An asymptomatic 52-year-old computer programmer is diagnosed with stage T1 localized breast cancer.

Mr. S, a 74-year-old retired gas station owner with Alzheimer disease and coronary artery disease, is admitted with a stroke. An ECG also shows an acute myocardial infarction with many premature ventricular contractions.

Assume the same medical facts as in Case 10, but Mr. S has made no statements about his preferences for care. His wife and daughter believe that he would not want to receive continued intensive care after failing to improve from his stroke.

Assume the same medical facts as in Case 10, but Mr. S has made no statements about his preferences for care and has no family members. He has lived in a nursing home for several years and has no friends who visit him regularly.

Assume that Mrs. O, the 64-year-old retired grocery store owner with end-stage interstitial lung disease from Case 9, was intubated in the ED.

Assume that Mrs. O, the 64-year-old retired grocery store owner with end-stage interstitial lung disease from Case 9, is transferred out of the ICU with DNAR and DNI orders, based on the family reports of her previous statements.

A 58-year-old woman with dysphagia is found to have inoperable carcinoma of the esophagus. She realizes her poor prognosis and opts for palliation.

A 74-year-old man with severe Alzheimer disease is transferred from a nursing home for treatment for pneumonia.

Mr. D is a 72-year-old homebound man with multisystem failure admitted to a community hospital for pneumonia, a myeloproliferative disorder, and failure to thrive.

Mrs. M is 57-year-old machinist who has recurrent head and neck cancer that has progressed despite radiation and chemotherapy. She cannot swallow foods and secretions and has to sit upright at night to spit out her secretions

Mrs. M, the patient with head and neck cancer in Case 18, is found at home by her husband after a suicide attempt. She has ingested a combination of tricyclic antidepressants, barbiturates, and alcohol and has left a long explanatory note.

A 64-year-old man has inoperable pancreatic cancer and obstructive jaundice.

Mrs. O, the 64-year-old retired grocery store owner with end-stage interstitial lung disease from Case 9, has mechanical ventilation withdrawn based on evidence that she would not want such treatment.

A 34-year-old unemployed homeless man with acquired immunodeficiency syndrome (AIDS) (CD4 level 47) is admitted to your service with Pneumocystis carinii pneumonia. His IV has infiltrated, and you are asked to restart it.

Suppose your favorite uncle has been recommended to have coronary artery bypass and graft (CABAG) by his primary care physician and cardiologist in New York.

Recall the first time you did a lumbar puncture (LP) (or central line, major suturing, or other major procedure).

On a clerkship you observe what you consider unethical behavior by one of your attending physicians. On several occasions, his speech is slurred and you smell alcohol on his breath.

A 42-year-old man is admitted to you with diabetic ketoacidosis. After treatment with intravenous fluids and an insulin drip, the patient’s glucose declines from 745 to 289 mg per dl after 4 hours.

A 15-year-old high-school student comes to the physician because of dysuria and a discharge from his penis after intercourse without a condom.

A 10-year-old boy is taken to the ED with vomiting and right lower quadrant abdominal pain and is found to have appendicitis.

A 34-year-old grade school teacher is hospitalized after an automobile accident that ruptures his spleen. A devout Jehovah’s Witness, he refuses transfusion.

A 45-year-old sales clerk has a 1/2-cm breast mass that is found to be malignant on needle aspiration. With either mastectomy or lumpectomy plus radiation, she has an excellent chance of being cured of her cancer.

A 76-year-old retired teacher with a history of coronary artery disease is hospitalized after a syncopal episode. He is found to have ventricular tachycardia.

A colleague asks your advice on a difficult case. A 19-year-old college swimmer reveals that she has started to take anabolic steroids, which she obtains through friends at the gym where she lifts weights.

A 40-year-old auto mechanic is found to have a localized breast cancer, which is treated with lumpectomy and radiation.

A 72-year-old retired lawyer comes into the hospital with lower abdominal pain. He is found to have guaiac positive stools and anemia. You plan to do a colonoscopy, but the patient refuses.

