Assess and diagnose the patient presenting with double vision, difficulty climbing stairs, and upper limb weakness.

The patient reports a 1-month history of experiencing double vision (diplopia), difficulty in climbing stairs, and weakness when trying to brush her hair. She notes that these symptoms tend to worsen after physical activity but improve significantly after a few hours of rest.

Difficulty climbing stairs
Weakness in upper limbs
Improvement of symptoms after rest

Non-smoker, drinks wine occasionally. Works as a graphic designer.

Patient denies experiencing any chest pain, palpitations, shortness of breath, or recent infections.

Presence of ptosis (drooping of the right upper eyelid) that worsens with sustained upward gaze.

Diminished motor strength observed in the upper extremities, with normal tone and no obvious atrophy.

Decreased muscle response with repetitive stimulation

Normal, no thymoma or other masses detected.


Evaluate and diagnose the patient presenting with gait and limb ataxia, and a significant medical history.

The patient presents for a follow-up regarding her Crohn disease, and reports new-onset difficulty walking, described by her peers as 'appearing drunk'. She has a significant history of Crohn disease diagnosed 2 years ago, which has escalated in severity, failing to respond to standard therapies. She has been on natalizumab for the past year.

Difficulty walking with a 'drunken gait'

Reduced strength in the right upper limb

Crohn disease diagnosed 2 years ago, current treatment includes natalizumab for the past year.

Lesions consistent with Progressive Multifocal Encephalopathy (PML).

T1/T2 images showing multifocal demyelinating lesions without gadolinium enhancement, indicative of PML.

Progressive multifocal encephalopathy (PML)


Diagnose the underlying condition based on clinical presentation and examination findings in an 8-month-old boy with feeding difficulties and abdominal distension.

The patient has been very fussy and has shown decreased interest in feeding for the past few days. His mother reports that despite the feeding difficulties, she believes the child has been gaining weight. There were no complications during birth at 39 weeks of gestation.

Crying, especially intense with abdominal palpation

Distended abdomen
Decreased feeding
Weight gain despite decreased feeding

No significant past medical or surgical history. Delivered vaginally at 39 weeks without complications.

First child to young parents, no history of similar illness in the family.

No episodes of fever, vomiting, or diarrhea. The baby has not had any known illnesses since birth.

Tympanitic sound noted in the left lower quadrant

Abdomen is soft but distended, with crying intensifying on palpation especially in the left lower quadrant

Dilated bowel segments with absence of gas in the rectum, suggesting a possible obstruction

A transition zone in the distal colon, compatible with Hirschsprung disease


Evaluate and diagnose the patient presenting with fatigue, abdominal pain, night sweats, weight loss, and enlarged supraclavicular lymph node.

The patient reports experiencing fatigue, worsening abdominal pain for the past 4 weeks, excessive night sweats, and a noticeable weight loss of approximately 5.4 kg (12 lb). Additionally, the patient noticed neck swelling developing over the last 4 days.

Excessive night sweats
Weight loss of 5.4 kg (12 lb)
Neck swelling for 4 days

The patient does not report any significant past medical history. No previous major illnesses or surgeries.

The patient has a history of smoking, 1 pack per day for the past 30 years. Drinks alcohol socially. Works in a construction company.

Patient also reports feeling an unusual fullness in the belly area and has difficulty wearing his usual clothing due to this. Denies fever, cough, or recent travel.

Nontender, enlarged, and fixed supraclavicular lymph node observed.

Dullness noted over the left lower quadrant.

Splenomegaly detected, without rebound tenderness.

Massively enlarged axillary, mediastinal, and cervical lymph nodes.

Lymphocytes with a high proliferative index that stain positive for CD20.


Assess and diagnose the patient presenting with fatigue, flank pain, and fever after recent antibiotic treatment for acute sinusitis.

The patient presents with complaints of fatigue, flank pain, and a persistent fever. She reports that these symptoms have continued despite the resolution of her sinusitis symptoms. She was initially treated with amoxicillin for acute sinusitis for 12 days, during which she developed a rash. The antibiotic was then changed to cephalexin for an additional week, and the rash resolved. She has a medical history of essential hypertension, hyperlipidemia, and gastric reflux and has been on a stable regimen of lisinopril, simvastatin, and omeprazole.

History of rash during antibiotic treatment

Persistent symptoms despite resolution of initial sinusitis

Essential hypertension, hyperlipidemia, gastric reflux

Non-smoker, drinks alcohol socially, retired school teacher.

Denies nausea, vomiting, dysuria, or recent changes in urine color. Reports a resolved skin rash.

Mild flank tenderness, no rebound or guarding

3% binucleated cells with eosinophilic, granular cytoplasm


Assess and diagnose the patient presenting with knee pain following recent increased physical activity.

The patient presents with knee pain that started yesterday and has been steadily worsening. She cites recent participation in volleyball involving repetitive pivoting and twisting movements as a possible cause. She was advised at her last physical exam that weight loss could be beneficial for her health.

Knee pain, specifically over the medial aspect of the tibia just inferior to the patella

Recent weight loss attempt
Increased physical activity

Polycystic ovarian syndrome (PCOS), currently managed with oral contraceptive pills.

Denies any fever, recent injuries, swelling or discoloration of the knee, or previous similar complaints.

No visible abnormalities, erythema, or swelling.

Tenderness over the medial aspect of the tibia just inferior to the patella.

Full range of motion without significant pain or limitation.

Negative for ligamentous instability tests.

No fracture, dislocation, or appreciable joint effusion.

Can be considered if clinical suspicion persists despite negative initial workup, not mandatory for diagnosis in this simulated case.


Assess and diagnose the patient presenting with an episode of loss of consciousness.

The patient was brought to the emergency department after an episode of loss of consciousness that occurred 1 hour ago, immediately after micturating. His wife found him unconscious on the bathroom floor. He regained consciousness after about 30 seconds without any confusion or amnesia for the event. No history of urinary incontinence during the event.

Regained consciousness quickly without confusion

No significant past medical or surgical history. Not on any regular medications.

Non-smoker. Drinks alcohol socially. Works as a high school teacher. No recent travel or sick contacts.

Denies chest pain, palpitations, fevers, headaches, seizures, recent illnesses, or any other neurological symptoms.

Normal rate, regular rhythm, no murmurs.

Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.

Alert and oriented to person, place, time, and situation.

Normal strength and tone in all extremities.

Physiologic reflexes present and symmetrical.


Assess and diagnose the newborn with specific findings on physical examination and history provided.

The patient is a 3000-g (6.6-lb) female newborn delivered at term to a 23-year-old primigravida mother. The mother reports having had no prenatal care, and immunization records for the newborn are not available.

Bluish macules on the skin that do not blanch with pressure

Cloudy lenses in both eyes noticed upon examination

Failure to pass auditory screening tests

Newborn, no past medical history available.

Mother is a primigravida, no prenatal care received.

No additional symptoms noted by the mother.

Several bluish macules that do not blanch upon application of pressure


Evaluate and diagnose the patient presenting with a breast mass.

The patient noticed a mass in her left breast 4 weeks ago, which has rapidly increased in size. She denies any recent trauma or infections. No history of similar complaints in the past.

Rapid increase in size of the mass
No skin or nipple changes
No pain associated with the mass

No significant past medical or surgical history. No family history of breast cancer.

Non-smoker, moderate alcohol use. Elementary school teacher.

Denies fever, weight loss, night sweats, or changes in appetite.

No skin changes, nipple retraction, or discharge.

A 6-cm, nontender, multinodular mass palpated in the upper outer quadrant of the left breast. No palpable axillary or cervical lymphadenopathy.

Smooth polylobulated mass in the left breast.

Image shows leaf-like structures with stromal cellular overgrowth.


Evaluate and manage a patient presenting with postpartum fever and abdominal tenderness.

The patient is in the postpartum period after delivering an 11 pound boy vaginally at 40 weeks gestation. She experienced a prolonged course during labor. She reports increased frequency of urination and uterine tenderness. She also mentions a decrease in bowel sounds.

Decreased bowel sounds
Increased frequency of urination
Fever

Uncomplicated pregnancy leading up to a vaginal delivery. No significant past medical or surgical history.

Does not smoke, drink alcohol, or use illicit drugs. Lives with her partner.

Complains of minor difficulty in breathing but denies any urinary pain, headache, vomiting, or diarrhea.

Minor bibasilar crackles, no signs of respiratory distress


Assess and diagnose the patient presenting with rectal bleeding and a palpable rectal mass.

The patient reports a 2-week history of rectal bleeding occurring daily with bowel movements. She denies any pain with defecation and does not present with any other complaints.

Rectal bleeding daily with bowel movements

The patient's past medical history is unremarkable except for 5 normal vaginal deliveries.

The patient denies any changes in bowel habits, abdominal pain, weight loss, or other systemic symptoms.

A palpable, non-tender, prolapsed mass that can be easily pushed back into the anal sphincter by the examiner's finger.


Evaluate and diagnose the patient presenting with episodes of unresponsiveness accompanied by facial grimacing.

The patient has been experiencing recurrent episodes lasting 3–4 minutes each of facial grimacing and staring over the past month. During these episodes, he is nonresponsive and does not recall them afterward. He reports a muddy taste in his mouth before the onset of these episodes. His brother witnessed him waking up, staring, and making hand gestures during one episode. The patient felt lethargic and confused afterwards.

Recurrent episodes of facial grimacing and staring

Nonresponsiveness during episodes
No recollection of episodes
Muddy taste before onset
Lethargy and confusion after episodes

No significant previous medical history. No prior seizures or neurological evaluations.

Enrolled in second grade. Lives with parents and one sibling. No reported use of medications or exposure to toxins.

Denies fever, headache, visual or auditory disturbances, weakness, or other systemic symptoms.

Alert and oriented for age. No acute distress noted.

Normal tone, strength, and bulk in all four extremities.

Intact to light touch, pinprick, vibration, and proprioception.

No dysmetria on finger-nose-finger or heel-knee-shin tests.

Interictal spikes and sharp waves localized to the temporal lobes, more prominent on the right side.

No evidence of mass lesions, infarctions, or structural abnormalities.


Conduct a thorough assessment of a patient presenting with right groin pain and abnormal leg positioning following a rear-end collision, and diagnose appropriately.

The patient was involved in a rear-end collision where she was the restrained driver of the back car. She reports immediate onset of pain in both knees and severe pain over the right groin area following the accident.

Right leg is slightly shortened, flexed, adducted, and internally rotated

Works as an elementary school teacher. Non-smoker and drinks alcohol socially.

