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stellalisy

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[ "A 28-year-old woman presents to the clinic with 2 months of palpitations, tremor, heat intolerance, insomnia, and loose bowel movements.", "She has lost 20 kg (44 lb).", "A physical examination indicates that the body temperature is 37.8°C (100.0°F), the heart rate is 120/min, and the blood pressure is 130/80 mm Hg.", "The examination also reveals that a moderately-sized diffuse goiter and a bruit were present.", "She was agitated and experienced a fine tremor with warm moist palms; she also had increased deep tendon reflexes.", "No exophthalmos was noted.", "The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L), T4: 57 pmol/L (normal: 10–25 pmol/L), T3: 24 pmol/L (normal 3.1–5.4 pmol/L).", "Complete blood count was normal.", "A thyroid scan demonstrated diffusely increased uptake.", "A high level of thyroid-stimulating immunoglobulin antibodies was detected." ]

[ "1. A 28-year-old woman presents to the clinic with 2 months of palpitations, tremor, heat intolerance, insomnia, and loose bowel movements.", "2. She has lost 20 kg (44 lb).", "3. A physical examination indicates that the body temperature is 37.8°C (100.0°F).", "4. The heart rate is 120/min.", "5. The blood pressure is 130/80 mm Hg.", "6. The examination also reveals that a moderately-sized diffuse goiter and a bruit were present.", "7. She was agitated and experienced a fine tremor with warm moist palms.", "8. She also had increased deep tendon reflexes.", "9. No exophthalmos was noted.", "10. The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L).", "11. T4: 57 pmol/L (normal: 10–25 pmol/L).", "12. T3: 24 pmol/L (normal 3.1–5.4 pmol/L).", "13. Complete blood count was normal.", "14. A thyroid scan demonstrated diffusely increased uptake.", "15. A high level of thyroid-stimulating immunoglobulin antibodies was detected." ]

[ "1. She has lost 20 kg (44 lb).", "2. The body temperature is 37.8°C (100.0°F).", "3. The heart rate is 120/min.", "4. The blood pressure is 130/80 mm Hg.", "5. A moderately-sized diffuse goiter and a bruit were present.", "6. She was agitated and experienced a fine tremor with warm moist palms.", "7. She had increased deep tendon reflexes.", "8. No exophthalmos was noted.", "9. The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L).", "10. T4: 57 pmol/L (normal: 10–25 pmol/L).", "11. T3: 24 pmol/L (normal 3.1–5.4 pmol/L).", "12. Complete blood count was normal.", "13. A thyroid scan demonstrated diffusely increased uptake.", "14. A high level of thyroid-stimulating immunoglobulin antibodies was detected." ]

[ "A 45-year-old woman comes to the physician because of fatigue and irregular menstrual cycles for the past year.", "She also complains of recurrent sinus infections.", "During the past 6 months, she has had increased urinary frequency and swelling of her feet.", "She has also had difficulty lifting her 3-year-old niece for the past 3 weeks.", "She was recently diagnosed with depression.", "She works as a medical assistant.", "The patient has smoked one half-pack of cigarettes daily for 25 years and drinks four beers on the weekends.", "Her only medication is escitalopram.", "She is 160 cm (5 ft 3 in) tall and weighs 79 kg (175 lb); BMI is 31 kg/m2.", "She appears tired.", "Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/82 mm Hg.", "Physical examinations shows neck obesity and an enlarged abdomen.", "Examination of the skin shows multiple bruises on her arms and legs.", "There is generalized weakness and atrophy of the proximal muscles.", "Laboratory studies show: | Serum | Na+ 150 mEq/L | K+ 3.0 mEq/L | Cl- 103 mEq/L | HCO3- 30 mEq/L | Urea nitrogen 19 mg/dL | Creatinine 0.9 mg/dL | Glucose 136 mg/dL | A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50) and a 24-hour urinary cortisol is 425 μg (N < 300 μg).", "Serum ACTH is 169 pg/mL (N = 7–50).", "Subsequently, a high-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50)." ]