Mrs. O, a 64-year-old retired grocery store owner with end-stage interstitial lung disease, presents to the emergency department for shortness of breath that began several days ago.

A 16-year-old boy arrives in a Texas hospital emergency room in a semiconscious state. He was transported there after collapsing during football practice.

A previously healthy 30-year-old man notices difficulty completing his usual exercise routine over the last 2 weeks because of excessive fatigue during the workout.

An 18-month-old boy, with a high fever and cough and with a history of frequent infections, is brought to the emergency department by his father. A blood examination shows elevated numbers of neutrophils but no other defects.

A 15-year-old girl sees her family physician for a routine school athletic physical. Upon routine examination, her physician detects a reasonably loud systolic murmur when placing her stethoscope parasternally around the second and third intercostal spaces, but her physical exam is otherwise unremarkable.

An 8-year-old girl was diagnosed with type 1 diabetes. Nausea and vomiting, symptoms of ketoacidosis, which is not uncommon, were accompanied by polyuria, polydipsia, polyphagia, weight loss, and blurred vision.

Recovering from a heart attack and fighting pneumonia, a 65-year-old Vietnam veteran was transferred from the VA hospital to the university hospital to be evaluated for surgery to repair his blocked arteries.

A 6-year-old boy is brought to the pediatrician by his mother because of a puffy face and lethargy. A few weeks before, he had an upper respiratory tract infection, probably caused by a virus.

A previously healthy girl presented at age 10 years with anorexia, abdominal distention, abdominal pain, vomiting, and severe constipation that failed to respond to large doses of laxatives.

It was mid-August in San Antonio, another week of consecutive greater than 90°F days with high humidity.

A 20-year-old male patient presented with lack of sexual development. On examination, he was eunuchoidal and hypogonadal, and olfactory function testing showed he was anosmic.

Al Martini, a 44-year-old male who has been an alcoholic for the past 5 years, has a markedly diminished appetite for food.

Amanda Tin (amanitin) picked mushrooms in a wooded area near her home. A few hours after eating one small mushroom, she experienced mild nausea and diarrhea.

Amy Biasis (“amoebiasis”), a 23-year-old missionary, was brought to the hospital emergency room complaining of the abrupt onset of fever, chills, and severe pain in the right upper quadrant of her abdomen.

Amy Lloyd (“amyloid”) is a 62-year-old woman who presents with weakness, fatigue, an enlarged tongue (macroglossia), and edema.

Anne Jeina is a 54-year-old woman who arrived in the hospital 4 days ago, approximately 5 hours after she began to feel chest pain.

Ann O’Rexia is a 23-year-old buyer for a woman’s clothing store. Despite the fact that she is 5 feet 7 inches tall and weighs 99 lb, she is convinced she is overweight.

Ann Sulin returned to her physician for her monthly office visit. She has been seeing her physician for over a year due to obesity and elevated blood glucose levels.

Anne Niemick is a 4-year-old girl of Mediterranean ancestry whose height and body weight are below the 20th percentile for girls of her age.

Arlyn Foma, a 68-year old male, complained of fatigue, loss of appetite, and a low grade fever. An open biopsy of a lymph node revealed the presence of non-Hodgkin’s lymphoma, follicular type

Bea Selmass is a 46-year-old woman who 6 months earlier began noting episodes of fatigue and confusion as she finished her daily pre-breakfast jog.

Bea Twelvlow, a 75 year old female, went to see her physician due to a numbness and tingling in her arms and legs. A dietary history indicated a normal and healthy diet but Bea was not taking any supplemental vitamin pills.

Cal Kulis is an 18-year-old male who was brought to the hospital by his mother because of the sudden onset of severe pain in the left flank radiating around his left side toward his pubic area.

Candice Sucher is an 18-year-old female who presented to her physician for a precollege physical examination. While taking her medical history, the doctor learned that she carefully avoided eating all fruits and any foods that contained table sugar.

Carrie Sichel, Will Sichel’s 19-year-old sister, is considering marriage. Her growth and development have been normal and she is free of symptoms of sickle cell anemia.

