Patient will present as...

4-month old female with asymmetric thigh creases during a routine checkup. Physical exam reveals that the left lower limb is shorter than the right and lay externally rotated. Hip abduction is limited to 30 degrees. Ortolani's test is positive producing a soft "clunk" with anterior relation of the femoral head into the acetabulum. Radiographs reveal a superiorly displaced left proximal femoral metaphysis and a shallow, hypoplastic left acetabulum. The infant is treated in a Pavlik abduction harness for congenital hip dislocation

Developmental Dysplasia of the Hip

30-year-old married male who feels down most of the time for the past three years. He experiences frequent, intrusive thoughts that he is not good enough, despite personal and professional successes. He tries to overcompensate for his thoughts by taking on more than he can handle, which leads to failure and furthers his feelings of inadequacy. His wife suggests that he seek help after finding him crying

Dysthymia (Persistent Depressive Disorder)

26-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical examination and general laboratory profile showed no abnormalities

PMDD

64-year-old female who reports five weeks of occasional shortness of breath and pain radiating from the shoulder to the chest. The patient reports that the pain is worse with inspiration and lying down and is relieved by sitting forward. On physical exam, you note distant heart sounds. Her EKG shows low voltage QRS complexes and electrical alternans

Pericardial Effusion

67-year-old male with a history of recent fracture that occurred incidentally while he was walking reports fatigue and back pain, along with general achiness and "pain in his bones." While reviewing his chart you note he has been treated for multiple infections recently. Recent lab work demonstrated hypercalcemia, increased β2 microglobulin, an increased BUN and Cr as well as a peripheral smear that demonstrated an abnormal stacking of RBCs. Serum protein electrophoresis reveals a monoclonal immunoglobulin spike (M protein), Urine protein electrophoresis demonstrates Ig light chains (Bence Jones protein).

MM

32-year-old IV drug user complains of "bugs crawling on his skin." On examination, you note multiple open, oozing abscesses on his forearms along with several smaller pustules on an erythematous base on his forearms and legs. He has bilateral lower extremity erythema and 2 + pitting edema. When questioned about the duration of these symptoms he shows little concern but requests a number for a fumigator. His BP is 140/90, T 98.7 and RR 12. He has pinpoint pupil

MRSA

An obese 16-year-old boy with pain in his left groin, hip, and thigh. His mother notices a limp when he walks. The patient denies any recent significant trauma to his left lower extremity. On physical exam, his gait is antalgic. With the patient in the supine position, there is external rotation and abduction of the thigh with passive flexion of the hip. A radiograph of the affected hip is performed, which demonstrates an inferior displacement of the left epiphysis

SCFE

9-year-old boy who is brought to the emergency department by his mother. She reports that, as of this morning, he has had difficulty walking and seems unable to communicate with her. On exam, you note a thin, African American boy with mild conjunctival pallor. Vital signs reveal the following: T 36.2 C, BP 105/60 mmHg, HR 95 bpm, RR 16 rpm. Neurologic exam reveals weakness of the right arm and leg as well as expressive aphasia.

Sickle Cell Disease

34-year-old woman who arrives at the ED with acute-onset fatigue, fever, palpitations, and blurry vision. On chart review, it is revealed that she was recently diagnosed with AIDS and was on multiple antiretroviral medications. On physical exam, her skin is mildly jaundiced. She has multiple purpuras over her extremities. A complete blood count is significant for a platelet count of 37,000/μL (normal 150,000 - 400,000/μL) and mild anemia. Her peripheral smear reveals schistocytes. She has a negative Coombs test

TTP

19-year-old male transported to the ED following a car crash. Upon arrival, he is alert and anxious and appears to be in respiratory distress. A quick assessment reveals that she sustained trauma to his face, neck, and chest. His left hemithorax appears to be expanding more than the right. He is receiving oxygen via nonrebreathing mask. His vital signs are: respiratory rate 36 and labored. SpO2 is 85%. On physical exam, you notice decreased tactile fremitus, deviated trachea, hyperresonance, and diminished breath sounds

Tension Pneumothorax

15-year-old girl who comes to the office because she has missed her last three menstrual periods. History reveals she previously had regular periods, and menses began at the age of 12 years. She is very active and runs daily for the high school cross-country team. She says she is conscious of her dietary intake and eats a high protein low-fat diet. She has been sexually active for two years and reports using condoms most times. Vital signs reveal she is in the 75th percentile for her height and weight, and her heart rate is 55/min. Physical examination reveals normal Tanner stage 5 genitalia

Amenorrhea most likely secondary to pregnancy

45-year-old female who ate grandma Becky's famous canned tomatoes yesterday now presents with a dry mouth, blurred or double vision, drooping eyelids, slurred speech, and difficulty swallowing. Loss of pupillary light reflex along with symmetric descending weakness and flaccid paralysis without sensory deficits

Botulism

32-year-old lactating female with breast pain, swelling, fever, chills and a fluctuant mass of her left breast. The area directly above the lesion is warm, erythematous and tender to touch

Breast Abscess

66-year-old female with concern over a mass she felt in her left breast on recent breast self-examination. She denies any nipple discharge and reports a negative family history of breast or other cancers. Physical examination confirms the presence of a painless, firm, irregular, and immobile lump in the superolateral quadrant of the left breast; there are no evident overlying skin changes and there is no notable axillary lymphadenopathy on palpation

Breast Cancer

25-year-old cystic fibrosis patient complaining of chronic, frequent coughing productive of yellow and green sputum. She recently recovered from a Pseudomonas spp. pneumonia requiring hospitalization. On physical examination, you notice foul breath, purulent sputum, and hemoptysis along with a CXR demonstrating dilated and thickened airways with "plate-like" atelectasis (scarring)

Bronchiectasis

16-year-old male who briefly lost consciousness following a football collision and after regaining consciousness had an episode of nausea and vomiting

Concussion

14-year-old who is referred to your office for unusual animal cruelty and bullying at school

Conduct Disorder

A healthy 7-year-old girl who has reached all developmental milestones. On examination, the precordium is hyperdynamic with a prominent right ventricular heave. A grade III/VI systolic ejection murmur is present in the 2nd left intercostal space (pulmonic position) with an early to mid-systolic rumble and fixed splitting of the second heart sound (s2) during inspiration and expiration

ASD

A patient brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally and frothy pink sputum. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there is no cardiomegaly or pleural effusion noted. Oxygen saturation is 70%

ARDS

24-year-old male with severe pain in the right knee. He is a professional football player and a few hours prior to presentation, an opposing player hit his leg from his left side. Afterward, he felt a "popping" sound that was followed by severe knee pain and a sensation of knee instability. On physical exam, there is an anterior translation of the proximal tibia when pulled as the patient has the knee flexed at 90° and supine. Ice is applied to the knee and ibuprofen is prescribed. An MRI is ordered. Orthopedic surgery is consulted to evaluate if ligament reconstruction is needed

ACL Tear

a 5 y/o child with lymphadenopathy, bone pain, bleeding, and fever. Bone marrow demonstrates > 20% lymphoblasts

ALL

52-year-old male who reports that he has been feeling very tired lately and his wife thinks that he looks pale. You orders a complete blood count, which shows: Hgb 8.5 g/dL (normal 13.5-17.5); WBC 1,200/microliter (normal 4,500 - 11,000); platelets 70,000/microliter (normal 150,000 - 400,000). The patient is referred for bone marrow biopsy, which shows myeloblasts with Auer rods.

AML

14-year-old boy with dozens of erythematous papules, pustules, and cysts. On closer exam, he also has atrophic scars on the lateral forehead, consistent with permanent scarring from previous acne lesions. He is started on topical retinoids and topical benzoyl peroxide. You suggest that he also consider a systemic retinoid if this topical therapy does not work

Acne Vulgaris

45-year-old woman presented with a 4-year history of progressive increase in body size, lactation, and amenorrhoea, and a six-week history of worsening symptoms of heart failure. Physical examination showed coarse facial features, spade-like hands and feet, pitting pedal edema, galactorrhoea, and features of congestive cardiac failure. The chest radiograph showed gross cardiomegaly. On the skull radiograph, destruction of the floor of the pituitary fossa was noted, with an erosion of the clinoid processes. She had hyperprolactinemia. Fasting and post-glucose growth hormone values were elevated

Acromegaly

9-month old infant presents with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C (101.4 F), and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes are present

Acute Bronchiolitis

23-year-old-female with a one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheeze. Temperature is 99.9°F (37.7°C)

Acute Bronchitis

3-year-old boy who is brought to the ER with an sudden onset of fever (104.0 F), respiratory distress, and stridor. On examination, the boy appears acutely ill. He is sitting, leaning forward with his mouth open, he has a muffled voice and is drooling. When asked the parents report "we don't believe in vaccinations."

Acute Epiglottis

45-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis presents to the emergency department with dyspnea, cough, and chest pain. He describes the pain as worse during inspiration and when he is lying on his back

Acute Pericarditis

43-year-old female with high blood pressure unresponsive to therapy. She complains of headaches, palpitations, and sweating. She has a history of neurofibromatosis type 1, though without any neurological deficits. She has multiple café-au-lait spots on her body. The ECG demonstrates sinus tachycardia. She is found to be hypertensive to 154/121 mmHg. Her 24-hour urine metanephrines and VMA come back elevated. Her abdominal CT demonstrates an adrenal mass

Adrenal Tumor/Neoplastic Disease

45-year-old man with severe rectal pain when he defecates, lasts for several hours, and subsides until the next bowel movement. He has been constipated for the past 6 months and when he does have a bowel movement the stool is covered with bright red blood. A sentinel pile is noted on the physical exam

Anal Fissure

62-year-old male with a history of chronic kidney disease complains of weight loss, fatigue, and weakness. Iron studies reveal decreased serum iron, increased ferritin, and decreased TIBC. Peripheral blood smear shows normochromic RBCs

Anemia of Chronic Disease

69-year-old male who complains of rectal pruritus, bleeding with defecation, and a sensation of incomplete evacuation. A palpable mass is noted on digital rectal examination

Anorectal Cancer

25-year-old male recently started on phenytoin for seizure disorder is complaining of low-grade fever, fatigue, and weakness. Physical exam reveals a temperature of 99.2°F, purpura, pallor, and gingival bleeding. There is no hepatosplenomegaly. His blood tests show WBC 1100/μL, platelets 35,000/μL, Hb of 4.0 g/dL; MCV 90 fl; and 1% reticulocyte count. A bone marrow biopsy is obtained, showing hypocellularity, and increased adipose tissue

Aplastic Anemia

14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient's mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left.

Appendicitis

5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes

Asthma

5-year-old child presents with an occipital headache, an ataxic gait, nystagmus, and papilledema

Astrocytoma

59-year-old woman who is 9 years postmenopausal complains of urinary urgency, frequency, and occasional incontinence. On pelvic examination, her vaginal mucosa appears shiny, pale pink with white patches, and bleeds slightly to the touch. Her urinalysis and urine cultures are negative

Atrophic vaginitis

49-year-old female with progressive left hip pain and limp which has become progressively worse over 13 months. Her past medical history is significant for heterozygous sickle cell anemia and she is has been under hydroxyurea treatment for about 20+ years. She is on no other medication and denies alcohol or tobacco use. The pain is localized to the groin, lateral hip, and buttocks and she reports a sudden increase in pain about two months ago after her last sickle cell crisis. Physical exam reveals a left hip with painful restriction of ROM and a limp. Right hip has mild symptoms

Avascular Necrosis of the Hip

38-year-old man with a history of gastric bypass for morbid obesity comes to your office with a hemoglobin level of 10 g/ dL. His MCV is 111 mm3. His ferritin level is 35 mcg/ L, and his red cell distribution width is high. His reticulocyte count is high. Further questioning reveals mild anorexia, diarrhea, glossitis, and distal paresthesia. On exam, you notice she has a swollen red tongue

B12 Deficiency

70-year-old man with difficulty initiating a stream and post-void dribbling. He also reports having increased urinary urgency, nocturia, and a weak urinary stream. Medical history is significant for hypertension. The patient is not on medication. On digital rectal exam, his prostate is enlarged, non-tender, firm, and smooth. Urinalysis is unremarkable and prostate-specific antigen is elevated

BPH

24-year-old sexually active woman complains of a profuse, whitish-gray vaginal discharge with a fishy odor that becomes stronger after intercourse and during menses. She denies any irritation and states that her sexual partner has no symptoms. Microscopic evaluation of the discharge reveals granular-appearing epithelial cells

Bacterial Vaginitis

27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient's girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient's vital signs are within normal limits

Bipolar I

19-year-old male who has had bouts of sadness for the course of 1 year in which he says that oftentimes cannot even get out of bed so he tells his parents he is ill. Jim states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he did become irritable and others stated that he was louder than usual and wondered if he took something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is not sure how he will pay them off before he goes to school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed which has continued to be a struggle today

Bipolar II

21-year-old who returns from a camping trip early complaining of a dull numbness affecting his upper left extremity. He recalls a sharp pinprick sensation before the development of symptoms. The patient now describes cramping pain and muscle rigidity of the back and chest area. A red, indurated area is found on the distal left arm. The patient has profuse sweating, nausea, vomiting, and shortness of breath

Black Widow Spider Bite

85-year-old man who comes to his primary care provider after a week of hematuria. He has not been ill lately and has had no complaints of pain on urination. A CT scan with contrast is ordered demonstrating a variable filling defect

Bladder Cancer

45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn't fully emptied after urinating

Bladder Prolapse

32-year-old man who approximately 5 days ago, was cleaning out his dark, undisturbed attic. That day he noticed an erythematous lesion with a clear center on his arm. Since then the lesion has necrosed in the center, giving rise to a crater-like eschar lesion

Brown Recluse Spider Bite

60-year-old male complains of fatigue, blood tests demonstrate severe anemia, decreased neutrophil count, and small, abnormal B lymphocytes in the bone marrow (>30%) with levels at 90,000 per cubic millimeter. He has painless cervical lymphadenopathy and hepatosplenomegaly.