Alert and active. No head injury, abdominal pain, or chest pain reported.

The right leg is slightly shortened, flexed, adducted, and internally rotated. No visible wounds.

Limited due to pain and abnormal positioning

No fractures identified in the pelvic ring or femoral neck, but alignment suggests posterior dislocation of the right hip.


Assess and diagnose the infant brought in by a concerned mother due to bilious vomiting and inability to pass meconium, with observed abdominal distension.

The infant was born via a home birth without complications. The mother reports that the infant has had bilious vomiting and has not been able to pass meconium since birth. She also notes that the infant's abdomen appears distended.

Inability to pass meconium
Abdominal distension

Newborn, no prior medical history. Birth was uneventful.

The infant is the first child of the family. No known family history of genetic or congenital diseases.

The infant shows signs of distress, possibly due to abdominal discomfort.

The abdomen is firm and distended, with palpable bowel loops; the infant shows signs of discomfort during palpation.

Dilated loops of bowel with no gas in the rectum, suggestive of a distal obstruction.

Absence of ganglion cells in the submucosa and myenteric plexus, consistent with Hirschsprung’s disease.


Evaluate and diagnose the patient presenting with progressive swelling and pain in the right ring finger.

The patient reports that the pain and swelling in his right ring finger began 2 days ago while playing football. He recalls his finger got caught in the jersey of another player, who then pulled away forcefully.

Progressive swelling and pain in the right ring finger

Inability to flex the right ring finger at the distal interphalangeal joint when making a fist

Pain at the distal interphalangeal joint

Extended right ring finger in resting position

Student and active in sports, particularly football. Non-smoker and drinks alcohol socially.

Denies fever, numbness, or tingling in the affected finger.

Right ring finger is extended, with visible swelling at the distal interphalangeal joint.

Tenderness localized at the distal interphalangeal joint of the right ring finger.

Patient unable to flex the right ring finger at the distal interphalangeal joint while attempting to make a fist. No joint laxity.

Normal capillary refill, no sensory deficits.

No bone fractures or dislocations visible. Soft tissue swelling noted around the distal interphalangeal joint of the right ring finger.

Expected to show details regarding the integrity of tendons.

Rupture of the flexor digitorum profundus tendon at its point of insertion


Evaluate and diagnose the patient presenting with a neck swelling.

The patient reports a progressively increasing swelling on the nape of his neck for 2 months. He denies having a fever, pain, or any discharge from the swelling. He mentions a history of colon cancer for which he underwent colectomy at the age of 43. He also has a history of type 2 diabetes mellitus, hypertension, and osteoarthritis of the left knee. He takes insulin glargine, metformin, enalapril, and naproxen.

Progressively increasing swelling on the nape of neck for 2 months

No fever
No discharge
No pain associated with the swelling

Colon cancer (colectomy performed), type 2 diabetes mellitus, hypertension, osteoarthritis of the left knee.

Works as a traffic warden, frequently plays golf.

Overall healthy appearance, no other complaints or symptoms noted.

A 2.5-cm (1-in) firm, mobile, painless nodule on the nape of the neck. The skin over the nodule cannot be pinched.

Clear lungs bilaterally, no rales, rhonchi, or wheezes.

Well-circumscribed lesion in the subcutaneous tissue suggestive of a cystic nature.


Evaluate the patient for the cause of acute diarrhea and manage appropriately.

The patient has been treated for community-acquired pneumonia with levofloxacin on the medical floor. She reports developing watery diarrhea with at least 9 episodes within the last two days, accompanied by lower abdominal discomfort and cramping.

Lower abdominal discomfort
Abdominal cramping

Currently being treated for community-acquired pneumonia. No other significant past medical history.

Non-smoker, does not consume alcohol. No recent travel or dietary changes reported.

No fever, no recent antibiotics usage apart from levofloxacin for pneumonia, no vomiting, no blood in stool.

Tympanic throughout, no shifting dullness.

Diffuse mild tenderness in the lower abdomen, no guarding or rebound tenderness.


Evaluate and diagnose the patient presenting with a painful, ulcerative skin lesion on her leg.

The patient reports a skin lesion on her right leg that has been present for 1 month. The lesion began as a small red spot and has increased in size. She recalls an ant bite at the site before the lesion developed. She has a history of anterior uveitis treated with corticosteroids 8 months ago, as well as Crohn's disease, type 2 diabetes mellitus, and hypertension.

Painful ulcerative lesion on the right leg

Lesion has a central necrotic base and purplish irregular borders

History of ant bite at the site of the lesion

Pitting pedal edema of the lower extremities

Dilated tortuous veins in both lower legs

Treated for anterior uveitis 8 months ago

Recently returned from a visit to Wisconsin 2 months ago.

No additional systemic symptoms mentioned.

A 4-cm tender ulcerative lesion on the anterior right leg with a central necrotic base and purplish irregular borders. Pitting pedal edema is noted along with dilated tortuous veins in both lower legs.

Tenderness over the lesion. Femoral and pedal pulses palpable bilaterally.

Neutrophilic infiltration without infection, consistent with pyoderma gangrenosum.


Evaluate and manage a pregnant patient presenting with vaginal bleeding and abdominal pain.

32-year-old woman, gravida 2, para 1, at 38 weeks' gestation

The patient reports experiencing vaginal bleeding for the past hour accompanied by severe abdominal pain. She mentions that she felt contractions before the onset of the bleeding, but the contractions ceased once the bleeding began. Her first childbirth was a cesarean section due to nonreassuring fetal heart rate.

Severe abdominal pain
History of contractions that stopped
Previous cesarean delivery

One previous childbirth via cesarean section. No other significant past medical history.

Non-smoker, occasional alcohol consumption. Works as an elementary school teacher.

Reports feeling the baby move before the onset of symptoms but is unsure about movement since the symptoms started. Denies any recent trauma to the abdomen or any urinary symptoms.

Diffuse abdominal tenderness without rebound or guarding

No contractions felt at the time of examination

Suggestive of a disruption in the uterine wall continuity adjacent to the scar from the previous cesarean section, with associated hemoperitoneum.


Evaluate and diagnose the patient presenting with sudden-onset lower back pain radiating down the leg.

The patient reports exercising in the gym several hours ago when she suddenly felt a sharp pain in her lower back. She describes the pain as radiating down the side of her leg and into her foot.

Sharp lower back pain radiating to the leg and foot

Pain worsens with movement
The onset of pain while exercising

No significant past medical history. No prior episodes of similar pain.

Non-smoker, rarely drinks alcohol. Regular gym-goer.

Denies fever, weight loss, changes in bowel or bladder function.

Normal spine curvature, no visible swelling.

Tenderness localized to the lower lumbar spine.

Positive straight leg raise test with pain radiating down the leg.

Intact to light touch and pin-prick throughout the leg and foot.

Evidence of L5-S1 disc herniation impinging on the adjacent nerve root.


Evaluate and diagnose a 34-year-old male patient presenting with decreased vision and seeing black spots in his right eye, having a medical history of AIDS.

The patient presents with a 2-day history of decreased vision and seeing black spots in the right eye. He reports no pain, and the left eye is asymptomatic. He mentions being treated for fungal esophagitis 6 months ago and was diagnosed with Kaposi's sarcoma 2 years ago.

Decreased vision and black spots in the right eye

AIDS, fungal esophagitis treated with fluconazole, Kaposi's sarcoma

Efavirenz
Tenofovir
Emtricitabine
Azithromycin
Trimethoprim-sulfamethoxazole
Multivitamins
Nutritional supplement

Multiple violaceous plaques over the trunk and extremities

Granular yellow-white opacities around the retinal vessels and multiple areas of dot-blot hemorrhages


Evaluate and diagnose the patient presenting with increasing pain and swelling of his right knee, episodes of pain with urination, and a history of a painful, swollen left ankle joint that resolved without treatment.

The patient has been experiencing increasing pain and swelling in his right knee for the past 12 days. He reports pain with urination for the past 3 weeks and had a swollen, painful left ankle joint that resolved on its own about a week ago. He mentions being sexually active with 2 female partners and using condoms inconsistently. He also reveals that his mother has rheumatoid arthritis. The patient appears anxious.

History of painful, swollen left ankle joint

Bilateral inflammation of the conjunctiva

Tenderness at the left Achilles tendon insertion site

No significant past medical history reported.

Sexually active with multiple partners, inconsistent condom use.

Experiences anxiety; denies recent flu-like symptoms, denies any known sexually transmitted infections.

Tender, erythematous, swollen, limited range of motion due to pain

No visible swelling or erythema but history of previous symptoms


Assess and diagnose the patient presenting with a chest skin lesion.

The patient reports noticing a skin lesion on his chest 2 months ago, which he believes has increased in size. He denies any associated pain or itching with the lesion. He has a medical history significant for type 2 diabetes mellitus, hypercholesterolemia, and glaucoma.

Lesion has increased in size
Not painful
Not itchy

Type 2 diabetes mellitus, hypercholesterolemia, glaucoma

Smokes 1 pack of cigarettes daily for the last 40 years, drinks two to three beers on weekends

Denies recent weight loss, fever, fatigue, or changes in appetite.

A single, partly elevated lesion located on the chest. The lesion exhibits asymmetry, border irregularity, and varied color with diameter larger than 6mm.

The lesion is firm on palpation with a partly elevated nature, and it does not change form on pinching.

Atypical melanocytes that infiltrate the epidermis and dermis, confirming the diagnosis of malignant melanoma.


Evaluate and diagnose the patient presenting with chronic diarrhea and lower abdominal discomfort.

The patient reports experiencing chronic diarrhea on most days for the past four months. She mentions lower abdominal discomfort and cramping, which is relieved by diarrhea. The patient notes the bowel movements are urgent, occasionally accompanied by mucus discharge, and often followed by a feeling of incomplete evacuation. She went camping several months ago and recalls another member of the camping party falling ill recently.

Sensation of urgency before bowel movement

Feeling of incomplete evacuation post bowel movement

No notable past medical history provided.

No pertinent social history related to symptoms.

Denies any recent weight change, fever, nausea, or vomiting.

Mild diffuse abdominal discomfort but no rebound tenderness or guarding.


Evaluate and diagnose the patient presenting with shortness of breath, increased abdominal girth, and a large ovarian mass.

The patient reports experiencing shortness of breath and noticeable increase in abdominal size over the past month. She denies any significant medical history, previous surgeries, or use of medications.

Increased abdominal girth
Fatigue
No significant weight loss or gain

Non-smoker, does not consume alcohol regularly. Works as a high school teacher.