Colin Tuma had two intestinal polyps at age 50, which were removed via a colonoscope. However, he did not return for a five year colonoscopic examination as instructed.

Colleen Lakker was born 6 weeks prematurely. She appeared normal until about 30 minutes after delivery, when her respirations became rapid at 64 per minute with audible respiratory grunting.

Cora Nari is a 64-year-old woman who had a myocardial infarction (MI, often referred to as a “coronary”) 8 months ago and had a significant loss of functional heart muscle.

Dennis “the Menace” Veere, age 3, was brought to the emergency department by his grandfather, Percy Veere. While Dennis was visiting his grandfather, he climbed up on a chair and took a half-full 500-tablet bottle of 325 mg aspirin (acetylsalicylic acid) tablets from the kitchen counter.

Deria Voider is a 20-year-old exchange student from Nigeria who has noted gastrointestinal bloating, abdominal cramps, and intermittent diarrhea ever since arriving in the United States 6 months earlier.

Dianne (Di) Abietes is a 26-year-old woman who was diagnosed with type 1 diabetes mellitus at the age of 12. She has an absolute insulin deficiency resulting from autoimmune destruction of the ß-cells of her pancreas.

Emma Wheezer presented to the emergency room 3 days after discharge from the hospital following a 10-day admission for severe refractory bronchial asthma. She required high dose intravenous methylprednisolone (a synthetic anti-inflammatory glucocorticoid) for the first 8 days of her stay.

Erin Galway is a 3-week-old female infant who began vomiting 3 days after birth, usually within 30 minutes after breastfeeding. Her abdomen became distended at these times and she became irritable and cried frequently.

Erna Nemdy (“earn an M.D.”), a 25-year-old junior medical student brings her healthy 4-month-old daughter, Beverly, to the pediatrician for her second diphtheria, pertussis, tetanus (DTaP,acellular pertussis) immunization, which she received along with the pneumococcal, inactivated polio, haemophilus influenza and rotavirus vaccines.

Ivan Applebod’s brother, Evan Applebod, was six feet tall and weighed 425 pounds (BMI = 57.6 kg/m2). He had only been successful in losing weight once in his life, in 1977 when he lost 30 lbs through a combination of diet and exercise with the support of a registered dietitian, but quickly regained this weight back.

A newborn baby girl, Getta Carbo, was born after a 38-week gestation. Her mother, a 36-year-old woman, developed a significant viral infection that resulted in a severe loss of appetite and recurrent vomiting in the month preceding delivery.

Homer Sistine, a 14-year-old male, had a sudden grand mal seizure (with jerking movements of the torso and head) in his eighth grade classroom. The school physician noted mild weakness of the muscles of the left side of Homer’s face and of his left arm and leg.

Ivan Applebod is a 56-year-old accountant who has been morbidly obese for a number of years. He exhibits a pattern of central obesity, called an?apple shape, which is caused by excess adipose tissue deposited in the abdominal area.

Ivy Sharer is a 26-year-old intravenous (IV) drug user who has shared needles with another addict for several years. Five months before presenting to the emergency department with soaking night sweats, she experienced a 3-week course of a flu-like syndrome with fever, malaise, and muscle aches.

Jay Sakz is a 9-month-old male infant of Ashkenazi Jewish parentage. His growth and development were normal until age 5 months when he began to exhibit mild, generalized muscle weakness.

Jean Ann Tonich, a 46-year-old commercial artist, recently lost her job because of absenteeism. Her husband of 24 years had left her 10 months earlier.

Jim Bodie, a 19-year-old body builder, was rushed to the hospital emergency room in a coma. One-half hour earlier, his mother had heard a loud crashing sound in the basement where Jim had been lifting weights and completing his daily workout on the treadmill.

Katie Colamin, a 34-year-old dress designer, developed alarming palpitations of her heart while bending forward to pick up her cat. She also developed a pounding headache and sweated profusely.

Katta Bolic, a 62-year-old homeless woman, was found by a neighborhood child who heard Katta’s moans coming from an abandoned building. The child’s mother called the police, who took Katta to the hospital emergency room.

