirubin (1.2 mg/dL) levels are all elevated. Peripheral blood smear shows burr and helmet cells (schistocytes) and polychromasia. Direct and indirect Coombs tests are negative. You suspect microangiopathic hemolytic anemia.
Echocardiography
A 26-year-old HIV-positive man presents after a series of strange dreams and lack of concentration. He started on antiretrovirals 1 week ago. For his HIV infection, he takes zidovudine, lamivudine, and efavirenz. For pneumocystosis prophylaxis, he takes trimethoprim/sulfamethoxazole. He also takes a multivitamin.
Efavirenz
A 26-year-old G1P0 pregnant woman with type 1 diabetes presents to her obstetrician for her 20-week appointment. Over the past day, she has had to urinate more frequently; she has also developed a burning sensation with urination. Urinalysis reveals the following:
Escherichia coli
A 29-year-old African American woman and a 31-year-old African American man present for preconception counseling for sickle cell disease.
Evaluation of both patients by hemoglobin electrophoresis
An 11-year-old boy presents with a chronic history of mild hemolytic anemia, intermittent jaundice, and right upper quadrant pain. He denies any shortness of breath, muscle aches, or joint pain.
Folic acid
A 29-year-old African American man develops dysuria and increased frequency of micturition. In the emergency room, he is found to have a urinary tract infection and is treated with nitrofurantoin and recommended to follow up with his primary care physician in the office. Over the next few days, the patient experiences fatigue, fever, jaundice, abdominal and back pain, and dark urine. Blood tests show Hb 4 g/dL, reticulocyte count 6%, and MCV 93. Coombs test is negative. Bilirubin levels are elevated. Peripheral smear reveals cell fragments, microspherocytes, and blister or bite cells. Heinz bodies are present.
G6PD deficiency
A 13-year-old African American boy presents with a 4-month history of increasing fatigue, pallor, exertional dyspnea, and depression. Past medical history is significant for an ischemic stroke due to sickle cell disease 6 years ago. Since his stroke, the boy has been receiving chronic red cell transfusion therapy, and subcutaneous iron chelation therapy started 3 years ago. On physical exam, pulse is 150 bpm, respirations are 20/min, blood pressure is 105/75 mm Hg, and O2 saturation by pulse oximetry is 92% on room air. In general, he appears ill; he is dyspneic and refuses to lie flat on the bed during his examination. Otherwise, he is cooperative with his exam. He is diaphoretic, with no rashes or skin abnormalities noted. His cardiovascular exam is significant for a 4/6 systolic ejection murmur and a gallop. His pulmonary exam demonstrates scattered expiratory wheezes throughout all lung fields. His liver is 4 cm below the right costal margin; no spleen is palpable. The remainder of his exam is unremarkable.
Hemoglobin, ferritin, liver function tests, chest X-ray, echocardiogram
A mother presents with her 5-year-old Caucasian son; he has a significantly swollen right knee. She states that her son has a blood coagulation disorder and frequently bleeds into his joints when he sustains any injury. His past medical history includes the use of the blood product cryoprecipitate or factor VIII concentrates for treatment for his disorder.
Hemophilia A
A 12-year-old Jewish girl is brought in by her father. The father reports that the child started to bleed profusely following tooth extraction 2 hours ago. Further questioning reveals that there is a history of bleeding disorder in the child's maternal uncle and aunt. Examination reveals tachycardia and bleeding from the site of tooth extraction. Coagulation profile reveals prolonged activated partial thromboplastin time (aPTT), normal prothrombin time (PT) and thrombin time (TT), and deficiency of factor XI. The child was treated with fresh frozen plasma (FFP) and fibrin glue.
Hemophilia C
A 43-year-old woman presents with 4 days of fever and cough. She is diagnosed with right lobar pneumonia with mild pleural effusion and is admitted to the hospital for IV antibiotics and hydration. Past medical history includes hypertension, systemic lupus erythematosus, and arthritis. On day 2 of hospitalization, she is afebrile but still has a productive cough and shortness of breath. She reports left arm pain and swelling, and her physician is concerned about a possible upper extremity thrombosis. She is given a bolus of IV heparin and started on a heparin infusion. 5 days later, her labs show Hb 12 g/dL, WBC 11,000, and platelet count 56 micro/L (down from 250 on admission). Her EKG is normal sinus rhythm, and CXR show decreased consolidation with a resolving pleural effusion.