Denies fever, night sweats, chest pain, or swelling in the legs. She has not noticed any changes in bowel or urinary habits.

Mild use of accessory muscles to breathe.

Dullness noted on the right lower lung fields.

Decreased breath sounds on the right basal areas.

Shifting dullness suggestive of ascites.

A palpable mass on the right side of the pelvis.

Large mass in the right ovary, significant ascites present.


Assess and diagnose the patient presenting with generalized fatigue, severe pruritus, and abnormal liver function tests.

The patient reports a 2-month history of increasing generalized fatigue and severe pruritus. He has known hypertension and was diagnosed with ulcerative colitis 5 years ago. He mentions being sexually active with 2 female partners and inconsistent condom use.

Multiple scratch marks on trunk and extremities

Sexually active with inconsistent condom use

Denies fever, diarrhea, joint pain, or recent travel.

Scleral icterus and multiple scratch marks on trunk and extremities

Soft and non-tender. No hepatosplenomegaly.

Thickening of the bile ducts and focal bile duct dilatation.


Evaluate and manage a patient presenting with chronic bladder discomfort and frequent urination.

The patient reports a 5-month history of worsening bladder discomfort, which is relieved by voiding. She mentions an increased frequency of urination, voiding 10–15 times during the day and waking up 2–3 times at night to void. She denies any involuntary loss of urine. Attempts to manage the discomfort with reduced fluid intake and NSAIDs have provided minimal relief. She also reports recent painful intercourse.

Increased frequency of urination
Nocturia
Painful intercourse

Significant for bipolar disorder, currently managed with lithium.

Married and sexually active with her husband. No significant alcohol, tobacco, or recreational drug use.

Denies fever, hematuria, back pain, pelvic pain other than with intercourse, and any recent infections.

Tenderness to palpation of the suprapubic region, no masses palpated

No external lesions, vaginal discharge, or obvious masses. Cervix appears normal upon speculum examination. Bimanual examination reveals normal uterus and adnexa, with discomfort noted on palpation of the bladder region.


Assess and diagnose the patient presenting with chronic left shoulder pain without a history of trauma.

The patient reports a 2-month history of insidious onset left shoulder pain, worsening with extreme ranges of motion and activity. Pain disrupts sleep, and there's noted difficulty with activities of daily living like brushing hair and dressing. No history of shoulder trauma, neck pain, arm/hand weakness, numbness, or paresthesias. The patient has type 2 diabetes mellitus, treated with metformin and glipizide.

Difficulty sleeping on the affected side

Difficulty with brushing hair and dressing

Denies neck pain, arm/hand weakness, numbness, or paresthesias.

Tenderness around the shoulder joint, no warmth or crepitus.


Assess and diagnose the patient presenting with mental status changes.

The patient has been brought to the emergency room by her family due to altered mental status. The family mentions that she has been increasingly confused over the past few days. No recent head trauma or known drug use. The patient has a smoking history of 30 pack-years.

Patient has a history of hypertension, managed with medication. No other significant medical history is reported.

Patient is a smoker with a 30 pack-year history. Drinks alcohol socially. No illicit drug use is reported.

Denies headache, seizure, vision changes, chest pain, dyspnea, nausea, vomiting, recent illness, or fever.

Alert but noticeably confused. Oriented to person but not to time or place.


Assess and diagnose the young patient presenting with wrist pain, fever, and skin lesions.

The patient presents with a 3-day history of pain in his left wrist, which worsened this morning accompanied by chills and malaise. He recounts having a self-resolving left knee pain the previous week. Reports recent return from a camping trip in Minnesota. Sexually active with one female partner. No history of trauma to the wrist.

Painless violaceous vesiculopustular lesions on both wrists and hands

Severe tenderness to palpation and passive movement of the left wrist

Otherwise healthy with no significant past medical history.

Admits to being sexually active with one female partner who uses a diaphragm for contraception. Recently went on a camping trip to Minnesota.

Denies trauma to the wrist, reports a history of knee pain that resolved on its own. No other systemic symptoms mentioned.

Painless violaceous vesiculopustular lesions noted on the dorsum of both wrists and hands; two lesions on the left palm.

Swelling, erythema and severe tenderness to palpation and passive movement.


Evaluate a newborn presenting with respiratory distress and diagnose appropriately.

The newborn is presenting with respiratory distress 2 hours after birth. The mother had an uneventful pregnancy until premature onset of labor. There was no significant prenatal care history mentioned.

Grunting
Intercoastal and subcostal retractions
Peripheral cyanosis

Premature birth at 33 weeks of gestation.

The newborn is showing signs of respiratory distress including increased respiratory rate, grunting, and retractions. No other system review was mentioned due to the age of the patient.

Subcostal and intercoastal retractions, peripheral cyanosis

Decreased breath sounds, with fine crackles

Fine reticular granulation with ground glass appearance on both lungs


Evaluate the patient presenting with fatigue, malaise, and unintentional weight loss, and assess the need for further diagnostic workup.

The patient complains of fatigue and malaise over the last few months. He also reports an unintentional weight loss of 18.1 kg over the past 6 months. He does not recall any changes in diet or exercise routines that could explain the weight loss.

Significant unintentional weight loss
No change in diet or exercise

Has a history of diabetes mellitus type II, hypertension, non-seminomatous testicular cancer treated in the past, and hypercholesterolemia.

Currently smokes 1 pack of cigarettes per day and drinks a glass of wine daily. Denies any illicit drug use.

No fever, night sweats, or significant changes in bowel habits.

Bilateral cervical and inguinal lymphadenopathy palpable.

Evidence of splenomegaly upon palpation.

Presence of monoclonal B lymphocytes with a phenotype consistent with CLL/SLL.


Assess and diagnose the patient presenting with agitation, yellowish coloring of the skin and eyes, and abnormal lab findings.

The patient was previously healthy and has been brought to the emergency department due to agitation over the past 24 hours. Family members have noticed a yellowish coloring of his skin and eyes over the past week. The patient has a history of occasional cocaine and ecstasy use, and drinks alcohol socially on weekends. The patient also admits to high-risk sexual behaviors without using appropriate protection.

Jaundice on the skin and mucous membranes

Occasional use of cocaine and ecstasy. Social alcohol consumption (about 20 g on weekends).

The patient shows signs of psychomotor agitation and confusion. No other symptoms provided.

Presence of asterixis indicating possible liver failure

Jaundice observed on the skin and mucous membranes


Evaluate the pediatric patient for the cause of systemic hypertension and perform a directed cardiovascular examination.

The patient is presented by his mother for a well-child visit. The boy was born at 39 weeks gestation via spontaneous vaginal delivery, is currently up to date on all vaccines, and is meeting all developmental milestones. His mother reports that he has been generally doing well with no concerns. No family history of cardiovascular disease. The boy does not take any medications.

High blood pressure on the right upper extremity

No significant past medical history. Born full term with an uneventful neonatal period.

Patient attends kindergarten. Lives with parents and one younger sibling. No exposure to tobacco smoke.

All systems review is essentially negative as reported by the mother.

2+ radial pulses and trace femoral pulses

Normal S1 and S2, 2/6 long systolic murmur with systolic ejection click over the left sternal border and back

Narrowing of the aorta distal to the left subclavian artery with a gradient, consistent with coarctation. Left ventricular function is normal.

150/80 mm Hg (Right), Compared to lower values in lower extremities

Normal heart size, rib notching not observed (may not be present in young children)


Evaluate and diagnose the patient presenting with a pruritic rash on trunk and extremities, recent history of low-grade fever, rhinorrhea, and headache.

The patient has been experiencing a mildly pruritic rash on her trunk and extremities for 2 days. One week ago, she developed symptoms of low-grade fever, rhinorrhea, and headache. A facial rash appeared 4 days later, sparing the perioral area.

Mildly pruritic rash on trunk and extremities

Facial rash not involving the perioral skin

Attends local school. Lives with parents and one younger sibling. No recent travel history.

Denies any respiratory distress, joint pains, or changes in bowel or urinary habits.

Lacy, reticular rash noted on the trunk and extremities. Facial rash present but sparing the perioral area.

Rash is slightly raised but not accompanied by significant warmth or tenderness.


Evaluate and diagnose the child presenting with frequent epistaxis, mucous membrane bleeding, and petechiae.

The child's parent reports that the child has been experiencing frequent episodes of nosebleeds and has had several instances of bleeding from the gums. Additionally, there have been occurrences of unexplained bruising and petechiae, primarily on the distal extremities.

Mucous membrane bleeding
Diffuse petechiae on distal extremities

No significant past medical issues. Up-to-date on vaccinations.

Attends preschool. Lives with parents and one older sibling.

Denies any fever, significant weight loss, joint pains, or recent infections.

Diffuse petechiae noted on the patient's forearms, legs, and a few on his trunk. No significant ecchymosis or active bleeding sites noted.

Mild bleeding noted from the gums on gentle probing. No significant ulcers or lesions.

No active epistaxis at the time of the exam, but dried blood is noted at the nares.

No clumping of platelets observed, normal morphology of other cells.

Platelet surfaces deficient in GIIb/IIIa receptors.


Evaluate and diagnose the patient presenting with increasing pain and swelling of the left knee for the past 2 months.

The patient reports increasing pain and swelling of the left knee over 2 months. Describes the pain as severe enough to awaken him from sleep on several occasions. States he tried taking ibuprofen with no relief. No family or personal history of significant illnesses.

Severe pain and swelling in the left knee

Pain intensifying over 2 months
Painful awakenings during night
No relief with ibuprofen

Non-smoker, drinks alcohol socially. Engineer by profession.

Denies recent fevers, weight loss, trauma to the knee, or previous similar episodes.

Mild swelling observed around the left knee.

Limited by pain, particularly on extension and flexion

Anterior and posterior drawer tests negative

A lytic lesion in the distal femur near the knee joint with a thin rim of bone on the external surface and a 'soap bubble' appearance.

A lesion in the distal femur with clear demarcation and non-invasive characteristics, suggestive of a benign process.


Assess and diagnose the patient presenting with progressive difficulty walking, urinary incontinence, and speech difficulties.

The patient has been experiencing a gradual difficulty in walking over the past 3 months, requiring wheelchair assistance for the last month. Additionally, there is a history of urinary incontinence for 1 year and recent onset of speech slurring making communication challenging.

Urinary incontinence
Slurred speech
Rigidity in limbs
Mild hand tremor
Orthostatic hypotension

Unremarkable. No known chronic diseases.

Occasionally consumes alcohol. Non-smoker. Works as a bank clerk.