[ "1. Patient is a 45-year-old woman.", "2. Patient has been experiencing fatigue and irregular menstrual cycles for the past year.", "3. Patient has had recurrent sinus infections.", "4. Patient has had increased urinary frequency and swelling of her feet for the past 6 months.", "5. Patient has had difficulty lifting her 3-year-old niece for the past 3 weeks.", "6. Patient was recently diagnosed with depression.", "7. Patient works as a medical assistant.", "8. Patient has smoked one half-pack of cigarettes daily for 25 years.", "9. Patient drinks four beers on the weekends.", "10. Patient's only medication is escitalopram.", "11. Patient is 160 cm (5 ft 3 in) tall.", "12. Patient weighs 79 kg (175 lb); BMI is 31 kg/m2.", "13. Patient appears tired.", "14. Patient's temperature is 37°C (98.6°F).", "15. Patient's pulse is 80/min.", "16. Patient's respirations are 18/min.", "17. Patient's blood pressure is 140/82 mm Hg.", "18. Physical examinations shows neck obesity and an enlarged abdomen.", "19. Examination of the skin shows multiple bruises on her arms and legs.", "20. There is generalized weakness and atrophy of the proximal muscles.", "21. Serum Na+ is 150 mEq/L.", "22. Serum K+ is 3.0 mEq/L.", "23. Serum Cl- is 103 mEq/L.", "24. Serum HCO3- is 30 mEq/L.", "25. Serum urea nitrogen is 19 mg/dL.", "26. Serum creatinine is 0.9 mg/dL.", "27. Serum glucose is 136 mg/dL.", "28. A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50).", "29. 24-hour urinary cortisol is 425 μg (N < 300 μg).", "30. Serum ACTH is 169 pg/mL (N = 7–50).", "31. High-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50)." ]

[ "1. The patient complains of recurrent sinus infections.", "2. Over the past 6 months, she has experienced increased urinary frequency and swelling of her feet.", "3. She has had difficulty lifting her 3-year-old niece for the past 3 weeks.", "4. The patient was recently diagnosed with depression.", "5. She works as a medical assistant.", "6. The patient has smoked one half-pack of cigarettes daily for 25 years and drinks four beers on the weekends.", "7. Her only medication is escitalopram.", "8. She is 160 cm (5 ft 3 in) tall and weighs 79 kg (175 lb); BMI is 31 kg/m2.", "9. The patient appears tired.", "10. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/82 mm Hg.", "11. Physical examination shows neck obesity and an enlarged abdomen.", "12. Examination of the skin shows multiple bruises on her arms and legs.", "13. There is generalized weakness and atrophy of the proximal muscles.", "14. Laboratory studies show: Serum Na+ 150 mEq/L, K+ 3.0 mEq/L, Cl- 103 mEq/L, HCO3- 30 mEq/L, Urea nitrogen 19 mg/dL, Creatinine 0.9 mg/dL, Glucose 136 mg/dL.", "15. A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50) and a 24-hour urinary cortisol is 425 μg (N < 300 μg).", "16. Serum ACTH is 169 pg/mL (N = 7–50).", "17. Subsequently, a high-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50)." ]

[ "A 39-year-old woman, gravida 3, para 2, at 39 weeks' gestation is admitted to the hospital with leakage of fluid and contractions.", "She noticed the fluid leak about an hour ago and has no associated bleeding.", "Contractions have been about 20 minutes apart.", "On admission, she is dilated 2 cm, 50% effaced, and at -2 station.", "Spontaneous rupture of membranes is confirmed and she is monitored by external tocodynamometer.", "Repeat evaluation after 2 hours shows dilation of 6 cm , 70% effacement, and -1 station.", "Four hours later, her pelvic exam shows no changes and she has 4 strong contractions every 10 minutes.", "The fetal heart rate is 120/min, with moderate accelerations and no late or variable decelerations." ]