Heparin-induced thrombocytopenia
A 24-year-old man presents with a large painless mass above his right clavicle. He reports no change in its current size over the last 6 months. He denies excessive fatigue/malaise, weight loss, fevers, or chills. Physical exam reveals no hepatosplenomegaly or palpable cervical, axillary, or inguinal lymphadenopathy. Excisional biopsy of the mass is performed and the pathologist reports the presence of Reed-Sternberg cells.
Hodgkin's lymphoma
A 44-year-old Caucasian woman is admitted to the hospital with a severe nosebleed. The patient states that there was no history of trauma, and she has never had nosebleeds before. She also reports a history of upper respiratory infection (URI) symptoms 1 week ago. The patient's blood work is notable for a platelet count of 10,000/mm3. The patient is treated with steroids for her presumptive diagnosis. The patient's platelet count is refractory, and a splenectomy is performed.
Howell-Jolly bodies
A 2-week-old male infant presents with his father for evaluation of enlarged scrotum. The father states that the scrotum was a little larger in the first few days after birth than it is now, but it has not reduced in size enough to make him feel comfortable that it is normal. Physical examination reveals normally developed penis with abnormally large scrotum that transilluminates on the right side when light is shined on it.
Hydrocele
A mother brought her 2-month-old infant son to a pediatric clinic because, during micturition, urine ran from the opening at the bottom of the midline groove of the scrotum instead of from the tip of the penis.
Hypospadias
A 59-year-old man starts to notice that he no longer has the energy for his morning jog. He starts to develop back pain, so he completely stops exercising, but this does not seem to help. He is always tired and seems to have a lot of aches and pains. One day, his back pain is particularly bad, so he sees his primary care physician. He also acknowledges constipation and polyuria. On physical exam, his doctor notes that he is pale. His laboratory tests are as follows:
IgG
A 56-year-old man presents with a painful lump on his neck that has been bothering him for the past 2 weeks. He denies other symptoms or recent illness. He has a past medical history of hypertension and kidney stones. Nursing staff reports that his temperature is 97.9°F, heart rate is 65, respirations 12, and blood pressure is 140/88. During your examination, you palpate an enlarged lymph node on his left suboccipital region that is soft and about 1 cm in size. The lymph node is non-movable, non-erythematous, and without warmth or fluctuance.
Immobility
A 24-year-old woman is evaluated in the endocrinology clinic. She is on 100 mcg of thyroxine per day for treatment of Hashimoto's thyroiditis and receives oral steroids for autoimmune adrenal insufficiency. In addition, she complains of fatigue, numbness, and tingling in her feet. When routine labs were drawn, the following values were noted:
Intramuscular injection of B12
A 7-year-old African American girl presents with a 6-hour history of severe pain in her hands and feet that started spontaneously. She has been having bouts of excruciating pain since she was 6 months old. She is an only child, and her parents have recently discovered that they are both carriers of her condition. On examination, her HR is 115 bpm and blood pressure is 90/50 mm Hg; she is also jaundiced. She has a mildly enlarged spleen but no source of infection. Laboratory investigations reveal hemoglobin of 8 g/dL.
Intravenous hydration
A 3-day-old male newborn starts to have mild epistaxis after vaginal delivery at home. The mother is a 38-year-old G2P2 who had diet-controlled gestational diabetes. She took a prenatal vitamin and iron supplement. Active labor lasted 3 hours. The midwife who examined the newborn after the delivery declared the newborn healthy. Since the delivery, the mother has been exclusively breastfeeding. The baby is eating every 1-2 hours and has had several wet diapers and 3 stools.
Intravenous vitamin K
A 33-year-old woman comes to your office after a 6-month sabbatical working in caves in the eastern part of the South America. Upon questioning, the patient reports fever, chills, productive cough, and joint stiffness that started 1 month before her return. Physical exam reveals 3 ulcerated lesions on her inner cheek.