CLL

49-year-old healthy male without complaints, but on a routine complete blood count (CBC) has markedly increased white blood cell count of 40,000 per uL (normal 4500 - 11,000). A peripheral blood smear demonstrates leukocytosis with myeloid cells present at various stages of differentiation, with more mature cells present at a greater percentage than less mature cells. The cytogenetic analysis is positive for the Philadelphia chromosome.

CML

23-year-old PA student with a 3-day history of bloody diarrhea, abdominal pain, and fever. She reports having passed liquid stools up to nine times that day. She started noticing blood earlier this morning. There is no history of recent travel or sick contacts but she reports eating grilled chicken during a recent study group. Stool microscopy revealed numerous WBCs and RBCs in the stool. A sample was cultured on Skirrow agar and incubated in a gas mixture with 5% oxygen

Campylobacter Jejuni Infection

32-year-old woman with an itchy vaginal discharge for the past 2 days. She has been healthy other than a recent sinus infection for which she took a 10-day course of amoxicillin. Her husband is her only sexual partner and he has no symptoms. On examination, the vulva is noted to be slightly erythematous and swollen with some evidence of excoriation. The discharge is white and clumpy

Candidal Vaginitis

36-year-old former injection drug user was diagnosed with HIV 3 years ago. Her most current CD4 count is 558. Today, she complains of an unintentional weight loss of 5 lb and some mild pain with swallowing. Oral mucosa is pink without lesions or exudates

Candidiasis

43-year-old man who comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sound

Carcinoid Tumors

37-year-old male who is brought to your ED after falling off a second-story scaffolding onto his back. On exam, HR is 126 bpm, BP is 80/56 mmHg, RR is 24 bpm, and temperature is 99.0 degrees Fahrenheit. Glasgow Coma Score is 8, jugular veins are distended,and heart sounds are distant

Cardiac Tamponade

A critically ill 69-year-old male with a history of coronary artery disease is hypotensive following a large anterior wall myocardial infarction. He is noticeably lethargic, somnolent, and confused. He has very weak peripheral pulses, a rapid heart rate and his extremities are cool to the touch

Cardiogenic Shock

27-year-old woman here for a routine visit. She denies any acute complaints and is currently sexually active with two men. She reports consistent use of condoms and denies any abnormal vaginal smell or discharge as well as dysuria. A pap test is performed, which shows atypical squamous cells of undetermined significance (ASC-US). Her last pap test was normal. A reflex human papillomavirus (HPV) test is performed

Cervical Dysplasia

21-year-old female who comes to the family planning clinic at her local health department for an annual examination. The patient is currently sexually active and has had three new partners over the past year. She uses oral contraceptives, however rarely uses condoms during her sexual encounters. Other than increased vaginal discharge, the patient is asymptomatic. Speculum examination shows a mildly friable, erythematous cervix with no active discharge. A pregnancy test is negative and no cervical motion tenderness or adnexal masses. Two weeks later, her vaginal nucleic acid amplification test (NAAT) comes back positive

Cervicitis - Chlamydia

27-year-old male with a lifelong history of pectus excavatum. Initially as a child, he was asymptomatic, but over the last several years, he had begun developing shortness of breath and chest pain secondary to his pectus. It was recommended that the patient undergo surgical repair based on his symptoms of shortness of breath and chest pain with mild exertion

Chest/Rib Deformity

4-year-old girl is brought to the emergency department by her mom because the child was found to be lethargic after being picked up from a new daycare. The child has been attending the new daycare for the past week. Medical history is noncontributory. Physical examination shows multiple bruises on the buttocks, a small circular burn mark on the arm, and retinal hemorrhages. A chest radiograph is obtained and shows a right-sided rib fracture

Child Abuse

21-year-old male complaining of pain on urination and a watery discharge from his penis. Gram stain of the discharge is negative for bacteria but shows many neutrophils. When questioned about his social history, he says that he uses condoms most of the time but occasionally has unprotected sex. The patient responds to treatment with azithromycin

Chlamydia

58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced

Cholangitis

49-year-old female with a 2-day history of right-upper-quadrant, colicky abdominal pain, as well as nausea, and vomiting. Examination shows significant pain with palpation in the right upper quadrant. Laboratory findings include an elevated WBC count, alkaline phosphatase, and bilirubin level

Cholecystitis

3-year-old woman who comes to the emergency department with a 12-hour history of right upper quadrant (RUQ) abdominal pain. The pain is severe now but waxes and wanes and is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She feels warm but has not checked her temperature. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. The patient has no similar history in the past. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 100 ° F and pulse of 102 beats/ minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals marked upper abdominal tenderness with guarding, especially in the RUQ. On palpation of the RUQ of the abdomen when the patient is asked to take a deep breath, there is a marked increase in pain. The bowel sounds are present but seem slightly sluggish. The patient has no drug allergies and is not taking any medications at present.

Cholelithiasis

33-year-old female with watery, nonbloody diarrhea and abdominal cramps for the past 2 days. She also reports a low-grade fever. She returned from a medical mission trip to South America yesterday. While on the trip she spent time in a remote area and is uncertain of the quality of the water she drank. She also ate shrimp one night for dinner. On examination, the stools are liquid with flecks of mucus. Physical exam reveals sunken eyes, dry mucous membranes and decreased skin turgor. The patient is afebrile. Blood pressure is 90/60 mmHg

Cholera

60-year-old female with shortness of breath of recent onset. She has a six-year history of cough and rhonchi and is on oxygen at home. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9F. Her SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm

Chronic Bronchitis

63-year-old white male with a chief complaint of blood in his stool. He is accompanied by his wife who also reports weight gain, abdominal distension, and swelling of his legs. Physical exam reveals a healthy-appearing male with 3+ bilateral lower extremity edema and distended abdomen with evidence of shifting dullness. You also note several skin lesions seen here. The patient is hemoccult positive and has blood on his urine dipstick. He denies tobacco and illicit drug use but admits to drinking 1-2 x per week and has about 6 beers on each occasion

Cirrhosis

45-year-old man who comes to your office with a 4-week history of recurrent headaches that wake him up in the middle of the night. The headaches have been occurring every night and have been lasting approximately 1 hour. The headaches are described as a deep burning sensation centered behind the left eye. The headaches are excruciating (he rates them as a 15 on a 10-point scale) and are associated with watery eyes, "a sensation of heat and warmth in my face," nasal discharge, and redness of the left eye

Cluster Headache

8-year-old boy who is seen for the first time in your office. His parents report that he tires easily and often complains of weakness in his legs. Physical exam shows a healthy boy with a blood pressure of 141/91 mmHg. You notice that his lower extremities are slightly atrophic with a mottling appearance. Upon further examination, he is found to have very weak and delayed femoral pulses with a blood pressure of 96/60 in the lower extremities. He has a late systolic ejection murmur on cardiac auscultation. CXR is performed demonstrating a "figure of 3 sign"

Coarctation of the Aorta

65-year-old male with several months of weight loss, vague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST

Colon Cancer

33-year-old man who has undergone ORIF of the left tibia. Fifteen hours postoperatively, the patient complains of increased pain and swelling of his left leg. His pain is unrelieved by medication, he is experiencing numbness, tingling, and loss of function in the extremity. Physical examination demonstrates decreased sensation and painful paralysis of his toes along with diminished pedal pulses on the affected side and coolness with a loss of color in the area

Compartment Syndrome

Primigravida with bilateral, painful breast engorgement

Congestive mastitis

65-year-old male with chronic low back pain complaining of bloating, abdominal pain, straining, and pain with bowel movements. He reports less than 3 bowel movements per week that are very hard and difficult to pass. The patient is on 50 mcg of transdermal Fentanyl and takes four 10 mg Norco per day for breakthrough pain

Constipation

65-year-old man comes to the office due to 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate chronic obstructive pulmonary disease. His medical history is relevant for a 40 pack-year smoking history, type II diabetes mellitus, hyperlipidemia, and coronary artery stenting 2 years ago. Physical exam shows barrel shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), the pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%

Cor Pulmonale

25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having a "nervous stomach," irritable bowel syndrome, and "depression." Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area

Crohn Disease

2-year-old boy who is brought to you by his father who is concerned about a "barking cough," mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals inspiratory stridor

Croup

49-year-old HIV positive male with a CD4 count of 9, he lives alone, drinks daily, he presents to the hospital with a headache, neck stiffness, and confusion. A lumbar puncture (LP) shows that his intracranial pressure is very high (45 cm) and that his spinal fluid contains Cryptococcus (India Ink and CrAg positive). Baseline blood ordered: full blood count, creatinine, ALT, and RPR serum cryptococcal antigen (CrAg) test is positive

Cryptococcosis

a one-year-old child who is brought to your office for his 12-month visit. You note that the boy's testicles are inappreciable on the exam. The medical record reports that the child's testicles had been examined at two previous visits. The mother is very concerned and asks if her son will need surgery

Cryptorchidism

42-year-old woman complaining of poor sleep. She has also beenfeeling restless and agitated for several months. Upon further questioning, she reveals that she has also been suffering from headaches and has gained 18 pounds over the same time period. She denies any chest pain, palpitations, diaphoresis, or increased appetite. She has no significant past medical history other than two uncomplicated pregnancies resulting in normal spontaneous vaginal deliveries. She denies any tobacco, alcohol, or illicit drug use. Her vital signs show Temp 37 C (98.6 F), BP 164/112 mm Hg, HR 88/min, and RR 12/min. Physical exam shows an overweight woman with no palpable thyroid nodules or abnormalities on the cardiopulmonary exam. On the abdominal exam, you notice skin atrophy and pigmented striae. Laboratory evaluation reveals the following: Sodium 141 mEq/L, potassium 3.1 mEq/L, chloride 96 mEq/L, bicarbonate 25 mEq/L, BUN 10 mg/dL, creatinine 0.8 mg/dL, glucose 220 mg/dL, and calcium 9.5 mg/dL

Cushing's syndrome

24-year-old male with c/o episodes of depression alternating with times of increased energy, restlessness, and decreased sleep for 2 years.

Cyclothymic disorder

3-year-old girl with growth retardation who has a long history of recurrent pneumonia and chronic diarrhea. Her mother states that he has 6-8 foul-smelling stools per day. Physical exam reveals a low-grade fever, scattered rhonchi over both lung fields,crepitant rales at the left lung base, and dullness to percussion. Other findings include mild hepatomegaly and slight pitting edema of the lower extremities. CXR reveals hyperinflation, mucus plugging, and focal atelectasis. Labs reveal an elevated quantitative sweat chloride test

Cystic Fibrosis

34-year-old woman with a 3-day history ofhematuria, dysuria, increased urinary frequency, and nocturia. She has had no fever, chills, or back pain. On examination, she does not look ill. Her temperature is 37.5 ° C. Her abdomen is nontender. There is no CVA tenderness

Cystitis

45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn't fully emptied after urinating

Cystocele

56-year-old male who is 3 months post liver transplant complaining of left eye pain and blurriness. At times he sees objects "floating" in his eyes. His partner reports that he has seemed unsteady on his feet lately, bumping into walls and knocking objects off of countertops by accident. On fundoscopic exam the eye is red, and the retina has multiple proliferative lesions

Cytomegalovirus

25-year-old male complaining of an unabated thirst that began three weeks ago. He is constantly drinking and goes to the bathroom around five times a night. He has lost five pounds over the last few weeks. The patient is on lithium for bipolar disorder. His BP is 115/70. The patient's labs are significant for serum Na of 145 mEq/L (normal: 135-145). Urine osmolality is 185 mOsm/kg, and urine specific gravity is 1.004 (normal: 1.012 to 1.030)

Diabetes Insipidus

A young patient with weight loss, increased thirst, and urination. The patient has felt tired and nauseous. On examination her weight is below the 5th percentile, she looks thin, and her skin is pale. her blood pressure is 100/70 and her pulse is 104 bpm. Her respirations are deep at a rate of 28 breaths/minute. Her breath smells fruity

Diabetes Mellitus, Type 1

35-year-old Mexican American male complaining of increased thirst, frequent urination, hunger, fatigue, and blurred vision random finger stick blood glucose is 225