Two years ago, Les Dopaman, a 62-year-old male, noted an increasing tremor of his right hand when sitting quietly (resting tremor). The tremor disappeared if he actively used this hand to do purposeful movement.

Lofata Burne is a 16-year-old female. Since age 14 months she has experienced recurrent episodes of profound fatigue associated with vomiting and increased perspiration, which required hospitalization.

Lopa Fusor is a 68-year-old woman who is admitted to the hospital emergency room with very low blood pressure (80/40 mm Hg) caused by an acute hemorrhage from a previously diagnosed ulcer of the stomach.

Lotta Topaigne is a 54 year-old woman who came to the physician’s office complaining of a severe throbbing pain in the right great toe that began 8 hours earlier. The toe has suffered no trauma but appears red and swollen.

Mannie Weitzels is a 56-year-old male who complains of headaches, weight loss related to a declining appetite for food, and a decreasing tolerance for exercise. He notes discomfort and fullness in the left upper quadrant of his abdomen.

Melvin (Mel) Anoma is a 46-year old male who noted a superficial, brownish-black, 5-mm nodule with irregular borders in the skin on his chest. He was scheduled for outpatient surgery, at which time a wide excision biopsy was performed (in an excision biopsy the complete mole is removed and biopsied).

Mya Sthenia is a 37 year-old female who complains of increasing muscle fatigue in her lower extremities with walking. If she rests for five to ten minutes, her leg strength returns to normal.

Newman Itis complains to his physician of a fever and cough. His cough is productive of thick yellow-brown sputum. He is empirically started on azithromycin for community acquired pneumonia.

Nick O’Tyne is a 62-year-old electrician who has smoked two packs of cigarettes a day for 40 years. He recently noted that his chronic cough had gotten worse.

Nona Melos is a 7-month-old baby girl, the second child born to unrelated parents. Her mother had a healthy, full-term pregnancy, and Nona’s birth weight was normal.

Otto Shape is a 25-year-old medical student who was very athletic during high school and college, and is now “out-of-shape”. Since he started medical school, he has been gaining weight.

Percy Veere is a 59-year-old schoolteacher who was in good health until his wife died suddenly. Since that time he has experienced an increasing degree of fatigue and has lost interest in many of the activities he previously enjoyed.

Piquet Yuria, a 4-month-old female infant, emigrated from the Soviet Union with her French mother and Russian father 1 month ago. She was normal at birth but in the last several weeks was less than normally attentive to her surroundings.

Rena Felya, a 9-year-old girl, complained of a severe pain in her throat and difficulty in swallowing. She had chills, sweats, headache, and a fever of 102.4° F. J1255

Sam Atotrope, a 42-year-old jeweler, noted increasingly severe headaches behind his eyes sometimes associated with a “flash of light” in his visual fields. At times his vision seemed blurred, making it difficult to perform some of the intricate work required of a jeweler.

Sis Lupus, a 28-year-old computer programmer, notes increasing fatigue, pleuritic chest pain, and a nonproductive cough. In addition, she complains of joint pains, especially in her hands.

Sissy Fibrosa is a 3-year-old Caucasian female who has been diagnosed with cystic fibrosis (CF). Cystic fibrosis is a disease caused by an inherited deficiency in the CFTR (cystic fibrosis transmembrane conductance regulator) protein, which is a chloride channel.

Sloe Klotter, a 6-month-old male infant, was brought to his pediatrician’s office with a painful, expanding mass in his right upper thigh which was first noted just hours after he fell down three uncarpeted steps in his home.

Spiro Site is a 21-year-old college student who complains of feeling tired all the time. Two years previously he had had gallstones removed, which consisted mostly of bilirubin.

Vera Leizd is a 34-year-old woman in whom pubertal changes began at age 12, leading to the development of normal secondary sexual characteristics and the onset of menses at age 13.

Victoria Tim was a 21-year-old woman who was the victim of a rape and murder. Her parents told police that she had left her home and drove to the local convenience store.