Denies recent infections, fever, weight loss, vision changes or seizures.

Speech slurred but cranial nerves grossly intact

Normal strength but with rigidity in upper and lower extremities

Unable to perform repetitive forearm movements

Unable to assess due to inability to walk unassisted

Multiple areas of atrophy and signal changes in the brainstem, cerebellum, and basal ganglia, consistent with neurodegenerative processes.

Marked orthostatic hypotension without compensatory tachycardia, indicating autonomic dysfunction.


Evaluate the newborn presenting with feeding intolerance and bilious vomiting, and provide a diagnosis.

Newborn, 3050-g (6-lb 12-oz) male, six hours post delivery

The newborn has had several episodes of bilious vomiting and is intolerant to feeding since birth. Was born at term following an uncomplicated pregnancy, though the mother missed several prenatal checkups. The patient's older brother underwent surgery for pyloric stenosis as an infant.

Vomiting started within first day after birth

No significant past medical history. Brother had pyloric stenosis.

Physical examination shows epicanthus, upward slanting of the eyelids, low-set ears, and a single transverse palmar crease. A grade 2/6 holosystolic murmur heard at the left mid to lower sternal border. The lungs are clear to auscultation.

Distended upper abdomen and a concave-shaped lower abdomen.

The provided x-ray image would show a 'double bubble' sign indicative of duodenal atresia.


Evaluate and diagnose the patient presenting with fatigue, difficulty to concentrate, and abnormal blood findings.

The patient has a 3-week history of fatigue, difficulty to concentrate, and dyspnea on exertion. He also experiences dizziness and digital pain that improves with cold. He has a long history of smoking.

Dyspnea on exertion
Dizziness
Digital pain that improves with cold

Hypertension, currently managed with enalapril.

Smokes half a pack of cigarettes a day since he was 20.

The patient denies any recent infections, bleeding disorders, or significant weight loss.

No acute distress, appears mildly fatigued

Splenomegaly noted without evident hepatomegaly.

No murmurs, rubs, or gallops. Peripheral pulses are intact.

Clear bilateral breath sounds without wheezes, crackles, or rhonchi.

Blood smear shows increased abnormal platelets.


Assess and diagnose the patient presenting with hematuria and right flank pain.

The patient reports experiencing visible blood in his urine accompanied by discomfort in his right flank. He denies any recent trauma to the area. He mentions a series of urinary tract infections over the past few years but has not been on renal dialysis.

History of recurrent urinary tract infections

No significant previous medical history except noted recurrent urinary tract infections. No history of renal dialysis or known genetic diseases.

Non-smoker, drinks alcohol socially. Works in an office setting.

Denies fever, nausea, vomiting, diarrhea, dysuria, or any recent illnesses.

Mild to moderate tenderness noted on palpation of the right flank, no palpable mass

Soft, non-distended, with no tenderness over the bladder area

Multiple cysts present in the collecting ducts of the medulla. No obstruction noted.


Assess and manage a patient presenting with difficulties conceiving and experiencing discomfort during sexual activity.

The patient and her husband have been trying to conceive for 15 months without success. They are sexually active at least twice a week. The husband occasionally has difficulties maintaining an erection. The patient reports discomfort and pelvic floor muscle tension during attempted vaginal penetration. Diagnosed with body dysmorphic disorder three years ago. No family history of serious illness. She is a non-smoker and does not drink alcohol. No medications.

Difficulty conceiving for over 15 months

Pelvic floor muscle tension during sexual activity

Husband occasionally has erectile dysfunction

Body Dysmorphic Disorder diagnosed three years ago.

All other systems reviewed are within normal limits.

No discharge. The initial attempt at speculum examination was aborted due to patient's pelvic floor muscles tensing up and discomfort.

Normal uterus and adnexa with no evidence of fibroids or ovarian cysts.


Evaluate and diagnose the patient presenting with generalized fatigue, mild fever, abdominal pain, and nausea.

The patient describes a 3-week history of generalized fatigue, mild fever, abdominal pain, and nausea. She recalls attending the state fair over a month ago where she tried various regional foods. Recently, she has observed the darkening of her urine, which she believes is due to inadequate water intake. She has a history of type 2 diabetes mellitus.

Consumes 1–2 beers daily. Works as a nursing assistant in a rehabilitation facility.

The patient appears tired. Notes a slight increase in fatigue over the past few weeks but no increase in thirst or urination. No recent travels abroad.

Liver palpated 2–3 cm below the right costal margin, tender on palpation


Evaluate and diagnose the patient presenting with sudden onset of abdominal pain, focusing on the relevance of the patient's medical history and current symptoms.

The patient presents with sudden onset of abdominal pain around the umbilicus 16 hours ago, with recent history of hospitalization for an acute myocardial infarction a week ago. Reports several episodes of bloody loose bowel movements. Denies vomiting.

Bloody loose bowel movements
No vomiting
Sudden onset

Known diabetes mellitus for 35 years and hypertension for 20 years. History of acute myocardial infarction.

Smokes 15–20 cigarettes per day for the past 40 years.

Denies fever, vomiting. Reports bloody loose bowel movements.

Evidence suggestive of reduced blood flow to the mesenteric arteries.


Assess and diagnose the patient presenting with episodic cough and shortness of breath.

The patient reports a 1-month history of episodic cough and shortness of breath. The cough is nonproductive and worsens when climbing stairs and at night. She experienced fever, sore throat, and nasal congestion 8 weeks ago.

Cough worsens with exertion and at night

History of recent upper respiratory tract infection symptoms such as fever, sore throat, and nasal congestion

10-year history of hypertension, currently managed with enalapril. History of smoking half a pack of cigarettes daily for 16 years.

Smoker, half a pack of cigarettes daily for 16 years.


Assess and diagnose the patient presenting with a generalized nonpruritic rash and a recent history of high fever and seizure.

The patient is brought in due to a generalized nonpruritic rash for 2 days. The rash started on the trunk and spread to the extremities. Five days ago, the patient had a fever of 40.5°C (104.9°F) and experienced a 1-minute generalized tonic-clonic seizure. The infant was born at term, has no history of serious illness, and her immunizations are up to date. The current medication includes acetaminophen.

History of a generalized tonic-clonic seizure

No significant past medical history. Immunizations up to date.

Current normal temperature. No reports of irritability or feeding difficulties at the moment.

Maculopapular rash that blanches on pressure, started on the trunk then spread to extremities

Posterior auricular lymphadenopathy present


Assess and diagnose the patient presenting with a pruritic rash on the bilateral upper extremities.

The patient complains of a pruritic rash on both upper extremities that has been present for 5 months. She notes that the rash occasionally worsens but has not completely resolved at any point. She denies any recent illnesses and mentions that she has not started any new medications or come into contact with any new substances that she is aware of.

Pruritic rash on the bilateral upper extremities

No fever
No joint pains
No recent illnesses

No history of serious illness. No known drug allergies. Takes no medications.

College student studying graphic design. Non-smoker, drinks alcohol socially. No recreational drug use.

Denies recent fever, joint pains, weight loss, or changes in bowel habits.

Bilateral erythematous, scaly, and crusted lesions localized to the upper extremities.

No warmth or induration. The lesions are slightly raised and rough to touch.

Intraepidermal accumulation of edematous fluid and widening of intercellular spaces between keratinocytes.


Evaluate and diagnose the patient who presents with chronic joint pain.

The patient presents with pain in his left great toe, hips, and knees that worsens with activity and improves with rest. He reports that the symptoms have progressively gotten worse over the past several years.

Pain in the left great toe, hips, and knees

Symptoms worsen with activity
Symptoms improve with rest

Obesity, type II diabetes mellitus, smoking history, hypertension.

Drinks roughly ten beers per day. Recent travel history to Bangkok with unprotected sex.

Patient did not report any other systemic symptoms.

Pain on palpation of the left great toe, hips, and knees. No swelling or redness noted.

Crepitus noted in patient's hip during flexion and extension.

Joint space narrowing with osteophyte formation, suggestive of osteoarthritis.


Evaluate the patient presenting with persistent bleeding post wisdom tooth extraction and history of easy bruising for possible bleeding disorders.

The patient was brought in by his mother for persistent bleeding following elective removal of wisdom teeth. The bleeding from the surrounding gums was minimally responsive to multiple gauze packs. The patient also has a history of easy bruising. Family history includes the patient's uncle who had similar issues with bleeding and a history of easy bruising and joint swelling.

Persistent bleeding from gums following tooth extraction

Family history of similar bleeding problems and joint swelling

Previously healthy, takes no medications.

The patient is a high school student with no history of smoking, alcohol, or drug use.

Denies fever, joint pains (except noted in family history), or significant past illnesses.

Persistent oozing noted from the site of wisdom tooth extraction.

Several old bruises of different ages noted on the extremities.


Assess and diagnose the patient presenting with a concerning rash and recent health changes.

The patient presents with a rash that started last night, finding it very concerning. He does not recall being exposed to any new environmental stimuli such as detergents or plants like poison ivy. He mentions he recently started seeing a primary care provider for arthritis management and a new onset cough.

Unaware of exposure to new environmental stimuli

Has been diagnosed with arthritis. No other significant past medical history has been mentioned.

The patient didn't provide any specific social history details during the initial consultation.

Reports a new onset cough along with skin and mucosal changes but denies fever, shortness of breath, joint pains, gastrointestinal symptoms, or recent illnesses.

Coalescing erythematous macules, bullae, desquamation noted.

Localized to the upper half of the back.

Ulcers and erythema present in oropharynx.

Normal rate and rhythm, no murmurs or gallops.

Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.

Soft, non-tender, no hepatosplenomegaly, normoactive bowel sounds throughout.

Epidermal necrosis and detachment, consistent with severe drug reaction.


Evaluate and diagnose the adolescent patient presenting with delayed menarche, unusual physical features, and a history suggestive of bone fragility.

The patient has not experienced menarche. She was noted to have partial labial fusion and clitoromegaly at birth. The patient's mother reports that during pregnancy she had abnormal hair growth on her chin. The patient has a history of severe acne and has sustained fractures following minor trauma. She is currently on oral isotretinoin and an oral contraceptive.

History of fractures following minor trauma

Partial labial fusion and clitoromegaly noted at birth

Currently taking oral isotretinoin for acne and an oral contraceptive.

The patient is a high school student without significant tobacco, alcohol, or drug use.

Denies any recent illnesses, appetite change, or weight change.

Numerous inflamed pustules on the face and upper back.

Breast development is at Tanner stage I.