Itraconazole
A 17-year-old girl presents with a sore throat and weakness; she has a fever of 100°F. There is cervical lymphadenopathy on physical exam, and the Monospot test is positive. After 14 days, the patient develops acute abdominal pain. During the abdominal examination, guarding is noted in the upper left quadrant. The patient is becoming increasingly pale, sweaty, and cold.
Laparotomy
A previously healthy 35-year-old man has had right flank pain radiating to his right groin for the past 3 hours. CT shows a 11 mm uric acid stone in his right proximal ureter.
Lithotripsy
A 17-year-old boy presents with pain in his wrists, elbows, and knees bilaterally. He has felt fatigued, and he has been unable to work his summer job as a cashier and bagger in his family's community grocery store for the past 2 weeks. He also reports intermittent fevers and a large rash on his back in the area of his right shoulder. All of these symptoms have emerged in the last 4 weeks after a week-long backpacking trip in upper state New York. He has no significant past medical history. His only medication is acetaminophen daily for joint pain. He does not use tobacco, alcohol, or illicit drugs. He has no known allergies. Physical examination reveals a thin male adolescent in no acute distress. Temp 99.1°F, P 100 bpm, RR 14, BP 120/70 mm Hg. Small non-tender mobile lymph nodes are palpable in the neck and axilla bilaterally. There is a large warm erythematous patch with central clearing at the patient's posterior right shoulder region; it extends across the arm and axilla and measures approximately 25 cm in diameter. There is limited range of motion in his right wrist and left elbow. There were no gross focal neurologic deficits.
Lyme disease
A 49-year-old man presents with chronic fatigue, headache, fevers, and muscle and joint pain. He describes the initial rash occurred on his arm with a red circular rash with central clearing. He describes transient "reddish spots" that can be quite large and have appeared on his skin then faded away. His symptoms developed about 4 months ago with no apparent cause; they have gradually gotten worse with the recent addition of the musculoskeletal pains. He is married and monogamous, and he lives in a small rural community; nevertheless, he is concerned that he may have somehow contracted a communicable STD.
Lyme disease
You are following up on laboratory results for your supervising physician while they are out of town. A bone marrow biopsy result for a 62-year-old man is noted.
Lymphadenopathy Chemoimmunotherapy
A 38-year-old woman of northern European origin is brought to the emergency room by her relatives who report abnormal behavior. The patient denies the accusation and reports numbness and a tingling sensation in both her hands and feet (gloves and stockings) and recurrent diarrhea. Physical examination shows an atrophic tongue (glossitis), and a neurologic examination reveals a loss of her sense of vibration and fine touch. Endoscopic examination shows atrophic gastric mucosa and fasting achlorhydria.
Megaloblastic erythropoiesis in bone marrow
A 60-year-old man presents with sharp pain in his ribs and sternum; he has a history of allergies and has been sneezing frequently. Except for a heart rate of 120/min, the physical examination is normal. With the exception of a tonsillectomy as a child, his medical and surgical history is unremarkable. He has chronic seasonal allergies. Family history reveals nothing significant. Radiographs on the ribs and sternum reveal lytic lesions and a significant fracture of the sternum. Neurological examination is unremarkable.
Multiple myeloma
A 65-year-old woman presents with pain in the back, chest, and at the right seventh rib. She appears to be quite pale, and she admits to fatigue. These symptoms have come on gradually over several weeks, with the back pain becoming the reason for consulting the physician. Physical examination reveals localized tenderness at the spine of T8 and ribcage with tenderness at the right seventh rib. CBC shows a normochromic normocytic anemia with hemoglobin of 8 g/dL. Peripheral smear shows marked rouleaux formation with normal platelet and white cell counts and morphology. Serum chemistry results include calcium elevation to 12.2 mg/dL with normal alkaline phosphatase. A dipstick urinalysis shows proteinuria. A bone marrow aspirate was dry. The bone marrow biopsy is pending. Plain film X-rays of the chest show a fracture of the right seventh rib and compression of the eighth vertebra.