Diabetes Mellitus, Type 2

28-year-old Caucasian female complaining of a one-week history of fatigue, progressively worsening shortness of breath, and swelling of her feet and ankles. She denies any chest pain. Her past medical history is unremarkable except for a recent cold two weeks prior to this presentation. She denies any past surgical history. She takes oral contraceptive pills as her only medication. She denies any recreational drug use. On physical exam, her temperature is 37 C (98.6 F), blood pressure is 120/70 mmHg, pulse is 84/min, and respiratory rate is 20/min. Her physical exam is also notable for bibasilar crackles, jugular venous distension, an S3 gallop (heard below), and 2+ pitting edema up to the ankles bilaterally. Her electrolytes and complete blood count are within normal limits. CXR reveals cardiomegaly with pulmonary congestion, EKG shows nonspecific ST and T wave changes, and echocardiography demonstrates left ventricular dilation and dysfunction and low cardiac output

Dilated Cardiomyopathy

14-year-old male, who recently immigrated with his parents from the Dominican Republic, presents with a 2-day history of fever, malaise, and sore throat. Immunization records are unavailable. On physical exam, temperature is 102°F (38.9°C). A friable grayish-white membrane is seen in the oropharynx that bleeds if scraped. There is an enlargement of the cervical nodes, resulting in a bull neck

Diphtheria

67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid-abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC

Diverticulitis

25-year-old woman who comes to your office for a new patient visit. Her complaints are 6 months of constant pelvic pain and low back pain, intermittent myalgias, insomnia for "many years," and feeling tired. When you ask about bruises of varying ages on arms, legs, and face, she notes that she is clumsy and bumps into things a lot. Her husband accompanies her to the visit and refuses to leave the room for the physical examination. On pelvic examination, purulent cervical discharge is noted, along with cervical motion tenderness. Her husband inquires as to why you are using so many tubes for laboratory specimens

Domestic Violence

62-year-old female with complaints of epigastric pain and belching which improves when she eats food but gets worse a few hours after her meal. She said he has noticed a change in the color of her stool

Duodenal Ulcer

35-year-old woman with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip two months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse and denies any vaginal discharge. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of STIs. On physical examination, her blood pressure is 120/ 80 mm Hg and her body mass index (BMI) is 32. Her pelvic examination is normal

Dysfunctional Uterine Bleeding

19-year-old nulligravid college female who complains of dull, throbbing, cramping lower abdominal pain during menses for the past three years. She reports nausea and vomiting during menses but denies irregular or heavy periods, pain with intercourse, or abdominal pain outside of menses. Pain tends to peak 24 h after the onset of menses and subsides after 2 to 3 days. A pelvic exam is normal

Dysmenorrhea

54-year-old female with odynophagia (painful swallowing), dysphagia and retrosternal chest pain

Esophagitis

14-year-old boy with 3-days of sore throat, fever, and generalized malaise. On exam, he has a temperature of 102.2 F (39.0 C), BP 96/50, and a diffuse exudate on both tonsils. He also is noted to have palpable splenomegaly, swollen painful lymph nodes, and mild hepatomegaly. Labs show leukocytosis of 12,000/mm3 with 50% neutrophils, 12% monocytes, and 38% lymphocytes. The rapid pharyngeal streptococcal screen is negative

EBV

25-year-old with fever. She has a history of intravenous drug use and had previously been treated for osteomyelitis. On physical exam, she is febrile, and heart auscultation reveals a new systolic murmur at the lower left sternal border. An echocardiogramreveals tricuspid valve vegetations

Endocarditis

75-year-old woman comes to the ED with her spouse because she fell in the shower. The husband says that his wife used to be highly functional and independent, but her function has declined over the past year. He answers all her questions for her and appears very concerned about her health and functional status. When asked to leave the room so that the patient can be examined, he refuses. Her appearance is unkempt and her clothes are dirty. In the course of discussing the management of the patient's clinical situation, you offer help in the form of home health services, but the husband refuses

Elder Abuse

4-year-old who is brought to the office by his mother. The child has had a low-grade fever, headache, and sore throat for the past week. Four days ago, he suddenly developed a bright red rash on his cheeks, which during the past two days has spread to the trunk, arms, and legs. On physical examination, the child has erythema of the cheeks and a maculopapular rash with central clearing on the trunk spreading to the extremities. There are no other significant findings

Erythema Infectiosum

15-year-old complaining of several red lesions on her palms, back of hands, and on her lips of one-week duration. On examination, you note a symmetrical red papular rash with many target lesions. The rash appeared just a few days after herpes facialis

Erythema Multiforme

65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chestedman with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation and a small, thin appearing heart. PFTs show a decreased FEV1 / FVC ratio

Emphysema

34-year-old male who is brought to the emergency department by his wife due to a seizure event. She reports that prior to the event, he complained of headache, fever, and nausea. She also reports her husband appeared confused. On exam, the patient cannot clearly answer questions. A CT of the head shows no evidence of hemorrhage or a space-occupying lesion. A lumbar puncture is performed, and cerebrospinal fluid analysis shows a normal opening pressure, a lymphocytic pleocytosis, normal glucose, and elevated protein. PCR is positive for herpes simplex virus-1

Encephalitis

53-year-old woman with no period for four years, now is having abnormal bleeding and bleeding after intercourse. She has lower abdominal pain, feels as though she may have her menses, pelvic heaviness, girth, and bloating

Endometrial Cancer

24-year-old nulligravid woman comes to your office with an 18-month history of painful intercourse, difficulty defecating, and dysmenorrhea. These symptoms are cyclical and come and go with her menses. Her menses are regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normal-sized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments

Endometriosis

6-year-old child presents with an occipital headache, an ataxic gait, nystagmus, and papilledema

Ependymoma

25-year-old male with a dull, achy scrotal pain that has been gradually increasing over the last several days. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/HPF

Epididymitis

60-year-old man who presents to your clinic for evaluation of erectile dysfunction. His wife died 5 years ago and he would like to start dating again. He denies having any life stressors. He reports having no morning or night-time erections. His past medical history includes hyperlipidemia managed with medication and pre-diabetes managed with an active lifestyle and diet

Erectile Dysfunction

62-year-old man with a history of alcoholism who complains of difficulty swallowing solids that has progressed to difficulty swallowing liquids. He has smoked 1-2 packs of cigarettes per day for the past 38 years. In addition, he reports occasional bouts of hematemesis and hoarseness, along with progressive weight loss and weakness

Esophageal Neoplasm

solid food dysphagia in a patient with a history of GERD

Esophageal Strictures

64-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the general surgery clinic where he was referred for further evaluation of blood in his stool. He reports occasional abdominal pain relieved transiently with meals and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas, but no palmar erythema or hepatosplenomegaly are observed on the exam

Esophageal Varcies

44-year-old Caucasian man with a four-year history of diabetes mellitus presents to your office for a routine check-up. He has no complaints. His medications include metformin, aspirin, and a multivitamin. He works as an insurance salesman and has a sedentary lifestyle. He smokes one pack of cigarettes per day and drinks two cans of beer on weekends. He denies any illicit drug use. His diet includes mostly meat and large amounts of "junk food." On physical exam, his blood pressure is 157/96 mmHg, heart rate is 82 bpm. His BMI is 34.2 kg/m^2. The remainder of his physical exam is unremarkable. Laboratory studies reveal an HbA1c of 7.8%. At his last check-up one month ago, his blood pressure was 151/93 mmHg

Essential HTN

65-year-old patient with shaking that occurs with simple tasks such as tying his shoelaces, writing, or shaving. According to his wife, the symptoms are aggravated by stress, fatigue, caffeine, and changes in temperature. The patient reports his dad had the same symptoms. On physical examination, there is a 4-10 Hz tremor elicited when both of his arms are outstretched forward. There is no tremor at rest

Essential Tremor

43-year-old obese woman with a history of diabetes presents for a routine visit. She denies having any complaints. On physical exam, her physician notices mild hepatomegaly without tenderness to palpation. A liver enzyme panel is sent and reveals elevated transaminases. She is sent for a hepatic ultrasound to evaluate for nonalcoholic fatty liver disease or steatohepatitis

Fatty Liver Disease

55-year-old male with complaints of heartburn, belching, and epigastric pain which is aggravated by drinking coffee, eating fatty foods, and lying down. He says it gets better when he takes antacids

GERD

An elderly bed-bound patient with impaired mental function and poor fluid/fiber intake who complains of incontinence of liquid stool. He also reports rectal pressure and lower abdominal pain. The pain is cramping in quality and the patient's abdomen is "bloated." Digital rectal examination reveals a large amount of stool in the rectum

Fecal Impaction

27-year-old female with a painless mass in the left breast. She discovered this mass three months ago while showering and reports it has been unchanged since that time. Her last menstrual period was 10 days ago. There is no family history of breast cancer. On physical exam, you palpate a 3 cm, firm, non-tender mass in the upper lateral quadrant of the left breast. The mass is smooth, well-circumscribed, and mobile. There are no skin changes, nipple discharge, or axillary lymphadenopathy

Fibroadenoma

42-year-old woman with breast masses that changes in size, especially during her menstrual cycles. These masses are usually painful and pain radiates into the axillae. She reports that her breasts often feel full and heavy. Occasionally she has a small amount of greenish-brown nipple discharge. Ultrasound exam shows cystic masses within the breasts

Fibrocystic Changes

35-year-old woman comes to your office with a 1-year history of "aching and hurting all over." She also complains of a chronic headache, difficulty sleeping, and generalized fatigue. When questioned carefully, she describes "muscle areas tender to touch."Although the pain is worse in the back, there really is no place free of pain. She also describes headaches, generalized abdomen pains, and some constipation

Fibromyalgia

20-year-old healthy male who was treated 4 days ago for an MRSA skin infection with sulfamethoxazole-trimethoprim (Bactrim). The infection is improving but he is increasingly weak and his sclera have turned yellow. Today his hemoglobin is 11 g/ dL (13.5 to 18 g/ dL) and his MCV is 85 (80 to 100 fL); the corrected reticulocyte count is elevated, he has increased indirect bilirubin and decreased haptoglobin. The peripheral smear demonstrates bite cells and Heinz bodies

G6PD Deficiency

20-year-old healthy male who was treated 4 days ago for an MRSA skin infection with sulfamethoxazole-trimethoprim (Bactrim). The infection is improving but he is increasingly weak and his sclera have turned yellow. Today his hemoglobin is 11 g/ dL (13.5 to 18 g/ dL) and his MCV is 85 (80 to 100 fL); the corrected reticulocyte count is elevated, he has increased indirect bilirubin and decreased haptoglobin. The peripheral smear demonstrates bite cells and Heinz bodies.

G6PD Deficiency

43-year-old alcoholic man who arrives at the hospital with alcohol withdrawal. He confabulates and trembles uncontrollably. He is started on supportive therapy for now. Bloodwork comes back with macrocytic megaloblastic anemia, an increased homocysteine, normal methylmalonic acid, and decreased folate. He is immediately started on folic acid supplementation

Folate Deficiency

35-year-old woman comes to your office complaining of "pimples in my armpit." She said that it first appeared five days ago and they are itchy and mildly painful. She denies fever, nausea, vomiting, and recent travel - she has never had any prior lesions like this in the past. She admits to going to a party where she used a hot tub two weeks ago. Temperature is 98.1°F (36.7°C), blood pressure is 132/75 mm-Hg, pulse is 76/min, and respirations are 14/min. Both axillae have short, 2-mm hairs, and lack lymphadenopathy. You note multiple papules and pustules in the right axillae. The lesions are mildly tender to palpation

Folliculitis

2-year-old male child who is brought to the emergency department by his mother with a sudden onset of choking, gagging, coughing, and wheezing. Vital signs are temperature 37 ° C; pulse 120/ min; and respirations 28/min. The physical examination reveals decreased breath sounds over the right lower lobe with inspiratory rhonchi and localized expiratory wheezing. The chest X-ray reveals normal inspiratory views but expiratory views show localized hyperinflation with a mediastinal shift to the left

Foreign Body Aspiration

26-year-old non-lactating woman with a 3-month history of bilateral milky breast secretions and amenorrhea. Her serum HCG is negative and her serum prolactin is elevated at 220

Galactorrhea

68-year-old man, who presents to your clinic with complaints of fatigue, loss of appetite, and abdominal pain/fullness. He reports a 15-pound weight loss over the last three months. Vital signs are within normal limits. On exam, you discover a firm, enlarged painless lymph node above the patient's left clavicle. Upon further questioning, the patient reports the node has been present for the past 2 months. His stool is Guaiac positive

Gastric Neoplasm

Abdominal discomfort that isworse with meals and gets better an hour or so later after eating

Gastric Ulcer

37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day

Gastritis

35-year-old female with a complaint of worry which she cannot control for the last year. She tells you that her symptoms daily consisting of sleep disturbances, difficulty concentrating, and irritability. She reports her symptoms started around age 17 but have worsened

General Anxiety Disorder

63-year-old man is brought to your office by his son due to progressively worsening headache and weakness. His headache began approximately 3 months prior to presentation and is described as diffuse but worse on the right side of the head. The headacheworsens with coughing and lifting heavy objects and is associated with nausea, multiple episodes of vomiting, and left-sided weakness. He previously worked for the synthetic rubber industry for over 30 year

Glioblastoma

45-year-old male from Ireland with complaints of diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension. He reports having 3-5 loose stools per day for the last six months. The condition improves when he fasts.