Will Sichel is a 17-year-old male who presented to the hospital emergency room with severe pain in his lower back, abdomen, and legs, which began after a 2-day history of nausea and vomiting caused by gastroenteritis.

X.S. Teefore is a 26-year-old male who noted heat intolerance with heavy sweating, heart palpitations, and tremulousness. Over the past 4 months he has lost weight in spite of a good appetite.

A 72-year-old man presents with leg pain that usually follows mild exertion. The pain is centered in both calves.

A 40-year-old African-American man presents with headache. He had been well until 1 week previously when he had become fatigued and developed a dull headache.

A 44-year-old woman presents with severe right upper quadrant pain and mild fever.

A 60-year-old man collapses at the community center after complaining of a severe tearing pain in the chest.

A 23-year-old man presents with a rapidly expanding red mass of the right calf.

An 85-year-old man presents to the ER complaining of fever and cough. Three years earlier, the patient had become increasingly forgetful and disoriented, and he was placed in a nursing home.

A 1-year-old boy presents with progressive cyanosis. The child was born after a normal 38-week gestation.

A 10-year-old boy presents with 1 month of recurring dizziness, headaches, and nosebleeds.

A 52-year-old man acutely develops chest pain and shortness of breath. He arrives at the emergency room 6 hours after the pain started.

A 62-year-old woman collapses at home and cannot be aroused. When the paramedics arrive 15 minutes later, she is pulseless.

A 74-year-old man develops a severe headache, dizziness, and weakness of his right arm. The patient has a long-standing history of type-2 diabetes mellitus.

A 42-year-old African-American man presents to the emergency room with 1 hour of severe chest pain radiating to his jaw. On physical examination, the blood pressure is 190/120 mmHg, pulse 83/min, and respirations 24/min.

A 68-year-old woman presents with severe shortness of breath. She has a 10-year history of progressive dyspnea.

A 72-year-old man presents with 8 weeks of fever, anorexia, weight loss, and night sweats.

A 20-year-old woman presents with severe shortness of breath. Her symptoms started approximately 6 months ago when she developed fatigue and mild dyspnea on exertion.

A 45-year-old man presents with jaundice and fatigue. He has a 5-year history of diabetes mellitus. One month earlier, he noted that his eyes were yellow.

A 44-year-old man presents with fever and productive cough that began 12 hours previously. The patient has and appendectomy at age 12.

A 28-year-old Cambodian woman presents to her family physician with shortness of breath and cough. The patient states that her symptoms began approximately 3 months prior and had been getting progressively worse.

A 72-year-old man who is currently undergoing a course of chemotherapy and radiation therapy for malignant lymphoma presents to the emergency room with a 1-day history of fever and chills.

A 39-year-old Caucasian woman presents for lung transplant evaluation. Her respiratory symptoms initially began 5 years ago, when the patient noticed shortness of breath with exertion.

A 58-year-old white man presents to his primary care physician with dyspnea on exertion.

A 24-year-old African-American woman is taken to the emergency department following a minor car accident.

A 63-year-old man presents with a 6-month history of productive cough. He had lost approximately 20 pounds over the past 4 months.

A 23-year-old woman presents with jaundice. She noted 2 weeks earlier that her eyes were yellow. She complains that she is fatigued.

A 57-year-old previously health man complains of indigestion. He experiences severe heartburn following meals.

A 43-year-old man presents with a 3-month history of abdominal pain. He states that the pain is unrelated to food intake.

An 18-year-old woman presents with a change in bowel habits. Since starting college 7 months before, she has noticed recurrent bouts of diarrhea with bloating and abdominal cramps.

A 10-month-old male infant refuses to eat. He has not passed stool in over 24 hours.

A 50-year-old man presents for a routine colonoscopy. The patient has adult onset diabetes mellitus, which has been well-controlled with diet modification.

A 27-year-old male presents with chronic diarrhea. He has been experiencing symptoms over the past 2 years.

A 23-year-old woman undergoes a routine Pap smear of the cervix. Atypical cells are detected. A biopsy of the cervix is performed.