Ovaries with multiple cysts and a normal uterus.


Assess and diagnose the child presenting with rapid breathing, abnormal physical findings including liver enlargement, and pitting edema.

The parents report that the child appears unwell and has been breathing rapidly. They also noticed some swelling in the child's legs but no fever, cough, or previous similar episodes. The child's appetite has diminished over the past few days. No recent illnesses or hospitalizations. The child is fully immunized.

Appears unwell
Diminished appetite
No fever
Swelling in the legs

No significant past medical history. Birth history unremarkable.

Lives with both parents and one older sibling. No known exposure to sick contacts or recent travel.

On review, there's no history of cough, fever, vomiting, or diarrhea.

Mild rales noted, fixed split S2 on inspiration. No murmurs.

Increased respiratory effort, no wheezes or stridor.

Liver palpable 1.5 times the normal size for age, no splenomegaly.

Enlarged cardiac silhouette, no pulmonary edema.

Presence of an atrial septal defect with left to right shunt.


Assess the patient and determine the cause of jaundice, pruritus, weight loss, pale stool, and dark urine.

The patient has experienced gradual yellow discoloration of the skin and generalized pruritus over the past 2 weeks. He also reports a decreased appetite and a weight loss of 6.3 kg (14 lb). The patient’s stool has been pale, and his urine is very dark. Three years ago, he had an episode of acute upper abdominal pain, which was managed with IV fluids, NSAIDs, and dietary modification. The patient has abstained from alcohol for these three years, after having consumed 1–2 beers daily for 40 years. He has a 50-year history of smoking a pack of cigarettes daily.

Generalized pruritus
Decreased appetite
Weight loss
Pale stool
Dark urine

Episode of acute upper abdominal pain treated three years ago. History of long-term alcohol consumption and smoking.

Stopped alcohol consumption three years ago; 50-year history of smoking a pack of cigarettes daily.

Jaundice noted in the conjunctivae and skin.

No tenderness, but a soft, cystic mass palpated in the right upper quadrant.

Anechoic cystic mass in the subhepatic region. Dilation of the intrahepatic and extrahepatic bile ducts.


Assess and manage a patient presenting with episodes of dizziness and vertigo.

The patient presents with sudden episodes of dizziness that are position dependent. She describes experiencing a false sensation of motion and occasional spinning, indicative of vertigo. She denies any recent illnesses, injuries, or significant changes in health status, apart from age-related hearing loss (presbycusis).

Episodes of dizziness and spinning sensation

Position dependent vertigo
No recent illness
No hearing loss besides presbycusis

No significant past medical or surgical history. No history of Meniere's disease, vestibular neuritis, or labyrinthitis.

Retired school teacher. Lives alone. Non-smoker, occasional wine. Enjoys light gardening.

Denies headache, tinnitus, hearing loss, nausea, vomiting, or recent respiratory infections.

Steady, no signs of imbalance when not experiencing vertigo

Positive for right-sided horizontal nystagmus when moving from sitting to supine position, suggestive of BPPV

Bilateral high-frequency sensorineural hearing loss, consistent with presbycusis. No sudden drops in hearing indicative of Meniere’s disease or labyrinthitis.

Normal vestibular response with the exception of response elicited during Dix-Hallpike maneuver, consistent with BPPV.

No evidence of central lesions or infarcts that would suggest central causes of vertigo.

Benign Paroxysmal Positional Vertigo (BPPV)


Evaluate and diagnose the patient presenting with unusual behavior and beliefs regarding telepathic communication with animals.

The patient presents with a chief complaint of 'failing health.' He reports an inability to communicate telepathically with animals, which he believes he could previously do, affected by the current weather conditions. He has started taking assorted Peruvian herbs without any improvement. He denies taking any medications. The symptoms have been ongoing for the past eight months.

Belief in telepathic communication with animals

Ingestion of Peruvian herbs
No improvement with self-medication

Patient is not on any medication and has no significant past medical history.

Lives alone, works at a health food store. Dresses in all burlap clothing and attempts telepathic communication during history taking.

Denies any other physical complaints or symptoms.

Healthy appearing young man, fully oriented, dressed in burlap clothes.

Attempts to communicate telepathically during interview

Presence of odd beliefs and magical thinking

Insight is poor, judgment is questionable due to self-treatment with herbs for his condition.


Evaluate and diagnose the dermatological condition presented by the patient, focusing on lesions with potential oncologic implications.

The patient has recently immigrated to the US from Africa and seeks evaluation for a non-healing, red, crusty lesion on the shaft of his penis and a similar lesion on his left middle finger. Previous treatments in his home country for syphilis and eczema have been unsuccessful. The patient is a smoker, with a history of two packs per day for the last 30 years.

Non-healing, crusty, red lesions on the penile shaft and left middle finger

History of unsuccessful treatment for syphilis and eczema

No known malignancies or hereditary diseases in the family. Previous treatments for syphilis and eczema.

Lives with his 4th wife, smokes 2 packs of cigarettes per day for the last 30 years, has recently immigrated from Africa.

Denies any systemic symptoms such as fever, weight loss, night sweats, or malaise. No other similar lesions elsewhere on the body.

An erythematous plaque with areas of crusting, oozing, and irregular borders observed on the dorsal surface of the penile shaft and on the left middle finger.

Lesions are firm to touch, non-tender, with no warmth.

No palpable cervical, axillary, or inguinal lymphadenopathy.

Cells with nuclear hyperchromasia, multinucleation, and increased mitotic figures within the follicle-bearing epithelium.


Assess and diagnose the patient presenting with behavior issues at school and at home.

The patient has been increasingly disruptive in class according to his teacher. He often refuses to participate in directed activities with responses such as 'You're not the boss of me' or 'You can't make me.' He is reluctant to participate in gym class, though he engages actively in similar physical activities during recess. His social interactions with peers are positive, and he is described as well-liked by his classmates. The patient's mother describes him as occasionally difficult but notes that he is helpful at home and plays well with his younger sister.

Reluctance to participate in certain school activities

Helpful and cooperative behavior at home

No significant past medical or psychiatric history.

Lives with mother, father, and a younger sister. Performs well academically when he chooses to engage. No known substance use in the family.

Denies any symptoms of depression or anxiety. No history of bullying or feeling unsafe at school or home.

Well-nourished, well-groomed male in no acute distress.

Appropriate mood and affect. No evidence of thought disorders. Exhibits some oppositional behaviors during interview.

Indicate patterns consistent with oppositional behaviors without conduct problems.

No evidence of an anxiety disorder, depression, or ADHD.


Assess and diagnose the patient presenting with fatigue, weight loss, and jaundice.

The patient complains of persistent fatigue and reports poor sleep quality. He mentions adopting a vegetarian diet in recent months to improve his energy levels but hasn't noticed significant benefits. The patient reports losing weight without trying over the last month.

Poor sleep quality
Unintentional weight loss
Jaundice

Smokes 1 pack of cigarettes per day and consumes 5 alcoholic beverages per day.

The patient does not report any fever, abdominal pain, or changes in bowel habits.

Resonant throughout abdominal quadrants.

No palpable mass or tenderness. No hepatomegaly or splenomegaly was noted. Enlarged gallbladder without tenderness.

Enlarged, thin-walled gallbladder. No evident stones.


Assess and manage a young adult male presenting with aggressive behavior, altered mental status, and autonomic dysregulation.

The patient's roommates report that he has been displaying increasingly aggressive and unusual behavior. They mention that he has been under significant stress due to final exams and has become more reclusive. Earlier this evening, he exhibited extreme irritability, yelled at his computer, broke it, and then spent several hours at the gym.

Prolonged physical activity (several hours at the gym)

No significant past medical history reported by the roommates.

Stress from upcoming final exams. No other social history provided.

Roommates did not report any fever, vomiting, diarrhea, dysuria, or flank pain prior to the event. During the physical exam, the patient is noted to be diaphoretic.


Assess and diagnose the patient presenting with severe abdominal pain, nausea, vomiting, and dysuria.

The patient presents with a 5-day history of severe abdominal pain and cramping, accompanied by nausea and vomiting. She reports pain with urination and also experienced burning pain during sexual intercourse 3 days ago. She mentions being sexually active with one male partner, using condoms inconsistently.

Nausea
Vomiting
Pain with urination
Burning pain during intercourse

Menarche at 13 years, regular menses every 28 days, lasting for 5 days. No significant past medical or surgical history.

Currently in a relationship with one male partner. Reports inconsistent condom use.

Denies recent fever (notes current temperature), no urinary frequency or urgency, no change in bowel habits.

Generalized tenderness, more pronounced in the lower quadrants


Evaluate and diagnose the patient presenting with occasional shooting ear pain and difficulty wearing earrings post tympanoplasty.

The patient has a history of polycystic ovarian syndrome, depression, and chronic bilateral ear infections. She underwent right ear tympanoplasty 12 weeks ago. Although audiology report from one week ago showed improved hearing by 20 decibels, she reports occasional shooting pain when eating and discomfort when wearing earrings. She describes her job as stressful and mentions poor sleep quality.

Occasional shooting pain in the ear with eating

Discomfort when wearing earrings
Stress from job
Poor sleep quality

History of polycystic ovarian syndrome, depression, and chronic bilateral ear infections. Underwent right ear tympanoplasty 12 weeks prior.

Works as a cashier at a local department store.

Reports shooting pain and discomfort in the right ear. Denies neck pain or facial tenderness.

Denies dizziness, loss of consciousness.

No tenderness with palpation bilaterally.

No jaw clicking heard. No tenderness with palpation.

Right postauricular tapping causes tenderness in right tonsillar area.

Even and symmetric molar teeth bilaterally. Uvula is midline. Gag reflex intact.

Improved hearing by 20 decibels post tympanoplasty.

MRI of the brainstem and cerebellopontine angle with and without contrast could be considered to rule out underlying causes if clinical suspicion persists.


Assess and diagnose the infant presenting with recurrent episodes of stridor and wheezing, especially during specific activities.

The patient has been experiencing recurrent episodes of stridor and wheezing. The mother notes that the wheezing exacerbates when the child is crying, feeding, and when his neck is flexed. Additionally, there are instances where the child vomits after feeding.

Recurrent episodes of stridor and wheezing

Exacerbation during crying
Exacerbation during feeding
Exacerbation with neck flexion
Relief with neck extension
Occasional vomiting post-feeding

No significant past medical or surgical history. Born full term with no complications during birth.

First child in the family. Lives with both parents. No exposure to smoking or pets in the household.

Denies fever, diarrhea, rash, or other respiratory symptoms such as cough.