Gluten Intolerance

19-year-old sexually active woman who presents to your office with complaints of yellow vaginal discharge and intermittent postcoital vaginal bleeding for 1 week.She otherwise feels well. On examination, there is purulent discharge visible in the endocervical canal. After you collect vaginal fluid for a wet prep and cervical samples for gonorrhea and chlamydia cultures, you note bleeding at the cervical os. On bimanual examination, the patient complains of tenderness on cervical palpation but denies uterine or adnexal tenderness. Wet prep reveals vaginal pH 4; negative whiff; 20 white blood cells (WBCs) per high-power field; and no clue cells, trichomonads, or pseudohyphae

Gonococcal Infections

14-year-old boy who notices a lump under the nipple of his left chest. He reports mild pain when touched. There is no breast discharge or changes in the skin. On physical examination, pubic hair is Tanner stage IV and has a testicular volume of 9 mL bilaterally. Palpation of the left chest shows a 3.5 cm mass beneath the nipple

Gynecomastia

54-year-old male on chronic potassium-sparing diuretic with bilateral breast tissue swelling and tenderness

Gynecomastia

25-year-old white male who was recently discharged from the hospital with a diagnosis of bacterial pneumonia. His past medical history is significant for nephrectomy after a motor vehicle accident 10 years ago, aseptic meningitis 12 months ago, and one prior episode of bacterial pneumonia 5 months ago. His physical examination is remarkable for oral thrush. In the hospital, the results of an HIV EIA and Western blot returned positive. A CD4 T-lymphocyte cell count was 30, and HIV RNA (viral load) was more than 100,000 copies/mL. His Venereal Disease Research Laboratory (VDRL) test result returned positive (1:256), and a tuberculin skin test (TST) response measured 8 mm of induration. His hemoglobin was 11.7 g/dL, and he had a white blood cell count of 4000 cells/mm3 and a platelet count of 70,000 cells/mL

HIV

27-year-old female who complains of exquisite vulvar pain and blisters. She reports that she has experienced several similar episodes for the past 5 years. On examination, you find multiple, painful vesicles on her left labia minora. You recall that on a previous visit she had a positive chlamydia culture that was treated with azithromycin tablets

HSV

63-year-old man who is sent to the ED by his primary care PA for hypertension. He was at a general health maintenance appointment when his blood pressure was found to be 182/122 mmHg. The patient is otherwise currently asymptomatic and states that he feels well. He has no other medical problems other than his hypertension and his labs that were drawn last week were within normal limits. At the ED his temperature is 97.3°F, blood pressure is 198/110 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is unremarkable. Labs at the ED are significant for a serum creatinine of 2.4 mg/dL

HTN Emergency

68-year-old Caucasian female who comes to the ED because of severe headaches, visual disturbances, and vomiting. Her medical history is relevant for tension headaches. The physical exam is noncontributory. Her temperature is 98.8°F, pulse is 92/min, respirations are 20/min, blood pressure is 230/120 mmHg. Urinalysis reveals hematuria with red blood cell casts and proteinuria. A funduscopic exam is obtained and reveals papilledema

HTN Retinopathy (Malignant HTN)

42-year-old woman complaining of poor sleep. She has also been feeling restless and agitated for several months. Upon further questioning, she reveals that she has also been suffering from headaches and has gained 18 pounds over the same time period. She denies any chest pain, palpitations, diaphoresis, or increased appetite. She has no significant past medical history other than two uncomplicated pregnancies resulting in normal spontaneous vaginal deliveries. She denies any tobacco, alcohol, or illicit drug use. Her vital signs show Temp 37 C (98.6 F), BP 164/112 mm Hg, HR 88/min, and RR 12/min. Physical exam shows an overweight woman with no palpable thyroid nodules or abnormalities on the cardiopulmonary exam. Laboratory evaluation reveals the following: Sodium 141 mEq/L, potassium 3.1 mEq/L (normal 3.5-5.0), chloride 96 mEq/L, bicarbonate 25 mEq/L, BUN 10 mg/dL, creatinine 0.8 mg/dL, glucose 220 mg/dL, and calcium 9.5 mg/dL

HTN Secondary to Cushing Syndrome

63-year-old man who is sent to the ED by his primary care PA for hypertension. He was at a general health maintenance appointment when his blood pressure was found to be 182/122 mmHg. The patient is otherwise currently asymptomatic and states that he feels well. He has no other medical problems other than his hypertension and his labs that were drawn last week were within normal limits. At the ED his temperature is 97.3°F, blood pressure is 198/110 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is unremarkable. Labs at the ED are within normal limits

HTN Urgency

63-year-old male presents to his primary care physician assistant withright upper quadrant pain that has progressed over the last three months with unexplained weakness and joint pains. On history, you note the patient lives a sedentary lifestyle, rarely leaves the house, has controlled diabetes diagnosed 13 years ago, and has documented cardiomyopathy. On physical exam the man appears non-toxic, sclera are icteric, cornea appear normal, pain is elicited on palpation of the right upper quadrant, and skin appears quite bronzedon his extremities.

Hemochromatosis

55-year-old rock musician who comes to the office because he has been feeling increasingly tired for 6 months. He has a history of intravenous drug use and alcohol abuse. He states that he feels quite tired, but otherwise has no complaints. The examination is noncontributory. His laboratory investigations are normal aside from elevated liver enzymes.

Hepatitis C

59-year-old male with complaints of fatigue, shortness of breath with physical exertion, and a sense of abdominal fullness. His wife accompanies him to his appointment and expresses concerns about his skin color, commenting that he has an "orange hue" to his skin. On physical exam the patient is noticeably jaundice with palpable splenomegaly. A peripheral smear comes back with spherocytes as well a smudge cells. His direct Coombs test is positive with anti-C3 and anti-IgG antibodies

Hemolytic Anemia

3-year-old boy whose mom is concerned about his prolonged nosebleeds. Ever since he was about 2 years old, he has had multiple episodes of nosebleeds that stopped only after hours. On physical exam, his right elbow is slightly swollen and tender to palpation. There is a family history of unexplained bleeding in the patient's maternal uncle. Lab results reveal increased PTT that corrects after mixing studies. Lateral radiograph of the knee shows swelling of the soft tissues from blood accumulation in the knee

Hemophilia

33-year-old Caucasian woman who comes to the emergency department because of vomiting and fever. The patient works as a global health nurse and her medical history is relevant for recent travel to India. Upon further questioning, the patient mentions that she is concerned because it has been 9 weeks since her last menstruation. Physical examination shows yellowing of the skin and sclera, right upper quadrant tenderness, and hepatomegaly. Her temperature is 101.3°F, pulse is 98/min, respirations are 14/min, and her blood pressure is 120/70 mmHg. Laboratory studies reveal increased aminotransferase levels and a positive pregnancy test.

Hep E

38-year-old female who has just returned from a 2-week trip to Mexico. She complains of nausea, vomiting, loss of appetite, and right upper quadrant abdominal pain. She has been sick for the past 3 days. She complains of passing dark-colored urine for the past 2 days. She has had no exposure to blood products, has no history of intravenous drug use, and has no significant risk factors for sexually transmitted disease. On examination, she looks acutely ill. Her pulse is 100 beats/minute, blood pressure 110/70 mm Hg, respirations 18, and temperature 101°F. Her sclerae are icteric, and her liver edge is tender

Hepatitis A

39-year-old woman after total thyroidectomy for papillary carcinoma of the thyroid is noted to have carpal spasm when her blood pressure is taken and facial muscle contractions with tapping over the facial nerve. You also note increased deep tendon reflexes along with perioral paresthesia. Lab work reveals decreased serum calcium, decreased parathyroid hormone, and elevated serum phosphate. On EKG there is a prolongation of the QT interval

Hypoparathyroidism

35-year-old woman presents with severe left hip pain. She was sitting in the passenger seat of a car when the car was hit head-on by another vehicle. On physical exam, she has significant pain and deformity in her left hip. She is unable to move her hip or bear weight. She is neurovascularly intact distally. Her left hip is adducted, flexed, and internally rotated

Hip Dislocation

67-year-old male who arrives at your emergency department for pain in his right leg. The patient was reaching for a box of cereal when he fell from a small footstool. He experienced immense pain in his right leg and presented to the emergency department shortly thereafter. The patient has a past medical history of osteoporosis and diabetes mellitus managed with insulin and metformin. On physical exam, you note a shortened, externally-rotated right lower extremity

Hip Fracture

25-year-old woman presents to the ER after a syncopal episode. She had a loss of consciousness 3 times over the past 12 months. Each event occurred during orjust after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and an III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage

Hypertrophic Cardiomyopathy

24-year-old male presents with a cough and mild shortness of breathfor three days. The cough is occasionally productive of yellowish mucus. He reports a low-grade fever with this episode but says that he has otherwise been healthy. He has spent the last monthworking in bat caves in the Ohio and Mississippi River Valleys. He denies tobacco or alcohol use. Laboratory findings reveal worsening pancytopenia and liver function. A chest radiograph demonstrates diffuse, fine, nodular interstitial prominence and superior mediastinal widening. On admission, a CT scan of the chest revealed diffuse miliary pulmonary infiltrates without mediastinal mass or lymphadenopathy

Histoplasmosis

35-year-old male with a family history of Huntington's disease is brought by his wife who reports that the patient has had noticeable behavioral changes (personality, cognitive and intellectual) as well as new rapid, involuntary movements of his face, neck, trunk, and limbs

Huntington's Disease

Premature infant who is born at 32 weeks and after several hours develops rapid shallow respirations at 60/ min, grunting retractions, and duskiness of the skin.The chest X-ray reveals diffuse bilateral atelectasis, ground glass appearance, and air bronchograms

Hyaline Membrane Disease

healthy newborn male is undergoing routine examination, upon examination of the genitalia the urethral meatus is found located proximal to the tip of the glans on the ventral aspect of the penile shaft

Hypospodiasis

62-year-old female complaining of joint pain, polyuria, polydipsia, and generalized fatigue. The patient reports a history of recurrent kidney stones and depression. Radiographs show osteopenia and subperiosteal resorption on the phalanges (bones, stones, abdominal groans, and psychic moans).

Hyperparathyroidism

34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite. On physical exam, you note exophthalmos and pretibial myxedema. She has a pulse of 110, a fine tremor, and 4+ deep tendon reflexes. Her hair is fine in texture and you note a palpably enlarged thyroid gland

Hyperthyroidism

25-year-old male who is being seen for an immigration physical. On physical examination, you note delayed secondary sexual characteristics - childlike voice, bilateral gynecomastia, minimal axillary hair, small testes 3 MLS, and a small penis ( < 1 cm). The patient is normotensive (BP 110/70), weight 74.8kg, height 160.7 cm, BMI 29. When questioned, he reports a lack of early morning erection. No history of tiredness or blurred vision. Laboratory investigation reveals a 9 am testosterone 2.8 nmol/L (8-30), LH 37 U/l, FSH 30.1 U/l, Prolactin - 96 mIU/L, 9 am cortisol - 374 nmol/L, T4 13.19 pmol/L, and TSH 1.3 mU/L. A chromosomal analysis reveals a 47 XXY, compatible with Klinefelter's syndrome. MRI of the pituitary demonstrates a small pituitary, no mass lesion seen

Hypogonadism

43-year-old female with complaints of increased fatigue and a 10-lb weight gain over the last 2 months. She states that she "feels cold" all the time, has decreased energy, and is experiencing worsening constipation. She has also been having heavy periods. On physical exam, her pulse is 45/minute, her skin is dry and cold, and her eyebrows are thinned. You notice delayed deep tendon reflexes. Routine blood tests demonstrate a TSH level of 9.5 uU/mL (normal 0.35 to 5.0 uU/ml) and Thyroxine (T4), serum: 9.8 ug/dL (normal 5-12 ug/dL)

Hypothyroidism

40-year-old woman who comes to your office with a several-year history of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between abdominal pain and specific food intake. On physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize

IBD

30-year-old obese white female presents with fatigue and generalized weakness for several weeks. Physical exam reveals pale nail beds, spoon nails, mucosal pallor,and an atrophic tongue. Upon further questioning, the patient reveals a "craving for ice and inanimate objects." Laboratory data shows a microcytic, hypochromic appearance to the RBCs, an elevated TIBC, low serum iron of 16 µg/dl, and low plasma ferritin of 12 µg/dl.