A 41-year-old woman presents to the emergency room with abdominal pain, fever, nausea, and vomiting.

A 59-year-old presents with 3 days of diffuse abdominal pain. The patient states that he feels tired all the time.

A 22-year-old woman presents to the emergency room with severe abdominal pain. The symptoms began approximately 2 days prior.

A 57-year-old woman complains of 3 months of pruritus. The pruritus is not responsive to over-the-counter topical medication.

A 30-year-old man presents with jaundice of 1 week's duration. He had been well until 1 week ago when he noted dark urine and yellowing of his eyes.

A 45-year-old man has blood work drawn for insurance physical. The AST is 100 IU/L and the ALT 110 IU/L.

A 25-year-old woman is brought by her husband to the emergency room with severe lethargy. She had been depressed in the last few weeks.

A 57-year-old man presents to the emergency room with severe abdominal pain and vomiting. The patient describes the pain as knife-like, centered around his umbilicus and radiating towards his back.

A 40-year-old man presents with abdominal pain and diarrhea. He has a long history of alcohol abuse and has been admitted several times over the past 5 years for acute pancreatitis.

A 62-year-old man presents with decreased appetite and vague abdominal pain. The patient has lost 20 lbs in the last 4 months.

A 41-year-old woman presents to the emergency room after being found unresponsive in her apartment.

An 82-year-old man presents with shortness of breath and swelling of the legs and feet.

A 6-year-old boy presents for a physical examination prior to entering elementary school.

A 37-year-old African-America man presents with leg swelling. The patient has been otherwise asymptomatic.

A 67-year-old man presents with the complaint of blood in his urine, which he has noticed intermittently over the past 6 months.

A 52-year-old man presents to his family physician for a routine physical. The patient last saw a physician 12 years earlier.

A 10-year-old boy is brought to his pediatrician for lassitude. The child's mother states the child appears full in his face.

An 18-year-old white male presents to his primary care physician for a pre-college physical examination.

A 62-year-old African-American man is found unresponsive in his home. Despite multiple attempts to resuscitate the patient, he dies while in the ambulance.

A 73-year-old man presents with recurrent right flank pain. The patient has a long-standing history of passing renal stones.

A 60-year-old man presents with cough and hemoptysis. A chest x-ray shows a large left lung mass. A needle biopsy shows squamous cell carcinoma.

An 82-year-old man with a history of hypertension and osteoarthritis presents with lower back pain.

An 85-year-old male resident of a nursing home develops fever and obtundation. He had been complaining of pain on urination for 2 days.

A 62-year-old man presents with the complaint of blood in his urine. He has noticed the blood over the past 4 weeks.

A 33-year-old man presents with a painless, rapidly enlarging left scrotal mass.

A 55-year-old man presents with drowsiness. He had been well until 1 week ago when he developed severe and persistent headaches.

A 24-year-old nulliparous woman presents for her annual gynecologic exam.

A 64-year-old post-menopausal woman presents with vaginal bleeding for 5 months duration.

A 43-year-old woman presents with heavy menstrual periods. She has been noticing increasing bleeding over the past year.

A 73-year-old woman presents with increasing abdominal girth. The patient has noticed her abdomen to be increasing in size over the past several months.

A 41-year-old Asian woman presents with vaginal bleeding. The patient is 14 weeks pregnant.

A 45-year-old man develops severe substernal chest pain and shortness of breath. The pain started 1 hour previously.

A healthy 21-year-old woman presents to her physician with a breast mass. She palpated a small lump upon self-breast examination.

A 59-year-old woman presents with an ill-defined density on her mammogram. She has a history of atypical ductal hyperplasia, diagnosed in her right breast 2 years prior.

A 50-year-old man presents with weakness. He was well until approximately 1 month ago when he began to feel lethargic and occasionally dizzy.

A 25-year-old woman presents with 2 weeks dizziness, easy bruisability, and nose bleeds.

A 52-year-old woman presents with several months of fatigue. She has a long history of Crohn's disease for which she has had multiple small bowel resections.