Multiple myeloma
A 70-year-old African American man with a PMH of HTN x 23 years and type 2 DM x 20 years was admitted to the hospital due to a high-grade fever, nausea, infection, and severe back pain. Nearly 2 years prior, while walking down his steps, he fell without incurring any apparent fractures. Since then, he has been experiencing mild back pain that worsens when coughing. Physical exam is significant for pallor and hepatosplenomegaly. Skin exam is normal. Lab reports reveal low red blood cell count but normal neutrophil and platelet count. Renal function is decreased. The serum protein electrophoresis reveals the presence of paraprotein. Bone marrow biopsy reveals 50% infiltration by plasma cells.
Multiple myeloma
A 32-year-old Latinx woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications and is gravida 4, para 4, Ab 0. She is married and recently emigrated to the US from Central America. Vital signs: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. Patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The following morning, the patient is found to be alert, oriented, and afebrile.
Neurocysticercosis
A 50-year-old man presents for the evaluation of a 1-year history of progressive cognitive, motor, and behavioral problems. He complains of inattention, reduced concentration, slowing of processing, and difficulty changing mental sets. What started as slow movements now is clumsiness and problems with coordination. His friend states that the patient is "not himself anymore" and has become apathetic, non-communicative, and "down." He is HIV-positive and was diagnosed with AIDS 2 years ago because of the presence of Pneumocystis carinii with CD4 of 100. He had an excellent response to antiretroviral therapy, however, and his last CD4+ lymphocyte counts were normal and viral load undetectable. On examination, you find an apathetic male in mild distress. Neurological exam shows loss of coordination, unsteadiness, generalized weakness (more pronounced in legs), ataxia, and tremor.
Neuroimaging methods
A 55-year-old male firefighter suddenly develops fever, palpitations, and shortness of breath 7 days after skin transplant for severe facial burns. He also has fever resistant to intravenous antibiotics therapy introduced at the onset of fever. Because of oropharyngeal lesions, he is on parenteral nutrition. On examination, transplant shows neither signs of infections nor signs of rejection. Patient appears lethargic, with a blood pressure of 80/40, pulse rate of 120, respiratory rate of 18, and temperature of 103.4°F. Stat CBC shows neutropenia and eosinophilia.
Neutropenia
A 43-year-old man visits the internal medicine clinic of a university hospital presenting with a 3-week history of shortness of breath, fever, and chills. Examination shows a temperature of 38.0°C. Laboratory results suggest hypoxemia with PO2 of 74. Previous history shows the patient has been HIV-1 positive for 4 years and presently has a CD4+ T-cell count of 50/mm3. A presumptive diagnosis of Pneumocystis carinii pneumonia (PCP) is made, which is confirmed by bronchoalveolar lavage.
No findings
A 31-year-old man presents with a tick bite. He describes locating a tick in the left axillary area while showering in the evening, and he denies that the tick was present the previous evening. He removed the tick with forceps and cleaned the wound with alcohol. Examination of the bite shows local erythema and mild induration 3-5 mm diameter. The tick is identified as an adult female Ixodes scapularis.
No treatment needed
A 54-year-old man presents with a recent lump in his scrotum. After answering questions about possible symptoms and undergoing a thorough genitourinary examination, it is determined that the lump is actually a collection of fluid in the patient's tunica vaginalis.
Nontender fluid-filled lesion that transilluminates
A 2-month-old infant who is breastfeeding presents with low hemoglobin levels. The infant was born at home and the mother received no prenatal care; she did not, and does not, take any medications. Family history is unremarkable. On examination, the infant appears healthy.
Normal process
A 62-year-old man was diagnosed with multiple myeloma 1 year ago; he is currently hospitalized with intractable nausea and vomiting. Since he was asymptomatic at the time of diagnosis, he has not been treated for his cancer. His wife reports he has not eaten in several days, but he is constantly drinking water. He appears confused and lethargic. When adjusted for the albumin level, serum chemistries reveal an elevated level of calcium (12.0 mg/dL).