IDA

42-year-old male complaining of easy bruising and gingival bleeding.He reports his symptoms began one day prior to presentation and has never occurred before. Medical history is significant for a recent diagnosis of hepatitis C infection. On physical exam, there is mild bleeding of the gums. There are petechiae throughout the chest, arms, and legs.There is no evidence of splenomegaly on the abdominal exam. A complete blood count is significant for a platelet count of 24,000/μL (normal 150,000 - 400,000/μL) and peripheral blood smear demonstrates enlarged platelets. He has a + Direct Coombs Test. He is started oncorticosteroids

ITP

55-year-old female who is a current smoker presents with a 9-month history of respiratory symptoms, including dyspnea on exertion, thoracic pain and dry cough, which were preceded by a pulmonary infection. On auscultation, you hear inspiratory crackles.Pulmonary function tests (PFTs) show only mild impairment of vital capacity with decreased lung volume and a normal to increased FEV1/FVC ratio

Idiopathic Pulmonary Fibrosis

Breastfeeding woman 3 weeks postpartum complaining of a painful area of the breast that is reddened and warm. The patient feels very fatigued with a fever generally > 101 ° F and chills. She reports a burning pain present constantly or at times only while breastfeeding. On exam, the patient appears ill. Breast examination shows an erythematous right breast with a palpable mass, induration, erythema, and tenderness to palpation

Infectious Mastitis

33-year-old G1P0 female with difficulty becoming pregnant. She and her husband have been trying to conceive for over 12 months, but have been unsuccessful. She reports menarche at age 15 and has had regular periods since then. Her past medical history includes an abortion at age 20 with dilation and curettage procedure. She has also had a pelvic inflammatory disorder, treated successfully with antibiotics

Infertility

5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgia, especially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes

Influenza

43-year-old who has recently noticed bright red blood on the toilet paper when he wipes. He denies any fatigue, decreased exercise tolerance, abdominal pain, or maroon-colored or black, tarry stools. He has no family history of colon cancer. He has never had a colonoscopy. On physical exam, his temperature is 98.6 F, heart rate 70/min, and blood pressure 120/75 mmHg. He does not have conjunctival pallor. There are no abnormalities on cardiac, pulmonary, and abdominal exams

Internal Hemorrhoid

71-year-old male with a history of atrial fibrillation with a sudden onset of severe abdominal pain occurring 10 minutes after eating. Physical exam findings are relatively benign, and the patient has only minimal pain with palpation of the abdomen. Stool guaiac is positive and blood tests reveal leukocytosis with elevated lactate, amylase, and LDH

Ischemic Bowel Disease

14-year-old with complaints of morning stiffness and fatigue for the past 3 months. She complains of worsening stiffness after periods of inactivity and finds it difficult to participate in sports, especially PE. Her mom is particularly concerned because her daughter has been missing school and this has begun to affect her academic performance. They are requesting a medical note to be dismissed from physical education

Juvenile Rheumatoid Arthritis

23-year-old male who is the front seat passenger in a motor vehicle accident. There is a noticeable deformity in his knee. Examination reveals an inability to extend the knee and weak foot pulses. After unsuccessful attempts at closed reduction, it is noted that the pulses are no longer palpable and the foot is cool

Knee Dislocation

25-year-old soccer player injures his knee after colliding with an opposing player during a game. On physical exam, his Lachman is weakly positive. He has laxity to varus stress with the knee flexed to 30 degrees. Dial test of the tibiashows increased external rotation at 30 degrees, but not at 90 degrees in comparison to the contralateral leg

LCL Tear

27-year-old female who has been experiencingpostprandial bloating, flatulence, diarrhea, and abdominal pain for one year. Symptoms occur following the ingestion of milk products

Lactose Intolerance

71-year-old male with abdominal distension and colicky pain. Physical exam reveals high-pitched bowel sounds and diffuse abdominal tenderness. The abdominal radiograph demonstrates a distended proximal colon with haustra, air -fluid-levels and no gas in the rectum

Large Bowel Obstruction

60-year old caucasian male with shortness of breathand fatigue on exertion. On physical exam, you note an S3 heart sound, crackles on pulmonary auscultation, and a displaced left apical impulse. He undergoes an echocardiogram and is found to have a dilated left ventricle and an ejection fraction of 35%

Left Ventricular Heart Failure

39-year-old African American woman with abnormally heavy menstrual bleeding along with increased pelvic pressure. She denies pain and is not using any hormonal contraception. She uses multiple sanitary pads per day. On pelvic examination, there is an enlarged uterus with asymmetric contours. The uterus is non-tender to palpation

Leiomyoma

68-year-old woman presents to the emergency department due to fatigue, malaise, and subjective fever. Her symptoms began approximately 1 week ago. Medical history is significant for small cell lung cancer recently treated with doxorubicin plus cyclophosphamide and etoposide. Her temperature is 102°F (38.9°C) and blood pressure is 100/80 mmHg. A complete blood count with differential is remarkable for an absolute neutrophil count of 320 cells/mm3. She is admitted to the hospital and administered intravenous cefepime

Leukopenia

2-year-old female with a history of cirrhosis secondary to long-standing alcohol abuse visits your office to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice, and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks

Liver Neoplasm

65-year-old woman with a 40 pack-year history of smoking presents with a 7kg weight loss over the last 3 months and recent onset of streaks of blood in the sputum. PE reveals a thin, afebrile woman with clubbing of the fingers, an increased anteroposterior diameter, scattered and coarse rhonchi and wheezes over both lung fields, and distant heart sounds

Lung Cancer

26-year-old college football player is brought to the emergency department after being hit on the lateral side of the left knee. He reports hearing a pop and then his knee buckled. He is now in severe pain and is having difficulty walking. On examination, there is swelling over the medial aspect of the left knee. There is laxity when a valgus stress test is performed on the knee. The results of the Lachman and McMurray tests are negative

MCL Tear

33-year-old woman complaining of fatigue and decreased interest in "the things that used to make me happy." She is sleeping less and eating less, and she says that she is forcing herself to eat "because I know I have to eat something." She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she used to have

Major Depressive Disorder

21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department.

Mallory-Weiss Tear

6-year-old child who is brought to the emergency room for a complaint of high fevers and a rash. His mother reports that she thought he had "just a cold" approximately one week ago—he had a mild fever, runny nose, conjunctivitis, and cough. Then he developed a rash that started on his face and gradually spread downward. The child has no significant past medical history, however, he was adopted from Russia at age 5, and his medical history prior to adoption is unknown. On examination, the child appears lethargic and has a temperature of 104.3. There is a mild injection of his conjunctiva and a generalized macular rash. White macules are noted on his buccal mucosa

Measles (Rubeola)

5-year-old boy who presents to his pediatrician with headache, nausea, and 2 episodes of emesis. His symptoms began approximately 1 month ago and his headache is most prominent in the morning. The patient also reports some mild fevers and chills. On physical exam, the patient has a wide-based gait with impaired heel-to-toe walking. Fundoscopy demonstrates bilateral papilledema. An MRI brain with intravenous contrast demonstrates a heterogenous midline lesion with hydrocephalus

Medulloblastoma

34-year-old man who is brought by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights. His temperature is 103.1° F, blood pressure is 134/82 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs

Meningitis

35-year-old man with complaints of swelling and pain in the left knee. The patient states that he sustained a twisting injury in a football game 3 days ago. The injury did not take him out of the game; he was able to continue participating with minimal difficulty. Over the last 2 days, the pain has progressed. He notes a catching sensation and pain that is more medially located. On physical examination, the patient is found to have tenderness over the medial joint line and limited range of motion. Forced flexion and circumduction of the joint cause a painful click

Meniscal Tear

52-year-old female with no menses for 12 months she also complains of hot flushes and dyspareunia

Menopause

25-year-old female who comes to your office with a 3-year history of recurrent headaches that have gotten worse during the past year. These headaches occur approximately twice per week. She is concerned that she may be having some kind of stroke because before the headache, nausea, and severe vomiting begin, she experiences a "type of odd visual feeling or sight—flashing lights, almost like a pattern in front of my eyes." With respect to the headache, it usually lasts 24 to 36 hours. It is throbbing in nature and often "switches from one side to the other" with each attack. She needs to be in a dark room and finds noise bothersome when she has these headaches

Migraine

46-year-old woman complains of severe episodes of headache, tremulousness, palpitations, and anxiety. The patient has noted a change in her voice and she has difficulty swallowing solids. On PE there is a palpable, nontender swelling in the front of her neck that moves with deglutition. There is no cervical lymphadenopathy. Lab studies show hypercalcemia. An X-ray of the cervical region shows irregular calcifications in mass, while an MRI of the abdomen shows confirms the presence of bilateral adrenal lesions

Multiple Endocrine Neoplasia

69-year-old female with a history of hypertension and fibromyalgia complaining of one month of intermittent chest pain, mild nonproductive cough, dyspnea on exertion, and a 22 lb weight loss over 4 months. Complete blood count revealed a macrocytic anemia with a mean corpuscular volume (MCV) as high as 108, with normal cobalamin and red blood cell folate. Coombs testing was negative, and her levels of lactate dehydrogenase (LDH), haptoglobin, and unconjugated bilirubin were normal. The peripheral blood smear showed dysplastic changes in all hematopoietic lineages including hypogranulation and hypersegmentation of the neutrophils and rare teardrop-shaped red cells, prompting a bone marrow evaluation.

Myelodysplasia

64-year-old man comes to the emergency department because of chest discomfort for the past 5 hours. When the patient is asked where the pain is located, he places a clenched fist to indicate a squeezing over his substernal region. The pain radiates to the neck, left shoulder, and left arm. His temperature is 36.8°C (98°F), pulse is 55/min, respirations are 17/min, and blood pressure is 117/78 mm Hg. The examination shows a diaphoretic male. ECG shows inverted U-waves in leads V5 and V6. The cardiac biomarker test shows an elevated concentration of troponin

NSTEMI

14-year-old male with dyspnea, wheezing, and urticaria. His symptoms developed approximately an hour after eating at a restaurant. Medical history is significant for asthma and a severe allergic reaction to peanuts and shellfish. Airway, breathing, and circulation are intact. Patient is started on intramuscular epinephrin

Nut Allergy

29-year-old field worker with a rash on his nails. The patient has a history of tinea pedis and tinea manuum and thought that this might be related. On physical exam, mild paronychia, loss of the cuticle of some nails, dirt-like yellowish-green nail pigmentation, subungual debris, and dystrophy of some nails is seen

Onchomycosis

15-year-old who back talks and resists following instruction from parents or authorities

Oppositional Defiant Disorder

31-year-old male complaining of unilateralscrotal swelling with pain radiating to the ipsilateral groin. Examination reveals a tender swollen testicle, scrotal edema witherythema, and shininess of the overlying skin

Orchitis

71-year-old man with a history of BPH who is hospitalized for an ST-elevation myocardial infarction and undergoes percutaneous coronary intervention. Upon discharge, he is prescribed aspirin, clopidogrel, prazosin, isosorbide mononitrate, carvedilol, enalapril, and atorvastatin. One week after discharge he presents to your office with complaints of faintness, lightheadedness, dizziness, confusion, and blurred vision that occur within seconds to a few minutes of standing and resolve rapidly on lying down. On physical examination, you note a drop of > 20 mm Hg systolic and 10 mmHg diastolic after a change from supine to standing

Orthostatic Hypotension

14-year-old boy with left knee pain. He denies any trauma to the knee. The patient runs cross country for his high school team and attends practice regularly. On physical exam, the tibial tubercle is pronounced and there is tenderness to palpation over the affected area. The patient reports pain upon resisted knee extension

Osgood-Schlatter Disease

65-year-old woman with left knee pain. The pain has been present in both knees for approximately 5 years and has been steadily getting worse. She describes stiffness, sticking and grinding of the right knee. Over the last 2 weeks, she has been taking ibuprofen almost every day, requiring an increasing frequency of doses for adequate pain control. On physical exam, there is swelling of the right knee and tenderness to palpation. There is palpable crepitus

Osteoarthritis

54-year-old male with fever, chills, and pain in the left foot. His symptoms progressively worsened over the course of a week. Medical history is significant for poorly controlled type II diabetes mellitus. On physical exam, there is tenderness to palpation of the left foot. Laboratory testing is significant for an elevated erythrocyte sedimentation rate and C-reactive protein; as well as, a leukocytosis. Plain radiograph demonstrates periosteal thickening and soft tissue swelling

Osteomyelitis

61-year-old white postmenopausal woman who comes to your office for a routine health examination. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, she weighs 115 pounds and she is not currently taking calcium supplements

Osteoporosis

66-year-old woman who complains of abdominal fullness, bloating, fatigue, and weight loss. She underwent menopause 17 years ago and has never had children. She had a pelvic mass but her PAP smear is atrophic. A pelvic ultrasound is performed

Ovarian Cancer

22-year-old nulligravida presents with pelvic pain and irregular menstrual bleeding. She denies sexual activity, and her β-hCG urine test is negative. She has never been on oral contraceptives. On pelvic examination, unilateral tenderness on the left side and a palpable cystic mass approximately 4 to 5 cm in size are present

Ovarian Cyst

23-year-old female comes to the emergency department because ofsharp, non-radiating, left lower quadrant pain that has worsened in intensity over the last three hours. She has nausea but denies diarrhea, urinary symptoms, or vaginal discharge. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 140/90 mmHg. Pulse oximetry in room air shows an oxygen saturation of 98%. Physical examination shows left lower quadrant tenderness with guarding. Pelvic examination shows left adnexal tenderness without cervical motion tenderness or discharge. A urine pregnancy test is negative. Doppler ultrasound of the left lower quadrant is obtained

Ovarian Torsion

78-year-old woman, G5P5, who presents to establish care. She is healthy and denies any additional problems. However, when specifically asked, she admits to having urinary incontinence for several years and reports that symptoms have recently worsened. The patient experiences the need to void almost hourly and she now uses four to five adult incontinence pads per day to manage the urine she leaks. She has had occasional accidents while asleep at night as well. She denies leaking urine with coughing or sneezing

Overactive Bladder (Urge Incontinence)

67-year-old man comes to the clinic because of urinary incontinence with the frequent loss of small amounts of urine for the past 2 weeks. He describes having difficulty initiating urination or telling when or if his bladder is full or empty. He denies frequency, urgency, or bowel dysfunction. Past medical history is significant for stroke 1 year ago in addition to hypertension and coronary artery disease. Past surgical history is significant for lower back surgery one month ago after a car accident. Physical examination shows decreased sphincter tone and 110 ml of post-void residual urine. Diagnostic tests show normal bladder capacity, no sign of infection, normal prostate-specific antigen levels, and normal creatinine

Overflow Incontinence

22-year-old recreational soccer player who sustained a right knee injury 6 months ago. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee "giving way." Physical exam reveals 10° varus alignment when standing and a varus thrust with walking. Strength is full compared to the other side. Ligamentous exam reveals a stable ACL and MCL but opens to a varus stress and a 3+ posterior drawer and positive dial test at both 30° and 90° degrees of flexion.