Wheezing audible during episodes, no crackles

No crepitus or significant findings on palpation

Evidence of tracheal compression and a vascular ring suggestive of a double aortic arch

Compression of the esophagus and trachea consistent with a vascular ring

Confirmatory findings of a double aortic arch


Evaluate and diagnose the pediatric patient presenting with multiple skin lesions.

The patient's mother reports noticing multiple painless, nonpruritic papules on the child's abdomen. The child attends daycare where another child was reported to have similar lesions recently. Patient's brother had chickenpox one month ago. Immunizations are up-to-date.

Skin-colored, nontender, pearly papules with central umbilication on the abdomen and extremities

Previously healthy, up-to-date immunizations, no significant illnesses.

No fever, rash in other locations, itching, or systemic symptoms.

Multiple skin-colored, nontender, pearly papules with central umbilication on the abdomen and extremities

Lesions are firm, without warmth or erythema

Optional and not typically necessary. Could show lobules of molluscum bodies (Henderson-Paterson bodies) in the epidermis, if performed.


Assess and diagnose the patient presenting with sadness, auditory hallucinations, and difficulties in concentrating and functioning at work.

The patient has been brought in by her boyfriend due to a 4-month history of feeling persistently sad. She reports that she has had significant trouble sleeping and eating during this period, and her ability to concentrate at work has deteriorated. She describes a feeling of emptiness and experiences auditory hallucinations, specifically voices telling her she is worthless. These hallucinations began 7 months ago, initially with the voices mocking her. The patient denies using alcohol or illicit substances.

Perceptual disturbances (attention directed towards non-apparent stimuli)

Denies alcohol or illicit drug use. No other relevant social history provided.

Dressed appropriately but displays minimal self-care.

No overt agitation, but appears withdrawn.

Slow, monotonous, with occasional stopping mid-sentence without completion.

Linear but impaired due to auditory hallucinations.

Auditory hallucinations with derogatory content, feelings of worthlessness.

Occasionally directs attention towards ceiling as if listening to someone.

No formal testing, but patient appears oriented.

Not fully assessed but likely impaired due to symptoms.


Evaluate and diagnose the patient presenting with intense itching and development of 'red bumps' on the thigh and other parts of the body.

The patient presents with intense itching of his right thigh region for the past few days. He also mentions the recent formation of ‘red bumps’ in the same area. The patient has recently attended a business conference in Miami. He has a past medical history of hypertension, diabetes type 2, and hyperlipidemia. The patient’s medication regimen includes enalapril, metformin, and atorvastatin. He denies any history of smoking or drinking.

Itching also present on the left leg and right forearm

Hypertension, Diabetes Type 2, Hyperlipidemia. Medications: Enalapril, Metformin, Atorvastatin.

Non-smoker, does not consume alcohol. Recently traveled to Miami for a business conference.

Denies fever, weight loss, recent illnesses, or other skin conditions.

A linear line with 3 red papules noted along the medial aspect of the right thigh. Small rows of bumps observed on his left leg and right forearm.

Excoriations present in the regions with the red bumps, indicative of significant scratching.

No evidence of mites or eggs, ruling out scabies.


Assess and diagnose the patient presenting with fatigue, lower leg swelling, and weight loss.

The patient reports a 10-day history of fatigue and bilateral lower leg swelling. He mentions a weight loss of 3.6 kg (8 lbs) over the past 6 months without trying. He has a history of chronic bronchitis and uses an albuterol inhaler as needed.

Lower leg swelling
Unintentional weight loss

History of smoking one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily.

The patient denies any recent cough, change in urinary habits, chest pain, dyspnea, or fevers.


Evaluate and diagnose the infant presenting with episodes of apnea and anemia.

The patient’s mother reports that the infant occasionally stops breathing while sleeping, with episodes increasing in frequency. The patient was born prematurely at 32 weeks due to placental insufficiency and required respiratory support immediately post-birth. Prenatal testing indicated the mother was not immune to rubella. The pregnancy was otherwise uncomplicated, with the mother taking only prenatal vitamins. The family history includes a healthy 3-year-old sister and a father with a heart condition.

Episodes of not breathing (apnea) during sleep

Increased frequency of apneic episodes
Pale conjunctiva

Premature birth at 32 weeks due to placental insufficiency. Stay in the neonatal intensive care unit for respiratory support.

The patient’s mother took prenatal vitamins. Father has a heart condition. One healthy sibling.

Patient has pale conjunctiva but no other symptoms or complaints provided by the mother.

Infant appears well-nourished but with pale conjunctiva.

No obvious distress while awake, but episodes of apnea observed during sleep.

Normocytic and normochromic red blood cells.


Evaluate and manage a pediatric patient presenting with a 3-week history of generalized fatigue, easy bruising, fever, and severe leg pain.

The patient has been experiencing generalized fatigue and easy bruising for 3 weeks. Over the past week, she has developed a fever and severe leg pain that wakes her up at night.

Fever
Severe leg pain that disturbs sleep

Attends preschool. Lives with parents and one younger sibling.

Positive for fever, bruising, and bone pain. Denies cough, vomiting, diarrhea, rash, or urinary symptoms.

Cervical and axillary lymphadenopathy detected

Palpable 3 cm below the right costal margin

Palpable 2 cm below the left costal margin

Predominantly immature cells that are positive for CD10, CD19, and TdT.


Evaluate and diagnose the patient presenting with wrist pain and difficulty in hand movement.

The patient reports experiencing pain in her right thumb and wrist, which radiates to her elbow for the past three months. The pain worsens when she holds her infant son and is alleviated somewhat with an ice pack. She mentions a history of falling on her right outstretched hand about six months ago. She also notes that her mother has a history of chronic joint pain treated with methotrexate. The patient has been taking ibuprofen as needed for her symptoms.

Pain in the right thumb and wrist, radiating to the elbow

Pain worsens with holding objects
Pain improves with ice pack application

Previous fall on right outstretched hand six months ago. No significant other medical history.

Patient is a mother of an infant, leading a relatively active lifestyle. Does not smoke or consume alcohol regularly.

Denies any fever, weight loss, or other joint problems.

Swelling over the radial styloid with no redness

Tenderness over the radial styloid. No crepitus.

Positive, eliciting pain on the radial side of the wrist when grasping the thumb and exerting longitudinal traction towards the ulnar side.

Normal range of motion of finger joints. No swelling, redness, or tenderness in other joints.


Assess and diagnose the patient presenting with confusion, abdominal pain, and vomiting.

The patient presents to the emergency department with confusion that started this morning. The patient's husband reports that she initially complained of abdominal pain, diarrhea, and fatigue after eating and has vomited 3 times. The patient has progressively become more confused throughout the day. The patient's past medical history includes morbid obesity, diabetes, hypertension, dyslipidemia, a sleeve gastrectomy 1 month ago, and depression with multiple suicide attempts.

Abdominal pain
Diarrhea
Fatigue
Vomiting

Morbid obesity, diabetes, hypertension, dyslipidemia, sleeve gastrectomy (1 month ago), depression with multiple suicide attempts.

Denies any fever. Reports abdominal pain, diarrhea, fatigue, and vomiting.

No visible surgical scars or distension.

Diffuse tenderness, no rebound or guarding.

Intact, as far as can be assessed in a confused state.

Assessment limited due to the patient's confusion.


Assess and diagnose the patient presenting with a scalp and forehead rash.

The parents report that the rash has been present for several weeks, noting that it sometimes appears red and scaly, especially during cold weather. The patient was born at 36 weeks' gestation and has been generally healthy since. The patient's father has a history of psoriasis.

Erythematous patches
Greasy yellow scales
Worse in cold weather

Premature birth (36 weeks), otherwise generally healthy. Family history of psoriasis.

The patient is 3 months old, so the social history is not applicable.

The patient appears comfortable, with no signs of distress or discomfort noted by the parents.

Erythematous patches observed on the scalp, forehead, and along the hairline.

Some patches covered by greasy yellow scales. No significant tenderness noted on palpation.


Evaluate the patient presenting with dizziness, nausea, and imbalance.

The patient reports a sustained sensation of the room spinning since this morning, which is low grade and constant. He occasionally feels nauseous and has taken diphenhydramine to help him sleep, which also alleviates his symptoms slightly. He mentions recent increased intake of garlic due to trying to recover from a cold a few days ago. Past medical history is unremarkable.

Sustained sensation of the room spinning

Use of diphenhydramine for symptoms and to aid sleep

Generally healthy with no significant past medical history.

Does not specify any social habits including smoking, alcohol use, or recreational drug use.

Denies fever, vomiting, significant headache, ear pain, recent foreign travel, known exposure to toxins or use of new medications.

Nystagmus noted, bilateral decreased hearing.

Unstable tandem gait but unremarkable baseline gait. Patient reports sensation of imbalance.

No examination details provided, but consider checking for signs of infection or inflammation.

Laying the patient flat rapidly with head turned to each side does not provoke symptoms.

Bilateral decreased hearing sensitivity, details not specified.

No acute abnormalities noted, specifically no signs of stroke or significant lesions.


Assess and diagnose the newborn presenting with yellowish discoloration of the skin.

The newborn's mother reports that her child has developed yellowish discoloration of the skin that started from the face and then spread to the trunk since the past day. There have been no changes in his bowel habits or urination. The baby was born full-term at 38 weeks’ gestation via an uncomplicated vaginal delivery and has been exclusively breastfed every 2–3 hours.

Discoloration started from the face then spread to the trunk

Born full term at 38 weeks via uncomplicated vaginal delivery. No past medical history.

Exclusive breastfeeding every 2–3 hours.

No reported changes in bowel habits or urination.

Jaundice noted on the face, chest, and abdomen.


Evaluate and diagnose the patient presenting with inappropriate behavior, changes in eating habits, and weight gain.

The patient has demonstrated inappropriate behavior, including making unfitting comments and attempts to kiss strangers, over the past 6 months. He shows disinterest in family interactions and has developed a particular craving for chocolate pudding and potato chips, resulting in a 10 kg weight gain. The patient also presents as unkempt.

Disinterest in family interactions
Craving for specific foods
Significant weight gain
Apathy
Blunted affect

No significant medical history provided.

No detailed social history provided; recent behavior includes attempting to initiate inappropriate physical contact with strangers.

The patient avoids questions and instead comments on unrelated subjects. Shows apathy towards surroundings and interactions.

Apathy and blunted affect, avoids answering questions. Mini-Mental State Examination score is 28/30.


Assess and diagnose the patient presenting with postmenopausal bleeding and an adnexal mass.