Normal saline
A 35-year-old woman just found out she is pregnant. She is experiencing polyuria, but she denies dysuria and incontinence. Her urinalysis is unremarkable. Her fetal ultrasound is normal, and her renal ultrasound shows normal physiological hydronephrosis of pregnancy. Her pre-pregnancy weight was 155 lbs, and she is 5 feet tall. Her calculated body mass index (BMI) is 30.3 kg/m2. She takes no medications. She smokes half a pack of cigarettes per day.
Normalize weight
A 32-year-old Hispanic woman presents with a 3-day history of vaginal pruritus. She is worried she has another infection. She was treated with penicillin 2 weeks ago for group A Streptococcus pharyngitis. The patient reports occasional sinus and urinary tract infections and always struggles with vaginal symptoms afterward. She has episodes of vaginal pruritus and thick white discharge approximately 3 times per year. She usually returns to her urgent care clinic for evaluation and treatment, then her symptoms resolve. She has no chronic medical conditions. She is non-obese and is not pregnant. On exam, the vaginal mucosa is inflamed and coated with thick clumpy white discharge. On a wet mount slide treated with potassium hydroxide, you see pseudohyphae. The patient would like treatment for her current vaginal symptoms and advice in preventing her symptoms in the future.
Offer fluconazole in combination with antibiotics if indicated.
A 45-year-old man is evaluated for a 6-month history of palpitations, easy fatigability, and chest pain on exertion. He does not smoke or consume alcohol; he has no significant past medical history. His body weight has remained stable. He has spent the last 2 years traveling the world. His wife says that he eats "unhealthily." He is a strict vegan, consumes a lot of snacks, and has never taken any vitamin supplements. Examination shows a 5'7" male with a BMI of 19. His BP is 130/70 and pulse 90/min; his temperature is 98.4°F. Conjunctival pallor is present. Auscultation shows a grade 2/6 murmur ejection systolic murmur heard all over the precordium.
Oral ferrous sulfate
A 52-year-old man is hospitalized for a left lower lobe pneumonia. The patient is HIV positive with a CD4 count <100/uL and is known to be neutropenic. He also has type 2 diabetes mellitus and diabetic nephropathy. He is started on ciprofloxacin, ceftriaxone, and clindamycin. During treatment, the physician notes a white coating of the tonsils and oropharynx. The physician obtains scrapings of the white coating. The sample is observed microscopically and confirms the presence of fungal hyphae and budding. The physician suspects a candidal infection of the oropharynx.
Oral fluconazole
A mother presents her 2-year-old son for a follow-up of a febrile urinary tract infection (UTI). He just finished a 10-day course of trimethoprim/sulfamethoxazole (Bactrim) and is asymptomatic. He had a UTI with fever at age 15 months. His mother is concerned because is not toilet trained. Physical examination is unremarkable. He is not circumcised. Urinalysis and renal ultrasound findings are normal.
Plan voiding cystourethrogram.
A 71-year-old male farmer presents because he is experiencing a gradual increase of frequency of urination over the previous 4-5 months. He has difficulties starting to urinate, the stream is slow, and he frequently has a sensation of incomplete emptying. He has not had a physical examination in several years. He has no history of sexually transmitted diseases (STDs) or urinary tract infections. Upon examination, his abdomen and his prostate are non-tender. His prostate seems moderately enlarged (estimated at 35 g) but smooth and symmetrical.
Post-void residual urine test
A 23-year-old woman presents with fatigue and the recent onset of a yellowing of her skin. Her physical examination is remarkable for the presence of splenomegaly.
RBC membrane
A 28-year-old female administrator is referred to your office for further evaluation. She has noted swellings on her neck for the past 3 weeks. She denies any history of cough, fever, or night sweats. She reports she has been getting pruritus after taking alcohol. She is not on any medication and has no prior admissions. On examination, she is not pale and her vital signs are normal. She has a 2 cm rubbery non-tender left anterior cervical node and a 3 cm left posterior cervical node. No other nodes are palpable. The systemic examination is essentially normal. CT scans done of the chest, abdomen, and pelvis are normal. Reed-Sternberg cells are seen on a biopsy of the node. The ESR is 30 mm/hr.