A 19-year-old woman presents with severe shortness of breath. She also complains of severe pain in her arms and legs.

A 15-year-old boy presents with diffuse purpura. Laboratory testing reveals a platelet count of 5,000/microliter.

A 26-year-old woman presents for delivery after a 38-week gestation. She has had a low-grade fever for 24 hours.

A 62-year-old man presents with 2 months of vague abdominal fullness and increasing fatigue. He has last 10 pounds in the last month.

A 60-year-old man presents with 1 week of fatigue, fever, and chills. He reports a 10-pound weight loss in the last 2 weeks.

A 20-year-old man presents with painless swelling of the lymph nodes on his right inguinal region.

A 70-year-old man presents with 2 months of mild fatigue and a swollen neck.

A 46-year-old man presents with 2 months of fatigue and back pain. An outpatient x-ray revealed lytic lesions of the skull and spine.

An 18-year-old college student presents to the student health clinic with a high fever, headache, vomiting, and marked nuchal rigidity.

A 34-year-old man presents to the physician after his wife proclaimed he looked different.

A 32-year-old woman presents for a pre-employment physical examination. The patient states she has no health problems.

A 29-year-old woman presents with a neck mass. The patient has noticed the lesion over the past 3 months.

A 45-year-old woman presents to her family physician with abdominal pain.

A 37-year-old man presents to his physician with anxiety attacks. The patient states that he has experienced several episodes of sweating, palpitations, increased heart rate, and headache.

A 35-year-old man presents with 3 months of severe weakness. Approximately 6 months previously, he lost his appetite and sustained a 10-pound weight loss.

A 42-year-old woman on chronic dialysis presents with substernal pain and shortness of breath. The pain started 2 days ago and is now constant.

A previously healthy 12-year-old girl is brought by her parents to her pediatrician because of a recent history of drinking very large amounts of water and soft drinks and frequent urination.

A 59-year-old man presents with crushing substernal chest pain, shortness of breath, and sweating.

A 42-year-old man presents with 2 months of abdominal pain and indigestion. He recounts considerable bloating and his wife has complained about his breath.

A 50-year-old man presents with increasing shortness of breath on exertion.

A 30-year-old professional basketball player presents because of decreased exercise tolerance. A chest x-ray shows numerous bilateral lung densities and mediastinal fullness.

A 37-year-old woman presents with complaints of an itchy rash.

An 18-year-old man presents with recent onset of blisters on his arms and legs.

A 32-year-old woman presents with a facial rash. The rash extends over her nose and bilateral cheeks.

A 42-year-old man presents to his family physician complaining of an intensely itchy and blistering rash.

A 30-year-old woman presents with complain of thickened skin. The patient has had a 6-month history of dysphagia.

A 59-year-old woman presents to her doctor with a pigmented lesion on her arm.

A 78-year-old man is seen for a nodule on his forehead. The lesion has been present for several months.

A 52-year-old man presents with a firm, painless nodule below his left ear.

A 43-year-old woman presents with a mass involving the right side of her face.

A 59-year-old man presents with a tongue ulcer. The lesion has been present for over 3 months.

A 43-year-old Asian man presents with fullness in the neck and difficulty swallowing.

An 81-year-old white man is seen in the emergency department following a fall from his bed.

A 22-year-old previously healthy man complains of right knee pain over the past 6 weeks.

A 52-year-old woman presents with increasing pain and swelling in her left knee.

A 14-year-old girl has a chest x-ray after demonstrating a positive PPD skin test.

An 82-year-old woman presents to the emergency department following a fall.

A 43-year-old woman presents with pain in her hand and knee joints, fatigue, and muscle pain.

A 3-year-old boy is brought by his parents to the pediatrician because of delayed development.

A 54-year-old woman presents with a 2-month history of progressive muscle weakness.

A 62-year-old woman presents to her family physician with complaints of urinary frequency for the past 3 months.

A 31-year-old man presents with increasing deterioration of vision.

A 67-year-old man presents to the emergency department with sudden onset of left eye pain.

A 2-year-old boy is seen by his pediatrician for a routine check-up. On examination, he appears healthy and is within the 50 percentile for both height and weight.