The patient presents with a 2-month history of intermittent postmenopausal bleeding. She denies any recent weight loss, fever, or changes in bladder or bowel habits. No previous history of similar symptoms. She has no history of serious illness and takes no medications regularly.

No recent weight loss
No fever
No changes in bladder or bowel habits

Non-smoker, does not consume alcohol, retired school teacher.

Denies nausea, vomiting, diarrhea, dysuria, or flank pain.

A palpable left adnexal mass, non-tender, uterus non-enlarged

Thickened endometrial stripe and left adnexal mass observed


Assess and diagnose the neonate who presents with seizures, lethargy, and other neurological signs three days post-delivery.

1100-g (2-lb 7-oz) newborn, 31 weeks' gestation

The patient was born three days ago with a birth weight of 1100 g at 31 weeks' gestation. The antenatal period was complicated by chorioamnionitis. Apgar scores were 3 and 6 at 1 and 5 minutes, respectively. The patient has become increasingly lethargic over the past 18 hours and experienced a tonic seizure lasting for 25 seconds.

Increasing lethargy over the past 18 hours

Premature birth at 31 weeks' gestation. Antenatal complications included chorioamnionitis.

Seizure, lethargy, slow conjugate back and forth movements of the eyes, decreased muscle tone in all extremities

Tense anterior fontanelle, pupils equal and react sluggishly to light

Slow, conjugate back and forth movements

Evidence of bleeding within the ventricles

Elevated, indicating inflammation or infection


Assess and diagnose the patient presenting with neck and arm pain, paresthesias, and muscle weakness.

The patient reports a year-long history of burning pain in his neck and arms, accompanying paresthesias in his hands. Over the past 3 months, he has experienced increasing weakness in both hands. He has a history of type 2 diabetes mellitus, hypercholesterolemia, and hypertension. He was involved in a motor vehicle accident 3 years ago.

Burning pain in neck and arms, and weakness in both hands

Paresthesias in hands
Absent reflexes
Decreased hand grip with fasciculations

Type 2 diabetes mellitus, hypercholesterolemia, hypertension, history of a motor vehicle accident 3 years prior.

Metformin Sitagliptin Enalapril Atorvastatin Aspirin

7 sexual partners, uses condoms inconsistently.

Oriented to time, place, and person. Vital signs within normal limits.

Absent over chest and bilateral upper arms

A syrinx (cavity) within the spinal cord extending from the cervical to the upper thoracic region.


Evaluate and manage a patient presenting with left chest pain, a productive cough with purulent sputum, and shortness of breath.

The patient reports experiencing left-sided chest pain and a productive cough with purulent sputum for the past week. He mentions shortness of breath. States he was diagnosed with influenza recently but did not adhere to the treatment plan provided.

Productive cough with purulent sputum
Shortness of breath

Diagnosed with influenza recently, with non-compliance to treatment. No other significant past medical or surgical history.

Non-smoker, occasional alcohol intake. Occupation and hobbies not specified.

Reports fever and malaise. Denies recent travel, animal exposures, or sick contacts.

No cyanosis or use of accessory respiratory muscles.

Decreased breath sounds at the left base, crackles.

Dullness to percussion over the left lower lung fields.

Alveolar infiltrates in the left base with air bronchograms


Assess and diagnose the patient presenting with sudden-onset symptoms of vertigo.

The patient presents to the emergency department with a sudden-onset sensation that the room is spinning, leading to several episodes of nausea and vomiting. The symptoms started as he was going to bed and lasted for approximately 3 minutes. He mentions that he has never experienced anything like this before and currently feels at his baseline.

Sudden-onset sensation of the room spinning

The patient is otherwise healthy with only a history of eczema. No prior episodes of similar nature.

Denies headaches, hearing loss, tinnitus, loss of consciousness or neurological deficits.

Physiologic nystagmus observed, with severe symptoms and notable nystagmus when head is turned to the left and laid back

Normal, with no evidence of stroke or masses.

Positive, inducing nystagmus and reproducing patient’s symptoms of vertigo when head is turned to the left and laid back.


Assess and diagnose the pregnant patient presenting with fever, headache, anorexia, fatigue, and malaise.

22-year-old female at 30 weeks gestation

The patient presents with a sudden onset of fever, headache, anorexia, fatigue, and malaise. She reports the consumption of ice cream 3 days prior to the onset of symptoms.

Unremarkable. The patient is currently pregnant, at her 30th week of gestation.

Non-smoker, does not consume alcohol. No recent travels or contact with sick individuals. No known allergies.

Denies cough, shortness of breath, abdominal pain, diarrhea, or urinary symptoms.

No abdominal distention apart from pregnancy.

No uterine tenderness. Fundal height appropriate for gestational age.

Alert and oriented, but appears fatigued.

Gram-positive rods that are catalase-positive and show distinctive tumbling motility in the liquid medium.


Assess and diagnose the patient presenting with swelling in the right knee and a familial history of similar problems.

The patient is brought in by his parents due to swelling in his right knee noticed after playing in the park. The parents report that there was no obvious injury or incident at the park that could have led to the swelling. Upon further questioning, the mother recalls that an uncle on her side of the family had similar problems, suggesting a possible genetic component.

No recent trauma or injury
Familial history of similar symptoms

The parents report no known allergies, normal birth and developmental history for the child.

Denies fever, rash, or recent illnesses.

Noticeable swelling in the right knee. No other swellings or deformities noted elsewhere.

Swelling is warm to touch, without overlying skin redness or signs of local infection.

Compatible with hemarthrosis of the right knee, no evidence of fracture or dislocation.


Assess and diagnose the patient presenting with abnormal behavior, difficulty swallowing, and involuntary movements.

The patient has been experiencing irritability, restlessness, and auditory hallucinations for the past year. Over the past month, the patient has also developed difficulty swallowing. She has a 2-year history of depression, and was terminated from her job 6 months ago due to performance issues linked to forgetfulness. Family history includes the patient's father committing suicide at the age of 50. The patient has smoked one pack of cigarettes daily for the past 20 years and has a history of cocaine use for 8 years but quit 1 year ago.

Hearing voices, irritability, and restlessness

Difficulty swallowing
Memory issues
Involuntary movements
Poor articulation

Current smoker, past cocaine use (ceased 1 year ago).

Patient exhibits confusion, and is oriented to person and place only.

Confused, oriented to person and place only.

Irregular, nonrepetitive, and arrhythmic movements of the neck and head observed.

Delayed return to neutral ankle position after triggering the plantar reflex.

Atrophy of the caudate nuclei with ex vacuo dilatation of the frontal horns of the lateral ventricles.

Positive for the huntingtin (HTT) gene mutation.


Assess and diagnose the newborn presenting with increasing yellow discoloration of the eyes and skin.

The patient has been experiencing increasing yellow discoloration of her eyes and skin for 2 days. She was born at 39 weeks' gestation, initially weighed 3066 g and now weighs 3200 g. The patient is exclusively breastfed.

Increasing yellow discoloration of the eyes and skin

Brother died 3 months after liver surgery

Born at 39 weeks' gestation. Exclusive breastfeeding. Family history notable for older brother's death possibly related to liver issues.

Temperature of 37.1°C, pulse of 145/min, and respirations of 40/min. No other symptoms reported by the caregiver.

Yellow discoloration of the eyes and skin extending to the palms and soles.

Liver palpated 1 cm below the right costal margin. No other abnormal findings.


Assess and diagnose the patient presenting with a 2-day history of fever and altered mentation.

The patient presents with a 2-day history of fever and altered mentation, reporting fever without chills and rigors. He denies sore throat, abdominal pain, headache, loose stool, burning micturition, or seizures. Has a history of tics and is currently taking haloperidol.

Normal deep tendon reflexes with bilateral downgoing plantar responses

History of tics, currently on a low dose of haloperidol.

Patient details on social and occupational history not provided.

Denies headache, abdominal pain, loose stools, burning micturition, or seizures.

Generalized rigidity, able to move all limbs


Assess and diagnose an 8-year-old patient presenting with difficulty sleeping, characterized by episodes of waking up frightened.

The patient has been experiencing difficulty sleeping for the past 2 months, with episodes of waking up frightened occurring one to two times per week. During these episodes, she yells and cries but does not seem confused after waking and can be consoled by her parents. The following day, she appears more tired than usual.

Difficulty sleeping with episodes of waking up frightened

Yelling and crying during sleep episodes

Met all developmental milestones with no significant medical history.

Attends school regularly, with usual playing habits and interactions with peers. Lives with both parents.

No significant findings in other systems. No history of trauma or significant stress identified.

Fully alert and oriented to time, place, and person

Normal motor strength and sensory responses throughout

The patient's sleep diary reveals a pattern correlating with the described episodes, with noted disturbances occurring 1-2 times a week.

Not indicated at this stage based on history and normal physical examination.


Assess and diagnose the patient presenting with a longstanding pruritic rash, numbness, and tingling sensation on the palms.

The patient reports a year-long history of an itchy rash on his upper body and face. Additionally, he has been experiencing a numbness and tingling sensation on both palms. He has been working on his family's rice farm, also caring for livestock.

Numbness and tingling sensation of both palms

Works as a farmer, no history of travel outside the local area.

Denies fever, weight loss, changes in vision, or any respiratory symptoms.

Multiple erythematous macules and papules on the face, arms, chest, and back. Hypopigmented macules around the elbows.

Insensitivity to light touch, temperature, and pinprick around the hypopigmented areas. Slight reduction in grip strength bilaterally.

Chronic inflammatory cells with features suggestive of leprosy.

Reduced sensory nerve action potentials in the ulnar nerves.


Evaluate and diagnose the skin condition present on the patient's left dorsal hand.

The patient is here for an annual well-check. She has a history of well-controlled diabetes and hypertension, managed with metformin and losartan, respectively. She reports maintaining a healthy diet primarily consisting of vegetables and lean meat, denies any tobacco or alcohol use, and enjoys outdoor activities like walking and sunbathing.

The presence of a rough, scaly, sandpaper-like plaque on the left dorsal hand

Non-smoker, denies alcohol use, enjoys outdoor activities

Unremarkable except for the skin condition described

A rough, scaly plaque observed on the left dorsal hand. No other visible abnormalities.

No tenderness or pain upon palpation of the lesion.

Hyperkeratosis with parakeratosis, solar elastosis, and atypical keratinocytes confined to the epidermis. These findings are consistent with actinic keratosis.


Assess and diagnose the patient presenting with fatigue, unintentional weight loss, and abnormal physical examination findings.