Radiotherapy and chemotherapy
A 40-year-old woman undergoing a gynecologic workup for metromenorrhagia presents with a several-week history of fatigue and lightheadedness. Laboratory evaluation reveals a hemoglobin of 11 g/dL (12-16 g/dL), hematocrit of 34%, MCV of 70 fL (80-100 fL), and MCH of 24 pg (27-33 pg). Further studies reveal a ferritin level of 25 ng/mL (12-300 ng/mL), TIBC of 500 mcg/dL (250-450 mcg/dL), and an iron level of 45 mcg/dL (60-170 mcg/dL). The patient is diagnosed with iron deficiency anemia. She is prescribed ferrous sulfate 325 mg po tid. Several days later, she presents to the ER. She reports resting dyspnea and chest discomfort. Oxygen and nitroglycerin are given. Cardiac enzymes are pending. The patient's hematocrit is 23% with hemoglobin of 7.5.
Red blood cell transfusion
An 18-month-old infant presents with a 5-day history of fever of 104°F. On physical examination, you note a mildly irritable infant who has not been feeding well. There are no other clinically significant findings. You prescribe acetaminophen (Children's Tylenol) and tell the mother to monitor the infant's fever for the next few days; if the fever goes down, everything should be fine. The mother calls the next day and says that the fever has stopped, but a rash has developed, and she is concerned. The infant examination reveals a diffuse fine maculopapular rash. Presently, the child does not appear ill.
Roseola
A 16-year old girl on her high school's swim team focuses her exercise regimen on endurance rather than building muscle mass. While her menses are regular and moderate in quantity, she is concerned that she may become iron deficient and that this will negatively affect her endurance and athletic performance. She asked if she should begin an iron supplement. Past medical history was unremarkable, and there was no history of tobacco, alcohol, or recreational drug use. Growth and development have been normal, and immunizations are current. Vital signs are normal. Examination is unremarkable, consistent with Tanner stage V. Hematocrit, hemoglobin, and ferritin were normal.
She does not need an iron supplement.
A 6-year-old boy is brought to the emergency room with chest pain and signs of respiratory distress. His mother states he has been ill with an upper respiratory infection that suddenly worsened with temperature elevation. Physical examination reveals an increased P2 and systolic ejection murmur. Chest X-ray shows lobar infiltrates. Labs show a leukocyte count of 18,000/mm3, hemoglobin 7 g/dL, and reticulocytes 12%.
Sickle cell disease
An 11-month-old African American boy presents with an acute onset of anorexia, irritability, unexplained bruising, and jaundice. On examination, you note pale conjunctivae, icteric sclerae, and splenomegaly. Laboratory studies reveal decreased hemoglobin and hematocrit and a significantly elevated reticulocyte count. Hemoglobin electrophoresis reveals the presence of hemoglobin S.
Sickle cell disease
A 16-month-old African American boy presents with a 2-day history of irritability and refusal to bear weight. His mother denies any recent history of fever, vomiting, diarrhea, rash, or trauma. Family history is significant for a maternal uncle who had a stroke and died when he was 35. On exam, vital signs are stable. Patient appears smaller than stated age and is irritable but consolable. He is in no apparent distress, but he refuses to bear weight or play. The only significant findings on exam are swollen hands and feet. CBC reveals WBC 18,000 mm3, with 40% neutrophils, 30% lymphocytes, and 1% monocytes. Hb is 8 g/dL and platelets are 400,000 mm3.
Sickle cell solubility test
A 38-year-old woman gave birth to a healthy female neonate 3 months ago. Her pregnancy and vaginal delivery were unremarkable. Over the past 3 months, she developed increased oral bleeding with hemorrhagic bullae.
Splenomegaly
A 26-year-old pregnant woman diagnosed with primary tuberculosis and wants to discuss treatment options. Initial labs come back with mild anemia, positive HCG, and elevated cholesterol. All other labs are within normal range.