[ "1. Patient is 39 years old.", "2. Patient is gravida 3, para 2.", "3. Patient is at 39 weeks' gestation.", "4. Patient has leakage of fluid and contractions.", "5. Patient noticed fluid leak about an hour ago.", "6. Patient has no associated bleeding.", "7. Contractions are about 20 minutes apart.", "8. On admission, patient is dilated 2 cm, 50% effaced, and at -2 station.", "9. Spontaneous rupture of membranes is confirmed.", "10. Patient is monitored by external tocodynamometer.", "11. Repeat evaluation after 2 hours shows dilation of 6 cm, 70% effacement, and -1 station.", "12. Four hours later, pelvic exam shows no changes.", "13. Patient has 4 strong contractions every 10 minutes.", "14. Fetal heart rate is 120/min.", "15. Fetal heart rate has moderate accelerations.", "16. Fetal heart rate has no late or variable decelerations." ]

[ "1. She noticed the fluid leak about an hour ago", "2. She has no associated bleeding", "3. Contractions have been about 20 minutes apart", "4. On admission, she is dilated 2 cm", "5. She is 50% effaced", "6. She is at -2 station", "7. Spontaneous rupture of membranes is confirmed", "8. She is monitored by external tocodynamometer", "9. Repeat evaluation after 2 hours shows dilation of 6 cm", "10. She is 70% effaced", "11. She is at -1 station", "12. Four hours later, her pelvic exam shows no changes", "13. She has 4 strong contractions every 10 minutes", "14. The fetal heart rate is 120/min", "15. The fetal heart rate shows moderate accelerations", "16. There are no late or variable decelerations" ]

[ "A 32-year-old homeless man presents to the emergency department with dyspnea, left-sided chest pain, chills, and a productive cough over the last week or so.", "He does not have medical insurance and has not seen a doctor for many years.", "His chest pain increases with inspiration.", "The pain does not radiate or worsen with movement.", "He states that has a productive cough with yellow sputum with flecks of blood.", "He drinks 6 beers a night and does not smoke or take illicit drugs.", "Temperature is 37.8°C (100.0°F), blood pressure is 124/90 mm Hg, pulse is 92/min, and respiration rate is 16/min.", "On physical examination, tactile fremitus is increased and there is a dullness to percussion over the lower part of the left lung.", "No murmurs are heard.", "Oral examination reveals poor dentition.", "Chest X-ray reveals a large left lobar opacification with extensive pleural effusion." ]

[ "1. Patient is 32 years old.", "2. Patient is homeless.", "3. Patient presents with dyspnea, left-sided chest pain, chills, and a productive cough over the last week or so.", "4. Patient has not had medical insurance and has not seen a doctor for many years.", "5. Patient's chest pain increases with inspiration.", "6. Patient's chest pain does not radiate or worsen with movement.", "7. Patient has a productive cough with yellow sputum with flecks of blood.", "8. Patient drinks 6 beers a night.", "9. Patient does not smoke or take illicit drugs.", "10. Patient's temperature is 37.8°C (100.0°F).", "11. Patient's blood pressure is 124/90 mm Hg.", "12. Patient's pulse is 92/min.", "13. Patient's respiration rate is 16/min.", "14. On physical examination, tactile fremitus is increased.", "15. On physical examination, there is a dullness to percussion over the lower part of the left lung.", "16. On physical examination, no murmurs are heard.", "17. Oral examination reveals poor dentition.", "18. Chest X-ray reveals a large left lobar opacification with extensive pleural effusion." ]