The patient reports a 6-month history of fatigue and an unintentional weight loss of 5 kg (11 lb) despite maintaining a good appetite. He denies any recent changes in his diet or physical activity. He takes no medications and does not smoke or use illicit drugs.

5 kg unintentional weight loss over 6 months

No significant past medical history. Patient denies any chronic illnesses or prior hospitalizations.

Retired engineer; denies tobacco use or illicit drug use. Drinks alcohol socially.

Denies fever, night sweats, changes in bowel or bladder habits, recent infections, or bleeding disorders.

Looks his stated age, no acute distress.

No pallor, icterus, or lymphadenopathy in the head and neck region.

Diffuse dullness over the left upper quadrant and right upper quadrant.


Assess and diagnose the patient presenting with concerns from her mother regarding attention issues and a change in behavior.

The patient's mother reports her daughter has been performing poorly academically since starting high school. The mother is concerned about her daughter's lack of communication and perceives her daughter as having attention issues.

Mother reports lackluster grades and perceived attention issues.

Patient shows irritability towards mother

Social withdrawal from previously enjoyed activities

Expresses unhappiness with current social situation

Denies suicidal ideation or intention to harm others

No significant past medical or psychiatric history.

Denies smoking cigarettes or marijuana use.

Mentions disinterest in previously enjoyed social activities like hanging out with peers from the cheerleading squad.

Negative for signs of depression or anxiety such as sleep disturbances, significant weight change, or excessive worries.

Casually dressed, chewing gum, appears her stated age.

Cooperative, but shows irritability in context of discussion about her mother.

Constricted, but appropriate to context.

Denies hallucinations, delusions, or suicidal ideation.

Alert and oriented to time, place, and person.

Patient scores on the lower end, indicating no significant signs of depression.

Patient scores do not suggest an anxiety disorder.

Patient's symptoms do not align with a diagnosis of ADHD.


Assess and diagnose the patient presenting with hand tremors and recent memory issues.

The patient first noticed the tremor in his left hand 1 year ago, which has been progressively worsening. Recently, he has faced difficulty in performing tasks that require steadiness, such as reading. His wife has observed a decline in his memory, taking note of his forgetfulness in paying bills, a task she has since had to assume.

Soft speech
Reduced facial expressions
Memory decline
Difficulty in managing finances

Hypertension, medicated with aspirin and amlodipine. Family history of schizophrenia in his mother. No other significant medical or psychiatric history.

Drinks 1-2 beers nightly and is a former cigar smoker.

Denies any other systemic complaints. Specifically, no urinary symptoms, no significant changes in bowel habits, no reported falls or dizziness.

Resting tremor present, worsened by emotional stress or concentration

Mild rigidity noted during manipulation of bilateral upper extremities

No acute abnormalities. Mild age-appropriate cerebral atrophy.


Evaluate and diagnose the patient presenting with headache and worsening vision over a 3-week period.

The patient reports a 3-week history of headache and progressively worsening vision. She has not noticed any other symptoms, including no recent weight changes, no fevers, no night sweats, and no pain elsewhere in the body.

Worsening vision over the past 3 weeks
No weight changes
No fevers
No night sweats
No other pain

The patient has hypertension, which is controlled with medication. She also has a history of high cholesterol.

Retired school teacher. Non-smoker and drinks alcohol socially. No recreational drug use.

Denies nausea, vomiting, diarrhea. No recent travel or sick contacts. No changes in hearing. Denies neck stiffness or photophobia.

Details are not provided in this scenario but imagine findings suggestive of retinal vein occlusion or hemorrhages.

Not specified in this scenario, but imagine findings are indicative of increased circulating immunoglobulins.

Increased concentration of a pentameric immunoglobulin, consistent with a monoclonal gammopathy.


Evaluate and diagnose the patient presenting with weakness and decreased sensation in the right arm.

The patient has been experiencing weakness in his right arm for a few weeks, which has progressively worsened to the point of dropping objects. He also reports a recent unexplained weight loss of 17 pounds and has a history of diabetes. The patient admits to chronic alcohol use, heavy smoking, and anabolic steroid use.

Dull aching and burning pain in the right arm

Drinks 2-7 alcoholic beverages per day. Has smoked 2 packs of cigarettes per day since he was 25. Uses anabolic steroids.

Denies recent fevers, changes in vision, difficulty speaking, or changes in balance.

2/5 strength in the right arm and 5/5 strength in the left arm

Mass noted at the apex of the right lung

Solid mass at the apex of the right lung, suggestive of a tumor


Assess and manage a patient presenting with chronic cough, weight loss, and generalized weakness.

The patient reports having a fever, cough, weakness, night sweats, and poor appetite persisting for 6 months. He has lost 7.5 kg (16.5 lb) over this period. No history of breathlessness, nasal discharge, nasal obstruction, palpitations, chest pain, or digestive symptoms. Released from prison 9 months ago after a 2-year sentence.

Weight loss
Night sweats
Generalized weakness
Poor appetite

No significant past medical history reported.

History of incarceration. No other relevant social history provided.

Denies breathlessness, nasal discharge, nasal obstruction, palpitations, chest pain, or digestive symptoms.

Diffuse crackles throughout the lung fields bilaterally

Three discrete, yellow-colored, 0.5 mm to 1.0 mm lesions with indistinct borders in the posterior pole


Evaluate the patient with persistent vomiting and chest pain, perform necessary examinations, and establish a diagnosis.

The patient presents to the emergency department with persistent, forceful vomiting after consuming a significant amount of alcohol. His medical history includes recent treatment for Lyme disease with doxycycline. Recently, after a prolonged episode of retching, the patient starts to choke and cough forcefully, experiencing chest pain. The patient appears unable to communicate effectively at this point.

Choking and coughing forcefully
Chest pain
Inability to communicate

Significant for Lyme disease, currently being treated with doxycycline.

Reported alcohol use; found next to an empty bottle of vodka.

Patient appears toxic and in acute distress, unable to provide a comprehensive review of systems.

Crunching, rasping sound heard over the chest

Possible crepitus on palpation of the chest and neck

Free mediastinal air visible, suggesting perforation


Assess and diagnose the patient presenting with a chronic wound on his right lower leg.

The patient reports a large wound on his right lower leg that has been present for 6 months. He mentions that his legs have been chronically swollen for over 10 years and that his mother and brother had similar leg problems. He had a documented deep vein thrombosis (DVT) in the affected leg 5 years ago but has no other significant past medical history.

Chronic leg swelling
Family history of similar leg problems

Deep vein thrombosis in the right leg 5 years prior. No other significant medical history.

Non-smoker, drinks alcohol socially. Works as an accountant.

Denies fever, recent injuries, heart disease, or diabetes.

Large ulcer on the right lower leg, presence of varicose veins

Edema in both legs, more pronounced in the right leg

Dorsalis pedis and posterior tibial pulses are palpable but diminished in the right leg

Skin around the wound is discolored with evidence of chronic changes such as pigmentation

Evidence of venous reflux and obstruction in superficial and deep venous systems of the right leg


Evaluate and manage a patient with psychiatric condition and new onset movement disorder.

The patient is here for a follow-up appointment. He was recently diagnosed with schizophrenia and started on risperidone approximately 2 months ago. Reports a significant improvement in psychiatric symptoms since the start of treatment.

Inability to remain still, persistent feeling of restlessness

Repetitive crossing and uncrossing of legs

Recently diagnosed with schizophrenia. No other significant past medical history.

College student, lives with parents. Denies tobacco, alcohol, or drug use.

Improvement in delusions, hallucinations, and paranoid behaviors since starting risperidone.

No history of seizures, headaches, or previous movement disorders.

Alert and oriented to person, place, time, and situation. Improved psychotic symptoms.

Normal tone and strength in all extremities. No involuntary movements noted.

Normal, but patient exhibits inability to sit still with frequent pacing


Assess and diagnose the newborn presenting with respiratory distress.

Newborn, born after the 32nd gestational week

The baby was born via cesarean delivery. The mother had gestational diabetes but was otherwise healthy with no other pregnancy-related diseases.

Tachypnea
Subcostal and intercostal retractions
Nasal flaring
Cyanosis

The mother had gestational diabetes. No other significant family or prenatal history.

The cyanosis improves with oxygen administration. No feeding difficulties were noted prior to onset of symptoms.

Cyanosis noted, especially around the lips. Subcostal and intercostal retractions present.

Reduced breath sounds, no distinct wheezes or crackles initially noted.

Ground-glass appearance, air bronchograms, suggesting Respiratory Distress Syndrome (RDS)

Neonatal Respiratory Distress Syndrome (NRDS)


Assess and diagnose the patient presenting with blisters on her forearm and ulcers on mucosal surfaces.

The patient reports the appearance of blisters on her forearm 3 days ago, accompanied by pain in her left cheek when eating and pain during sexual intercourse for the past week. She has been hiking in the woods recently but denies contact with poison ivy. She has a history of hypertension and osteoarthritis, recently started taking captopril, and discontinued meloxicam 2 weeks ago. Family history includes pernicious anemia and Graves' disease.

Ulcers on the buccal, gingival, and vulvar mucosa

Recently started captopril, stopped taking meloxicam 2 weeks ago.

Has started hiking in the woods on weekends. No relevant travel history.

No recent illnesses, denies fever, respiratory symptoms, or gastrointestinal symptoms.

Multiple, flaccid blisters on the volar surface of the forearm, with 10% total body surface area involvement.

Skin separation (Nikolsky sign positive) when lightly stroked.

Ulcers present on the buccal, gingival, and vulvar mucosa.

Acantholysis and intraepidermal blister formation.

Intercellular IgG and C3 deposition within the epidermis.


Assess and diagnose the patient presenting with right leg weakness, unsteady gait, multiple falls, forgetfulness, and paranoid behavior.

The patient's daughter reports a 1-week history of right leg weakness, unsteady gait, and multiple falls. Over the past 6 months, the patient has been increasingly forgetful, losing his way on familiar routes and facing difficulties operating simple kitchen appliances. He has also been paranoid, agitated, and restless recently.

Forgetfulness
Paranoid and agitated behavior
Difficulty in using kitchen appliances

Known history of HIV, hypertension, and type 2 diabetes mellitus. Noncompliance with medications for over 2 years.

The patient is somnolent and slightly confused, oriented to person but not to place or time. Mild lymphadenopathy is noted.

Somnolent, slightly confused, oriented to person but not place or time.

Right lower extremity weakness with normal tone, no other focal deficits.

Disseminated, nonenhancing white matter lesions with no mass effect.