Streptomycin
A 56-year-old African American man presents with urinary hesitancy, frequency, and nocturia. He gets up to urinate 3-4 times per night, unsure if he empties his bladder completely. This has been worsening for 2 years. His urinary stream is weaker than it was 1 year ago. He denies hematuria, dysuria, or history of UTIs. He has no significant past medical or surgical history. The remainder of the history and ROS is non-contributory. Vital signs are stable, and the patient is afebrile. General physical exam is unremarkable. Genital exam reveals a circumcised penis with no lesions or discharge. There is no inguinal adenopathy. Testicles are descended bilaterally with no lesions, masses, or hernias. Rectal exam reveals a smooth prostate with no nodules or tenderness. Urinalysis is normal, and prostate-specific antigen (PSA) test is within normal range for age. After emptying 250 mL of urine, the post-void residual urine volume is 50 mL.
Terazosin
A 29-year-old Caucasian man presents for a routine physical examination. He has a history of right-sided cryptorchidism corrected by orchiopexy at age 6 months. He has no problems at present. His physical exam reveals bilateral gynecomastia and a painless, firm right testicular mass approximately 1.5 cm in diameter. The right testicular mass does not transilluminate, nor does it disappear when the patient lies supine. There is no femoral or inguinal lymphadenopathy and no palpable hernia.
Testicular malignancy
A 15-year-old boy presents at 11:30 AM due to left scrotal pain and swelling; it started when he woke up at 7 AM. He recalls no trauma. When questioned, he says that he has never had intercourse. He has been feeling nauseated, and he vomited once. Physical examination demonstrates a well-nourished well-developed boy, appearing moderately uncomfortable. Vital signs are normal except for an oral temperature of 37.9°C. Pain assessment score (Wong-Baker scale) is 6/10. Tanner Stage III puberty. The left testicle is approximately 1.5 times the size of the right testicle and high-riding compared to the right. The skin is diffusely erythematous. It is difficult to palpate the scrotum due to tenderness. Cremasteric reflex is absent. Penis is circumcised and appears normal. Scrotal ultrasonography with Doppler ultrasound demonstrates decreased blood flow to the testis. Remaining physical examination is normal.
Testicular torsion
A 25-year-old Caucasian man presents to the local emergency department due to severe testicular pain. The pain began abruptly about 2 hours ago and has gotten progressively worse. He is numerically currently rating it as a 9/10. This is only affecting the left testicle. He has never had an episode like this before. He also states he has become nauseated during the time you are in with him.
Testicular torsion
A 1-year-old boy appears to be physically underdeveloped. His vital signs are not remarkable. His parents are concerned about his health because he seems to be weak and lethargic. The parents are recent immigrants from southern Italy. A brief history check reveals that both parents have a history of mild anemia. The child is afebrile. A complete blood count (CBC) is ordered: red blood cell (RBC) count of 3.0x 1012/L; Hb of 8.0 gm/dL; Hct of 24%; peripheral smear showed 1+ basophilic stippling; hypochromia; and the presence of codocytes.
Thalassemia
A 27-year-old woman who is 18 weeks pregnant states that her 3-year-old daughter was just diagnosed with erythema infectiosum (Fifth disease). An antibody test is ordered, and the woman is found to be seronegative. She is healthy and has no signs or symptoms of parvoviral infection. 2 weeks later, the test is repeated and the patient is IgM-positive.
The patient should undergo serial fetal ultrasounds to monitor for signs of hydrops fetalis.
A 54-year-old man presents after having a generalized seizure. The patient is HIV-positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he has become short-tempered and hypercritical; at times he seems confused. An MRI of the brain is performed, and it reveals several cortical ring-enhancing lesions.
Toxoplasma encephalitis
A 62-year-old woman with diabetes and hypertension is evaluated for incontinence. She is found to have a cystocele and grade 3 uterine prolapse. Her diabetes and hypertension are both poorly controlled. On examination, the uterus can be repositioned with firm digital pressure. In addition to being declared unfit for surgery, she is not keen on undergoing any procedure. She has no history of any urinary infections or pelvic inflammatory disease.