A 59-year-old man is admitted with severe shortness of breath. Two months previously, the patient had open heart surgery to replace the aortic valve.

A 55-year-old woman presents to the emergency room after vomiting bright red blood. Her past medical history is significant for chronic hepatitis B infection contracted 20 years ago following intravenous drug use.

An 8-year-old presents with marked shortness of breath and wheezing. The child had been playing in his backyard when he was stung on his right arm by a bee.

A 23-year-old woman presents with weakness. She had been well until 10 days ago when she developed a sore throat and fever.

A 25-year-old woman presents with skin rash and fever. She was well until 1 month ago when she noted that her face was reddened.

A 63-year-old woman presents with hematemesis. She describes 2 months of continuous, burning epigastric pain, with only mild relief after eating.

A 63-year-old man presents with a history of constipation for 1 month. During the last week, he developed vague abdominal pain.

A 51-year-old man presents with a 2-cm nodule in the left upper lung discovered upon routine chest x-ray.

A 10-year-old African boy presents with swelling of the jaw. The child was well until 1 month ago, when he had difficulty swallowing.

A 5-year-old boy complains that he cannot see well out of his left eye. The left pupil is white (leukocoria). The eye is surgically removed.

A 4-year-old boy presents to the emergency department with right lower quadrant pain and fever.

A 5-year-old boy is seen for a routine medical visit. He has been deaf from birth. The child was adopted from Africa.

A 3-year-old girl is evaluated for cardiac surgery. She is the product of a term pregnancy of a 42-year-old mother and a 48-year-old father.

A 28-year-old man collapses at work after complaining of sever chest pain. Upon arrival at the emergency department his blood pressure is 40 mm Hg systolic.

A 20-year-old man presents with severe pneumonia. The patient has a lifelong history of chronic cough with copious production of sputum.

An 8-month-old infant is noted by her pediatrician to have missed several developmental milestones.

A male infant is born after the onset of premature labor at 27 weeks gestation. The baby weighs 950 g and develops severe respiratory distress.

A 63-year-old man presents with shortness of breath. The patient has a long history of angina pectoris and had a myocardial infarction 1 year earlier.

A 40-year-old woman is admitted to the hospital after sustaining a left leg fracture while skiing. Examination reveals a clean break in the middle of the femoral shaft.

A 22-year-old solider is airlifted off the battlefield after sustaining a bullet wound to the abdomen. The paramedic in the field administers morphine and starts intravenous fluid administration with volume expanders.

A 62-year-old man presents with cough and hemoptysis. He had been well until approximately 1 month ago when he developed a persistent nonproductive cough.

A 40-year-old man presents with massive hematemesis. The patient had numerous hospital admissions for management of liver failure.

A 22-year-old woman is found unconscious in a motel room. The room contains several phials of heroin and drug paraphernalia

A 50-year-old man presents with 3 days of profound fatigue and fever. The previous day he noted bloodied eyes.

A 42-year-old woman presents after 6 months of therapy for breast cancer with contracture of the left arm.

A 3-year-old boy is brought to the emergency room with growth retardation and irritability. The child had been taken from a foster home that had been reported to the authorities for squalid conditions.

A 5-year-old African boy presents with a diffuse rash. The child had been well until 4 days earlier when he presented with fever, cough, and a runny nose.

A 23-year-old woman develops severe lethargy and is brought to the emergency room by her roommate. One week earlier she had the flu.

A 3-year-old boy developed a skin rash on his left leg over the last week. Several other children in his nursery developed similar rashes.

A 33-year-old woman presents with fever and a swollen and painful right knee. She also complains of vague right lower abdominal pain.

A 43-year-old man develops a red lesion on his penis. He has been healthy until now and has no other symptoms.

A 53-year-old man presents with 1 month of intermittent fever. He has had several drenching night sweats.

A 47-year-old man with chronic HIV infection presents with painful oral lesions.

A 27-year-old woman complains of recent onset of shortness of breath, a nonproductive cough, and fever.