PCL Tear

13-year-old girl who is overweight has her first menses at age 13 and then has no menses until she is 16 and then has another menstrual period 6 weeks later. Ultrasound shows enlarged cystic ovaries with a string of pearls on ultrasound. LH to FSH ratio is 3:1

PCOS

2-week-old infant with a history of prematurity presents with a pink torso and upper extremity and blue lower extremities. On cardiac auscultation, you notice a rough, continuous "machinery murmur" heard over the left sternal border at the 2nd intercostal space (pulmonary area)

PDA

27-year-old female who comes to the emergency department with a 2-day history of lower abdominal pain, fever, chills, and malaise. The patient also complains of nausea and multiple episodes of vomiting in the past 24 hours. On physical examination, there is bilateral adnexal tenderness, mucopurulent cervical discharge, and cervical motion tenderness

PID

72-year-old man presents to the emergency department after a fall outside of church. He complains only of left hip pain which has been progressively worsening for the past six months. He denies hitting his head during the fall, but according to his wife, he has been complaining of worsening headaches. His temperature is 98.6°F (37°C), blood pressure is 110/60 mmHg, pulse is 80/min, and respirations are 18/min. Examination of the right lower extremity reveals mild crepitus at the hip, appropriate range of motion, adequate distal sensation, and palpable posterior tibial and dorsalis pedis pulses. A review of his laboratories reveals a serum alkaline phosphatase level that is markedly elevated

Paget Disease

68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable non-tender gallbladder and clay-colored stool. Labs show total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150

Pancreatic Neoplasm

37-year-old male complaining of rapid onset of severe mid-epigastric pain with radiation to the back after eating a large meal. The pain typically lessens when the patient leans forward or lies in the fetal position. Physical exam shows low-grade fever, epigastric tenderness, diminished bowel sounds, and bruising of the flanks. An abdominal CT scan shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity

Pancreatitis

30-year-old male who arrives at your ED in distress stating that he had " a heart attack." The event started suddenly and was associated with diaphoresis, chest pain, tachycardia, and tachypnea. Troponins and ECG are within normal limits. Upon further questioning, he reports some numbing around his lips and that he has such episodes every few days for the past three months. The attacks have become so severe that he has been missing work and didn't go to last week's Christmas party. He denies recreational or illicit drug use. He further shares that he recently divorced and has had no social support. Recent lab results have all been normal or within standard limits, including TSH and vitamin B12

Panic Disorder

51-year-old male with involuntary movements of the left hand, which occur only at rest. The symptom has been obvious to his wife for two months. Exam reveals a resting tremor, a significant lack of arm movement while walking, and cogwheeling of the shoulder joints with passive ROM

Parkinson Disease

32-year-old female with a painful index finger. She obtains regular manicures, changing colors every 2 weeks. She recently had one a week ago and started feeling pain near the nail on her left index finger. Physical exam reveals redness, warmth, and pain along the nail margin of the index finger. When applying pressure to the nail plate, some pus drains from the nail. She is prescribed frequent warm soaks with chlorhexidine and oral antibiotics

Paronychia

39-year-old female who sustained a knee injury after falling from a step ladder onto her flexed knee. On physical exam, there is a palpable patellar defect, significant hemarthrosis and she is unable to extend the knee

Patella Fracture

22-year-old college basketball player with chronic anterior pain of her right knee. The patient has had over 6 months of physical therapy without improvement. It initially only bothered her during training, but she is now no longer able to compete and has pain with daily activities. Physical exam reveals swelling of the anterior knee and tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at distal pole of the patella in full flexion

Patellar Tendinitis

27-year-old female presents with knee pain. Her pain worsens when she is running downhill or climbing up the stairs. She describes the pain as "achy" and being behind the knee. When sitting for long periods of time, she reports her knees feeling stiff. She denies any recent history of trauma and has never had surgery. She has tried multiple over-the-counter analgesics but were not effective. She is a registered dietician and an avid runner who is preparing for a marathon

Patellofemoral Pain Syndrome (PFPS)

63-year-old uncircumcised male with a painless lump on the head of his penis. Over the last two weeks the lesion has been increasing in size and three days ago he began to notice a new foul-smelling discharge. On physical examination, you notice a 2 cm lesion on the prepuce and palpable inguinal lymphadenopathy

Penile Cancer

2-year-old man who presents to the emergency department with severe penile pain after hearing a "snapping" while having sex. On physical exam, the penis is very tender to palpation, s-shaped, and there is swelling and ecchymosis. Urology is immediately consulted

Penile Fracture

4-year-old boy with a severe cough followingone week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by a deep inspiration, and occasional post-tussive emesis

Pertussis (Whooping Cough)

57-year-old man with a history of prostatitis and complaints of anxiety related to penile pain and erectile difficulties. The patient is having pain at rest and the pain is worse on erection, not relieved by medications. Also, the patient reports dorsal curvature of the penis on erection. On examination, there was a thick circumferential plaque at the level of the coronal sulcus extending distally for 2 cm onto the glans dorsally and 4 cm onto the shaft of the penis dorsally with a maximum width of 4 cm

Peyronie Disease

2-month-old infant with blond hair, blue eyes, and fair skin. He has microcephaly and progressive impairment of cerebral function. On physical examination, you notice an eczematous rash and the patient is vomiting. In addition, he has a musty, mousy odor

Phenylketouria (PKU)

A lab technician calls to tell you that a 22-year-old man you have sent for a blood draw is very anxious. He says he is terrified of having his blood drawn and almost faints at the sight of the needle

Phobia

35-year-old female who presents to the ED for the sixth time within the past three months this time complaining of a fall from her front porch stairs. On physical exam, you not bruises on her arms and legs in various stages of healing. She is accompanied by her partner who remains closely by her side and insists on answering all questions. The patient maintains very poor eye contact. Upon review of her chart, you note that she has been seen several times over the past year for a broken right arm and recurrent urinary tract infections, abdominal pain, and chronic headaches

Physical Assault

3-year-old male who is brought to your office by his mother who is concerned that he is not growing appropriately. Physical examination is notable for frontal bossing and shortened upper and lower extremities. His axial skeleton appears normal. He is at the 4th percentile for height and 95th percentile for head circumference. He demonstrates normal intelligence and is able to speak in three-word sentences. He first sat up without support at twelve months and started walking at 24 months. Labs reveal decreased GH and decreased IGF 1

Pituitary Dwarfism

32-year-old man with a two-week history of fever and dry, nonproductive cough. For the past five days, he has been having shortness of breath. There is no history of pleuritic chest pain or rigors. Past medical history is significant for HIV. His temperature is 100.4°F (38°C), the pulse is 92/min, O2 saturation is 92%, respirations are 18/min, and blood pressure is 120/70 mmHg. Purified protein derivative (PPD) is negative. CD4 cell count is 190. The chest exam reveals bibasal crackles. The chest radiograph shows interstitial infiltrates bilaterally. The patient's condition worsens on levofloxacin

Pneumocystis

58-year-old female who returns to the hospital with chest pain and difficulty breathing several weeks after being discharged following a myocardial infarction requiring immediate cardiac catheterization. She has been coughing up frothy sputum for the past three days. The patient complains of a sharp pain that worsens during inspiration. Physical exam reveals decreased tactile fremitus, dullness to percussion, and diminished breath sounds on the left side

Pleural Effusion

53-year-old man presents to the office complaining of progressive dyspnea over the past few years. History reveals that he has worked in construction for the past 20 years demolishing and refurbishing old buildings. He rarely uses any protective breathing equipment. Physical examination demonstrates an afebrile man in mild respiratory distress with inspiratory crackles. The chest x-ray reveals a reticular linear pattern with basilar predominance, opacities, and honeycombing.

Pneumoconiosis (asbestosis)

45-year-old male with generalized symptoms such as malaise, fever, sore throat, and joint and muscle aches and pains. He also complains of numbness, tingling, sensory disturbances, and weakness. On physical examination, you notice the presence of tender lumps under the skin, especially on the thighs and lower legs. Laboratory testing is notable for a newly elevated creatinine of 2.6 mg/dL, erythrocyte sedimentation rate, and C-reactive protein. He is also seropositive for hepatitis B virus, ANCA-negative, and guaiac positive

Polyarteritis Nodosa

62-year-old female presents to the emergency room with complaints of severe, whole-body itching. She states that she first noticed her symptoms while in the bathtub at home. She has never had symptoms like this before. However, over the previous several months she has had episodes of severe joint swelling and pain in her hands as well as redness, burning pain, and swelling of her hands and feet. Her past medical history is significant for type II diabetes mellitus, hypertension, and osteoporosis for which she takes metformin, enalapril, and alendronate, respectively. In addition, she was found to have a deep vein thrombosis of her right leg five months prior to presentation. The patient's temperature is 98.6°F (37.0°C), the pulse is 80/min, blood pressure is 135/85 mmHg, and respirations are 13/min. Physical exam is notable for a woman in discomfort with excoriations over the skin on her forearms. The patient's laboratory tests demonstrate elevated RBC count, hemoglobin, and hematocrit of 54%, leukocytosis with a WBC count of 19,000 cells/mm^3 with normal differential, and thrombocytosis with a platelet count of 900,000/mm^3.

Polycythemia

62-year-old female complaining of headaches, muscle pain, and weakness. She has no history of headaches but has now started experiencing them every morning for the past two weeks. She reports feeling very weak and tired in the mornings and cannot even raise her arms to brush her hair. Physical exam shows that she has normal strengthand a normal range of movement. Passive range of motion is limited in all directions and she has difficulty rising out of the exam room chair. Erythrocyte sedimentation rate is elevated

Polymyalgia Rheumatica

47-year-old female with a complaint of feeling unusually tired and weak. She works as a hairstylist and in the past few weeks has experienced difficulty performing her job. She finds it difficult to work while she has her arms raised. She denies any fevers, weight gain or loss, or any other motor deficits. Physical exam reveals decreased strength in her shoulders. No rash is appreciated. Laboratory evaluation reveals increased creatinine phosphokinase, positive antinuclear antibody, and positive anti-JO 1 antibodies. She is started on high-dose corticosteroids

Polymyositis

16-year-old male who sustained a concussion three weeks ago during his high school football game, since he has been experiencing headaches and dizziness that occur almost daily, he reports difficulty sleeping, fatigue, and sensitivity to light and noise

Postconcussion Syndrome

40-year-old carpet installer who spends his working day on his knees, fitting carpets. In the past few months, he had been aware of a dull ache over his right knee, which had seemed to be aggravated by pressure and on flexion of the knee. He had been wearing kneepads, using a soft mat, and trying to avoid kneeling on that knee. However, he was alarmed to wake one morning with a large, tender, fluctuant swelling over the kneecap

Pre-patellar Bursitis (Housemaids Knee)

25-year-old female who complains of abdominal bloating, headache, irritability, depression, poor sleep quality, and breast tenderness. These symptoms occur on a monthly basis 5 days before menses. Her symptoms greatly improve within 4 days of the onset of menses

Premenstrual Syndrome

25-year-old male presents complaining of extreme weakness, 20-lb weight loss, lightheadedness, and dizziness. On physical exam, he appears ill, and his blood pressure is 90/70 mm Hg. He has dark skin and hyperpigmented creases on his palms. Serum sodium is low, potassium is elevated; urea level and serum calcium are both elevated as well

Primary Adrenal Insufficiency (Addison's disease)