Vaginal pessary placement
A 25-year-old man develops clinical signs of bacteremia in the hospital. Examination reveals erythema, tenderness, and a slight purulent discharge around the insertion site of a central venous catheter. Gram stain of discharge shows gram-positive cocci in grape-like clusters. Culture sensitivity of the fluid showed methicillin-resistant Staphylococcus epidermidis.
Vancomycin
An 18-month-old child presents with a 2-day history of fever that is currently 101°F rectally. You symptomatically treat the patient and ask the mother to return if the condition worsens. The mother returns 2 days later because the child has developed small red spots that became bumps and are now blisters. The mother also noted the child was scratching the lesions. Physical exam reveals macules, papules, and vesicles are on the face and thorax bilaterally. Each vesicle resides on its own erythematous base.
Varicella
A 4-year-old uncircumcised boy presents with a 2-day history of penile pain. The patient is afebrile and vital signs are stable. On genital examination, his foreskin is retracted proximally and the glans is edematous and cold. You are unable to reduce the proximal foreskin distally over the glans penis; it is strongly suspected that arterial flow is compromised. The only urologist available will arrive in 1.5 hours.
Vertical incision of the constricting band
A 33-year-old man presents with a 2-day history of severe diarrhea and vomiting. He had been on a business trip to Asia 3 days ago, and he reports eating food bought from street vendors. He describes his stools as watery and not bloodstained. He is allergic to seafood, and he takes antacids for peptic ulcers. On examination, he is moderately dehydrated; temperature is 37°C, PR is 100, and BP is 120/60 mm Hg.
Vibrio cholera
A 26-year-old woman presents for her second obstetric visit in the first trimester. Routine screening tests (blood typing, testing for syphilis, hepatitis, rubella immunity, and HIV) are performed; the test returns positive for HIV. She is counseled to start antiretroviral therapy and to have a cesarean delivery.
Virus replication
A 17-year-old girl presents to the clinic due to chronic fatigue. Her past medical history is unremarkable. There is no history of surgeries. Review of systems reveals heavy monthly menses since menarche at age 13. She admits to using more than 20 tampons on each of the heaviest 3 days of her menstrual cycle. Her last menstrual cycle commenced 1 week ago. There are no recent medications. Exam is within normal limits, with no vaginal discharge. Labs: pregnancy test negative; cervical cultures negative; thyroid studies within normal limits; Hb 10 g/dL, WBC 9000/μL, platelet count 250 x 103/μL. Peripheral blood smear is consistent with microcytic hypochromic anemia. Prothrombin time, partial thromboplastin time (PT, PTT), and fibrinogen are normal. Bleeding time is prolonged.
Von Willebrand disease
An 18-year-old woman presents with chronic fatigue and menorrhagia. Menorrhagia has been present since her first menstrual cycle, but it has recently become worse; she sometimes uses 20 tampons per day. About a year ago, she started using contraceptive pills but is now considering stopping using them because of migraine-like headaches. Her headaches are sometimes so severe that she has to take aspirin or other painkillers several times a day. The rest of her past medical history is unremarkable. Physical examination reveals pale skin and mucosa, pulse rate of 100 beats per minute, and a systolic ejection murmur 1/3 intensity over the precordium. Laboratory findings include white blood count 9 K, hemoglobin 10, platelet count 250 K, normal prothrombin time, slightly prolonged partial thromboplastin time, and normal fibrinogen. Her bleeding time is prolonged. Blood smear shows microcytic hypochromic anemia.
Von Willebrand disease
A 28-year-old woman presents with malaise. She is known to be HIV positive. Her CD4 count is unchanged at 350 cells/field, and her viral count is undetectable. She is afebrile and has a normal exam. She takes zidovudine, indinavir, potassium, hydrochlorothiazide, and glyburide.
Zidovudine
A 6-year-old girl presents with frequent and prolonged bilateral nosebleeds. Her parents are concerned because there is a family history of a bleeding disorder. Her father, paternal grandmother, and a paternal aunt are all affected. Bleeding time, platelet count, and clotting time are within reference ranges. Ristocetin cofactor activity is decreased, and coagulation factor assays show slight decrease in factor VIII, but reference range factor IX levels.
von Willebrand disease