65-year old man who presents to the ED at 1 am with 90 minutes of central chest pressure that awoke him from sleep. He says he thinks he has 'indigestion.' The pain is non-radiating, with mild shortness of breath but no nausea, vomiting or diaphoresis. He is an ex-smoker with a 20 pack-year history. There is no previous history of CAD, diabetes, hypertension, or high cholesterol. On arrival, he looks well, with a normal heart rate (54 bpm), blood pressure (127/86), and oxygen saturation (98% on room air). His pain has improved slightly with sublingual nitrates in the ambulance, although he still has some ongoing chest discomfort. His ECG is shown below. Troponins are positive. He is admitted to the hospital and undergoes emergent cardiac catheterization, where he is without obstructive coronary disease, but his symptoms can be provoked with the administration of intravenous ergonovine

Prinzmetal Variant Angina

31-year-old woman who complains of irregular, infrequent menstrual periods. On further questioning, she complains of headaches, fatigue, and breast discharge. She takes ibuprofen only occasionally. The serum prolactin level is 380 μg per L

Prolactinoma

71-year-old male who presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back painover the past four months. He has also experienced weight loss and fatigue

Prostate Cancer

63-year-old man with a history of benign prostatic hyperplasia who reports 3-days of fever, chills, and pain with urination. He was recently catheterized during admission to the hospital. Physical exam reveals a tender and enlarged prostate on digital rectal exam. Urinalysis reveals pyuria and hematuria

Prostatitis

65-year-old man with pain in his right knee. He says he fell and "banged it up fairly bad" approximately 6 months ago but that it had since recovered spontaneously and provided no further trouble until now. He further said the pain does not get worse during the day, and if anything, it hurts more on awakening. His past history showed no hypertension, and he never had any other joint pain of significance. On examination, his temperature is 37.5 °C and his blood pressure is 125/70 mm Hg. He has an inflamed, tender, swollen right knee. No other joints are affected. No other abnormalities are found on physical examination. A plain radiographic examination of the right knee reveals streaking of the surrounding soft tissue with calcium deposits (chondrocalcinosis). You remove accumulated synovial fluid for polarized light microscopic analysis and also obtain a serum sample

Pseudogout

68-year-old woman who underwent hip replacement surgery two weeks ago. The postoperative period was complicated by pneumonia, and the patient has been bed-ridden ever since. A nurse calls you to the patient's room due to vital sign abnormalities and complaints of chest pain. The patient's HR is 105 bpm, BP is 90/60 mmHg, RR is 35 rpm, and T is 100.2F. You note jugular venous distension and profound dyspnea. Upon auscultation you notice tachypnea and crackles

Pulmonary Embolism

43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings (seen here) demonstrate peripheral "pruning" of the large pulmonary arteries

Pulmonary Hypertension

35-year-old female who was found to have a small (2.5 cm) pulmonary lesion on chest radiograph found incidentally after a screening exam for a positive PPD at work. The patient has no significant past medical history and is asymptomatic

Pulmonary Nodules

32-year-old female presents with fever, chills, nausea, and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts

Pyelonephritis

6-week-old first-born baby boy with projectile vomiting after feedings over the last 24 hours. Mom says that he enjoys feeding, and even after he vomits, he appears eager and hungry. On physical exam, you palpate an olive-shaped mass in the epigastric region at the lateral edge right upper quadrant. Labs show blood pH 7.47 and potassium of 3.2 mmol/L. On a barium upper GI series report, the radiologist states a "string sign" is present

Pyloric Stenosis

21-year-old male who three days after returning from a camping trip has developed fever, chills, myalgias, and headache. He then developed a rash on the wrists, ankles, palms, soles, and forearms that rapidly extended to the neck, axillae, buttocks, and trunk

RMSF

5-month old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, subcostal and intercostal retractions are noted. Expiratory wheezes and cough are present

RSV

23-year-old male with redness of the eye as well as discharge. He reports that he experiences pain with urination and stiffness and pain of the knee and ankle. With further questioning, he reports a history of gonorrhea infection that was diagnosed and treated approximately 5 weeks ago. He is otherwise healthy. On physical exam, there is conjunctivitis, asymmetric oligoarthritis, and discharge from the urethral meatus

Reactive Arthritis (Reiter Syndrome)

47-year-old man with severe rectal pain when he defecates. He has a fever of 102.2 F (39 C). On exam, there is perianal swelling, redness, and tenderness. A palpable mass is felt at the anal verge.

Rectal Abscess

50-year-old female with pelvic pressure reports and a sensation of a mass present in the vagina. She reports chronic constipation and a sensation that the rectum is not completely emptied following a bowel movement. Occasionally, she experiences episodes of fecal incontinence

Rectocele

58-year-old man complaining of several months of worsening shortness of breath and ankle swelling. He denies palpitations, lightheadedness, syncope, or chest pain. He has a past medical history significant for hereditary hemochromatosis. On physical exam, his temperature is 37 C (98.6 F), pulse is 78, blood pressure is 130/72 mm Hg, and respiratory rate is 16. He has elevated jugular venous pressure, diminished breath sounds at the lung bases, tender hepatomegaly, and bilateral pitting ankle edema. There are no murmurs, rubs, or gallops. EKG shows low-voltage QRS complexes without any signs of ischemia. His chest x-ray shows a normal-sized heart and bilateral pleural effusions. Echocardiography showssymmetrical thickening of the left ventricle, normal left ventricular volume, and mildly reduced systolic function

Restrictive Cardiomyopathy

3-year-old child presents strabismus. His mother notes that sometimes of family photographs it appears that one eye is white while the other is red

Retinoblastoma

30-year-old woman presents with 2 weeks of arthralgias, migrating from distal to proximal joints. It began with increased warmth and erythema in her right ankle and left knee. She has a low-grade fever and reports a history of sore throat and swollen glands about 1 month ago. On physical exam she has red skin lesions on the trunk and proximal extremities, and also small, non-tender lumps located over the joints. Antistreptolysin O titer is positive

Rheumatic Fever

36-year-old woman who comes to your office with a 6-month history of malaise, paresthesia in both hands, and vague pain in both hands and wrists. She also has felt extremely fatigued. She tells you that the pains in her joints are much worse in the morning and improves throughout the day. She is also beginning to notice pain and swelling in both knees. The patient has a normal family history, with no significant diseases noted. She is taking no drugs and has no allergies. On examination, vital signs are normal. There is a sensation of bogginess and slight swelling in both wrists and multiple metacarpophalangeal joints. Both knees also feel somewhat swollen and boggy. There are no other joint abnormalities, and the rest of the physical examination is normal. Rheumatoid Factor and Anti-citrullinated peptide antibodies are positive

Rheumatoid Arthritis

5-year-old boy is brought by his parents due to poor growth, weakness, and abnormal gait. On physical exam, there is bowing of the legs and tenderness upon palpation of the lower extremity. Laboratory testing is significant for decreased serum calcium and phosphate levels and elevated parathyroid hormone and serum alkaline phosphatase levels

Rickets secondary to vitamin D deficiency

64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes with increasing shortness of breathand ankle swelling over the past month. On physical examination, you note jugular venous distention, increased hepatojugular reflex, and hepatomegaly. His lungs are clear to auscultation

Right Ventricular Heart Failure

46-year-old white woman who presents with facial flushing that she notes is worse when she has her morning coffee and when she is stressed at work. Physical examination reveals the presence of localized facial erythema, telangiectasias as well as several scattered papules and pustules on her cheeks

Rosacea

57-year-old male presents with complaints of fatigue, nausea, and headache that have developed over the past several weeks. His past medical history is significant for hypertension, diabetes mellitus, CHF, and small cell lung cancer diagnosed and treated four years previously. Vital signs are as follows: T 37.3 C, HR 82, BP 142/86, RR 16, O2Sat 97% on RA. On physical exam, peripheral edema is absent, and he is alert and oriented to person, place, and time. Abnormalities noted on initial labwork include glucose 138 mg/dL and sodium 122 mEq/L. Follow-up testing reveals a urine osmolality of 310 mmol/kg and a serum osmolality of 268 mmol/kg; BUN and creatinine levels are within normal limits

SIADH

60-year-old woman with a severe drug-induced reaction on both lower limbs with few lesions elsewhere in addition to mucosal involvement of the mouth of two days duration. The insulting drug was sulfonamide and the onset of the rash was within 48 hours of taking the drug. The rash comprised of bilateral symmetrical bullae on a background of erythematous macules and patches in addition to erosions and peeling

SJS

60-year-old man is brought to the emergency department because of crushing substernal chest painfor the past 45 minutes. He received 325 mg of aspirin en route. Nitroglycerin does not relieve his pain. He has a history of diabetes and hypertension. Medications include carvedilol and sildenafil. His temperature is 36.8°C (98°F), pulse is 99/min, respirations are 18/min, and blood pressure is 192/88 mm Hg. He appears diaphoretic. ECG shows ST-segment elevation in leads V1, V2, and V3

STEMI

21-year-old bodybuilder presents with complaints of diarrhea, cramps, and low-grade fever for 24 hours. He has been training for a competition, eating large amounts of protein, including shakes made with raw eggs. He reports three thick green "pea soup" stools with blood in the commode today. He denies nausea or vomiting and tolerates liquids and solids. Examination reveals a well-muscled man in no apparent distress; lungs and heart unremarkable; abdomen, with mildly hyperactive bowel sounds and no tenderness or organomegaly; no evidence of hemorrhoids or anal fissure, no masses, and no stool present for hemoccult

Salmonellosis

43-year-old Caucasian male who spent the past month on a business trip in the Caribbean. Two weeks following his return, he began experiencing diarrhea, pain in his abdomen, and a headache. He presents to the hospital and is noted to be febrile with discrete, blanching, rose-colored spots on his back, chest, and abdomen

Salmonellosis

30-year-old African American female with a cough, fever, and generalized body aches. You order a CXR which shows bilateral hilar adenopathy

Sarcoidosis

24-year-old male presents with abrupt onset of swelling, pain, redness, and increased warmth in his right knee. He denies any injury or previous joint issues. The symptoms began yesterday along with generally not feeling well and possibly a low-grade fever. His past medical history is unremarkable. He takes no medications and has no known drug allergies. He denies tobacco use, consumes alcohol socially with no recent episodes of heavy drinking, and follows a vegetarian diet. He is sexually active with a recent new partner. On physical examination, T: 100°F, right knee is edematous and erythematous with increased warmth, and ROM decreased by pain. The left knee has no change in skin color or temperature with full pain-free ROM in flexion and extension. The examination of the hip and ankle joints is unremarkable. Right knee synovial fluid analysis reveals increased leukocytes and the absence of crystals

Septic Arthritis

9-year-old girl who you are seeing for a wellness checkup. The girl's past medical history is non-contributory, and she has met all her developmental milestones. Her parents were recently called into the office as the girl was found touching the genitals of one of her classmates. The girl is asked what has happened and what she thinks is going on but she is too shy to reply. The girl and her mother recently moved in with a family member. They live in low-income housing subsidized by the government and are currently on food stamps. The mother states that her daughter has been particularly argumentative lately and that they have gotten into arguments in which her daughter screamed at her and locked herself in the bathroom

Sexual Abuse

24-year-old G1P0 female at 16 weeks gestational age is in your office for a routine prenatal visit. When performing an antenatal psychological health assessment the patient admits that over the past six weeks her boyfriend has been increasingly violent towards her. On two occasions he has grabbed her forcefully and pressured her to perform oral sex against her will. When she spoke to a friend about this she was told to let it go, and that her boyfriend was just "under a lot of stress." She is visibly upset and asks you what she should do

Sexual Assault

23-year-old prison inmate was brought in from the detention clinic with a 3-day history of crampy abdominal pain and diarrhea. Patient reports the stools were small volume and bloody. On examination his abdomen is tender, he has decreased skin turgor, and the temperature was found to be 101.5°F (38.6°C). Stool microscopy reveals numerousRBCs and WBCs and a stool culture was ordered

Shigellosis

55-year-old female patient complaining of inability to eat completely due to loss of teeth. Along with that the patient also complains of dryness of mouth, for 1 year, and dryness of eyes for 7-8 years. Extraoral examination showed bilateral parotid gland enlargement present on the right and left side of the parotid region

Sjögren Syndrome

49-year-old man who is brought to your office by his partner, who is concerned about his daytime sleepiness. Last week, the patient fell asleep while stopped at a red light. She says that he snores loudly and sometimes stops breathing for a few seconds while sleeping. His past medical history is significant for hypertension. He has a 20-pack-year history of smoking. His temperature is 98.6 F, heart rate is 86/min, blood pressure is 148/98 mm Hg, respiratory rate is 12/min. On physical exam, he is obese. His lungs are clear and his lower extremity exam is within normal limits

Sleep Apnea

65-year-old female with diffuse abdominal pain and vomiting. She has not had a bowel movement in three days. PE reveals high-pitched, hyperactive bowel sounds, tympany to percussion, no rebound tenderness, and a temperature of 100.4 F. Abdominal radiograph reveals distended loops of bowel with a step ladder pattern of differential air-fluid levels.

Small Bowel Obstruction

50-year-old woman with a history of hyperlipidemia and diabetes type 2 complaining of "chest pain attacks." She says that these attacks tend to occur while walking up five flights of stairs to get to her apartment, they last for 15-20 minutes and are relieved by rest. She describes the pain as sharp and substernal. A baseline EKG is unremarkable. Suspecting the diagnosis, you perform an exercise stress EKG and observe transient ST depressions in the anterolateral leads after significant exertion

Stable Angina

68-year-old woman who presents to your office with leakage of urine when she sneezes, laughs, or coughs. She reports that these symptoms strictly occur during the day and never at night. She denies any subjective fever, dysuria, or hematuria. Pelvic examination is notable for a protrusion from the anterior vagina

Stress Incontinence

44-year-old physician with a history of alcohol abuse and depressionis transferred to the ER after being found on the floor of his apartment next to an empty bottle of oxycontin and a handle of whiskey. Prior to this event, he had been giving away large amounts of money and was very thorough in creating a will

Suicidal Behavior

2-week-old newborn brought to the ER by his mom who reports a sudden loss of consciousness during feeding and with crying. She also has noticed that the infant's lips have turned blue on three occasions during feeding. blood pressure is 75/45 mmHg, a pulse is 170/min, and respirations are 44/min. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. A CXR shows a small boot-shaped heart and decreased pulmonary vascular markings

TOF

44-year-old female with intermittent joint pain. The joint pain began about 13 months ago affecting primarily the joints in her hands, wrists, and feet. She expresses concern regarding worsening fatigue, muscle aches, and feelings of depression. The physical exam reveals tender, edematous bilateral wrists; painless oral ulcers; and erythematous maculopapular lesions on her face

Systemic Lupus Erythematous (SLE)

39-year-old female who reports that her fingers often feel very swollen and stiff and sometimes feel "stuck" in a bent position. She reports that for several months she has been getting a really cold, numb feeling in her fingers throughout the day, especially when she is sitting in the air conditioning at her office. Overall, she has just not felt well for the past few months either. When she eats, she has trouble fully opening her mouth to put food in. Then, when she lies down at night after dinner, she gets a feeling of heartburn and sometimes feels she has to vomit. However, she says she has been eating poorly lately, so it's probably her fault she hasn't felt well. Additionally, she reports losing 20 pounds in the past month without any lifestyle changes. Physical exam reveals tightened, shiny skin with induration over her face and arms, sclerodactyly, and dry rales in the lungs. There are also telangiectasias on her left cheek

Systemic Sclerosis - Scleroderma

34 yo F nurse presents with worsening cough of six weeks' duration together with weight loss, fatigue, night sweats, and fever. A recent HIV test was negative. A CT scan of the chest reveals a 3 cm lesion in the upper lobe of the left lung and calcification around the left lung hilus. A sputum smear was positive for acid-fast organisms

TB

60-year-old woman with a severe drug-induced reaction with extensive skin involvement covering > 30% of her body surface area. The insulting drug was anticonvulsant medication and the onset of the rash was within 10 days of taking the drug. The rash comprised of bilateral symmetrical bullae on a background of erythematous macules and patches in addition to erosion and peeling. On examination, her skin peels away in sheets when pressure applied and rubbed

TEN

25-year-old male presents with a headache. He describes the headache as a tightening, band-like quality on both sides of his forehead. It is non-throbbing, but feels like a "tight cap." He denies phonophobia or photophobia, nausea, or vomiting. On physical exam, you note pericranial muscle tenderness

Tension Headache

32-year-old male who noticed a mass on his right testicle while showering. He reports this has never happened before and denies any pain or discomfort. On physical examination, there is a firm and fixed mass on the left testicle

Testicular Cancer

15-year-old boy with severe lower abdominal pain that awoke him from sleep about 3 hours ago. The pain is sharp and radiates to the left thigh. While in the emergency room, the patient experiences one episode of vomiting. He denies any fever, dysuria, or chills. The mom reports a childhood history of cryptorchidism. Physical examination reveals normal vitals with blood pressure 100/60 and a temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender. Lifting of the left testicle does not relieve pain and there is a loss of a cremasteric reflex. Transillumination test is negative. Doppler ultrasound shows absent blood flow

Testicular Torsion

45-year-old homeless injection drug user with fever, painful muscle spasms in his arms and legs, and difficulty eating because of painful spasms in his jaw muscles. Examination of his feet reveals shoes with holes in the soles and a small, puncture-type wound on the bottom of the right foot. It is surrounded by erythema and somewhat tender to touch

Tetanus

10-year-old boy with a chief complaint of paleness presents to your office. On physical exam, you note conjunctival pallor bilaterally and he has splenomegaly. Lab data show these results: Hb: 8.5 (normal 12-17.5), MCV 72 (normal 80-100), MCH 22.5 (normal 25-34), WBC: 50,000, Plt: 650,000 (normal 150,000 - 400,000). Hemoglobin electrophoresisshows an increase in the amount of Hgb A2 and normal Hgb F.

Thalassemia

29-year-old physically active young man and previously in good health arrives via ambulance to the coronary care unit with a history of severe precordial pain associated with sweating for 30 min while at rest. He is a non-smoker with no family history of hyperlipidemia, diabetes mellitus, hypertension, or coronary artery disease. ECG shows significant ST-wave elevation in the inferior leads suggestive of myocardial infarction (ECG). Serial cardiac enzymes confirm this. Complete blood counts consistently show raised platelet count of more than a million (1.2-1.4 million/mm3). His hemoglobin is (Hb; 13.5 g/dl), white cell count (WCC; 10.6 × 103 µl, with normal differential count), mean cell volume (89 fl) and hematocrit (40) are normal. Other investigations, including erythrocyte sedimentation rate, plasma viscosity, C-reactive protein, iron profile, chromosomal analysis, and splenic ultrasonography, were normal. Bone marrow is hypercellular, with a marked increase of megakaryocytes and many of the large ones showing nuclear hyperlobularity. Bone marrow karyotype was normal.

Thrombocytosis

40-year-old woman who is otherwise healthy presents to your office complaining of a lump in her neck. On examination, she is found to have a firm 2-cm nodule associated with the left lobe of the thyroid gland

Thyroid Neoplastic Disease

37-year-old female with a 2-week history of a painful mass in her neck after having a sore throat and fever for 3 days. The patient reports the mass has slowly been enlarging over that time span and has become more painful to the touch. She also reports feeling hot, even when her coworkers feel cold, and reports loose stools over the past week. The patient's vital signs are T 98.6F, BP 140/90, Pulse 110 bpm, and SpO2 100%. On exam, you note a diffusely enlarged thyroid that is painful to the touch. Thyroid stimulating hormone (TSH) is decreased, T4/T3 is elevated, and radioactive iodine uptake and scan at 24 hours reveals an uptake of 3% (normal 8-25%)

Thyroiditis

28-year-old man who arrives in your ER complaining of severe right knee pain after falling from a ladder. The patient arrives in a wheelchair and physical exam is extremely difficult secondary to pain. AP, lateral and obliqueradiographs are performed

Tibial Plateau Fracture

25-year-old male who reports repetitive blinking and throat clearing along with "unusual" sounds, symptoms are chronic and have been present since first grade

Tourette Disorder

24-year-old man with ulcerative colitisreceives Lomotil for excessive diarrhea and develops a fever, abdominal pain and tenderness, and a massively dilated colon on abdominal x-ray.

Toxic Megacolon

59-year-woman who has been in the hospital for five days for a lower GI bleed. Six units of blood have been administered over that five-day period. On the sixth day, after receiving a unit of blood she became dyspneic and had severe back pain. The transfusion was discontinued. Her temperature is 101.3 F, BP is 100/60, and a HR of 120/min and RR of 20/min. A foley catheter was placed and is draining reddish-brown urine

Transfusion Reaction

27-year-old G1P0 woman at 36 weeks is brought to the ED after a motor vehicle crash. She was wearing her seatbelt when another car broadsided her vehicle. The airbag did not deploy and the patient denies any pain or discomfort. Her blood pressure is 112/80 mmHg, pulse is 116/min, respirations are 24/min, and SaO2 is 96% on RA. Fetal monitoring reveals contractions every 10 minutes the pulse is 165/min. One hour later, the nurse notices that the patient's bedsheet is soaked with blood. Transabdominal and transvaginal ultrasound reveal placenta previa. One liter of normal saline is infused through a large-bore IV, a type and cross-sample is obtained, and RhoGAM is prepared as the patient is rushed to the OR for emergent delivery

Trauma in Pregnancy

25-year old female traveling in Vietnam during summer break is hit by an oncoming moped driver while crossing a busy street. The patient is found by her friends in a small local clinic distraught, awake and confused. When asked what happened she is unable to recall but was told by the English-speaking doctor that she was carried to the clinic by the driver who hit her but he left before she regained consciousness. You notice blood around her right ear and her cheek is concave. There is a primitive x-ray machine available which demonstrates a fracture of the left zygomatic arch. You are very concerned and immediately hail a taxi to have your friends transferred to the nearest hospital

Traumatic Brain Injury

23-year-old G1P0 at 20 weeks gestation presents for a routine obstetric visit and complains of vaginal discharge for one week. She describes the discharge as watery and yellow, and she has had an associated burning sensation on urination. Her pregnancy has been uncomplicated. She denies new sexual partners or previous history of sexually transmitted diseases. On pelvic exam, there is a foul odor. You note red punctate lesions and inflammation of her cervix

Trichomoniasis vaginosis

32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points.

Ulcerative Colitis

58-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia who presents to an emergency department for evaluation of chest pain. He reports somewhat suddenly experiencing dull left-sided chest discomfort while at rest at home that was not relieved with taking nitroglycerin. His vital signs are T 37.1, HR 94 beats per minute, BP 133/87, and O2 saturation 97% on room air. His ECG shows no ST-segment changes; serum troponin is not elevated. His chest pain subsequently resolves and he is admitted to the cardiac service for further management

Unstable Angina

a mother of a 3-year old girl who is concerned because she saw blood in her daughter's underpants. The patient complains of no pain. Examination demonstrates a complete circular eversion of the distal urethral mucosa

Urethral Prolapse

56-year-old male with pain during urination, decreased urinary stream, and incomplete bladder emptying. Uroflowmetry demonstrates poor bladder emptying and a low peak rate of urine flow

Urethral Stricture

22-year-old heterosexual male who recently started having unprotected intercourse with his new girlfriend. He now reports a painful itching and burning sensation with urination and discomfort in the urethra. He says that sometimes in the morning it appears that the walls of the meatus are stuck together with evidence of dried secretions. On exam, there is no purulent discharge. The meatus does appear red. His girlfriend does not have any symptoms

Urethritis

63-year-old, G5P5, Hispanic woman with a three-day history of increased pelvic pressure and a "bulge" that is felt in her vagina when she coughs. Additionally, she complains of incomplete emptying of her bladder, constipation and has noticed a recent worsening of lower back pain

Uterine Prolapse

4-year-old boy who is brought to your office by his parents because he gets tired very easily and cannot keep up with the other children. On exam, you hear a loud, harsh, holosystolic murmur at the left lower sternal border without radiation to the axillae

VSD

62-year-old woman, gravida 4, para 4, complains of abnormal vaginal bleeding that occurs intermittently between her predictable menstrual cycles

Vaginal Cancer

46-year-old female following a hysterectomy who complains of something "brushing on her panties"

Vaginal Prolapse

1-year-old female with a temperature of 103.1 and irritability. A culture of a urine specimen is obtained and shows more than 106 colony-forming units of pansensitive Escherichia coli per milliliter. She is treated with intravenous ampicillin for several days, followed by oral ampicillin, for a total of 14 days of therapy. After the patient no longer had a fever and a urine culture was sterile, voiding cystourethrography was performed while the patient was still receiving ampicillin. The voiding cystourethrogram demonstrates bilateral grade III vesicoureteral reflux, and renal ultrasonography revealed normal findings

Vesicoureteral Reflux

28-year-old male who comes to your clinic with his wife. They have been trying to get pregnant for the past 24 months without success. The patient was told that he had a low sperm count with 'poor quality sperm. Examination reveals a scrotum that, on the right side only, is enlarged and feels like a 'bag of worms' on palpation. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum

Varicocele

2-year-old female comes to the emergency department for a syncopal episode. Just prior to the syncopal episode, the patient experienced painful menstrual cramping. She experienced a cold sweat and palpitations with the cramping. The patient describes similar episodes to her menstrual cramps in the past. Her vital signs and physical examination are normal. ECG is unremarkable

Vasovagal Hypotension

50-year-old female with vaginal itching, and irritation red/white ulcerative crusted lesions on the vulva

Vulvar Cancer

30-year-old woman with a recurrent history of nosebleeds and heavy menses. She recently read that taking a baby aspirin was good for the heart. However, ever since she started taking aspirin, she has been experiencing more and more nosebleeds. Her father and paternal uncle similarly have histories of prolonged nosebleeds. Labs show increased PTT, normal PT, and increased bleeding time

vWD