[ "1. He does not have medical insurance.", "2. He has not seen a doctor for many years.", "3. His chest pain increases with inspiration.", "4. The pain does not radiate or worsen with movement.", "5. He has a productive cough with yellow sputum with flecks of blood.", "6. He drinks 6 beers a night.", "7. He does not smoke or take illicit drugs.", "8. His temperature is 37.8°C (100.0°F).", "9. His blood pressure is 124/90 mm Hg.", "10. His pulse is 92/min.", "11. His respiration rate is 16/min.", "12. On physical examination, tactile fremitus is increased.", "13. There is a dullness to percussion over the lower part of the left lung.", "14. No murmurs are heard.", "15. Oral examination reveals poor dentition.", "16. Chest X-ray reveals a large left lobar opacification with extensive pleural effusion." ]

[ "A 43-year-old woman presents with left calf pain.", "She denies any previous episodes of such pain.", "Past medical history is significant for cervical carcinoma treated with cryosurgery with no evidence of recurrence.", "Current medications are an estrogen-containing oral contraceptive and a multivitamin.", "The patient reports a 40-pack-year smoking history, but no alcohol or recreational drug use.", "The patient is afebrile and her vital signs are within normal limits.", "On physical examination, her left calf is swollen, erythematous, and tender to palpation.", "A D-dimer level is positive." ]

[ "1. Patient is 43 years old.", "2. Patient presents with left calf pain.", "3. Patient denies any previous episodes of such pain.", "4. Patient has past medical history of cervical carcinoma treated with cryosurgery with no evidence of recurrence.", "5. Patient is currently taking an estrogen-containing oral contraceptive and a multivitamin.", "6. Patient has a 40-pack-year smoking history, but no alcohol or recreational drug use.", "7. Patient is afebrile and her vital signs are within normal limits.", "8. On physical examination, her left calf is swollen, erythematous, and tender to palpation.", "9. D-dimer level is positive." ]

[ "1. She denies any previous episodes of such pain.", "2. Past medical history is significant for cervical carcinoma treated with cryosurgery with no evidence of recurrence.", "3. Current medications are an estrogen-containing oral contraceptive and a multivitamin.", "4. The patient reports a 40-pack-year smoking history, but no alcohol or recreational drug use.", "5. The patient is afebrile and her vital signs are within normal limits.", "6. On physical examination, her left calf is swollen, erythematous, and tender to palpation.", "7. A D-dimer level is positive." ]

[ "A 53-year-old woman with hypertension and hyperlipidemia comes to the physician because of a 3-month history of progressively worsening shortness of breath.", "Her pulse is 92/min, respirations are 22/min, and blood pressure is 110/70 mm Hg.", "Cardiac examination shows a grade 3/6 holosystolic murmur at the apex that radiates to the axilla and an extra heart sound during early diastole." ]

[ "1. A 53-year-old woman comes to the physician.", "2. She has hypertension and hyperlipidemia.", "3. She has a 3-month history of progressively worsening shortness of breath.", "4. Her pulse is 92/min.", "5. Her respirations are 22/min.", "6. Her blood pressure is 110/70 mm Hg.", "7. Cardiac examination shows a grade 3/6 holosystolic murmur at the apex.", "8. The murmur radiates to the axilla.", "9. There is an extra heart sound during early diastole." ]

[ "1. Pulse rate: 92/min", "2. Respiratory rate: 22/min", "3. Blood pressure: 110/70 mm Hg", "4. Cardiac examination: Grade 3/6 holosystolic murmur at the apex", "5. Murmur radiation: To the axilla", "6. Extra heart sound: During early diastole" ]

[ "A 66-year-old man presents to his primary care physician with abdominal pain in the setting of progressively worsening constipation.", "He complains of epigastric pain that waxes and wanes, and expressed concern that he has not defecated for the past 5 days.", "Upon further questioning, he relates that he has been taking three of his wife's multivitamins each day for the past three weeks to \"combat a cold.\" Vital signs are within normal limits.", "Physical exam reveals an abdomen with nonspecific tenderness to deep palpation without rebound tenderness, hyperpercussion, or flank tenderness." ]

[ "1. A 66-year-old man presents to his primary care physician with abdominal pain.", "2. The abdominal pain is in the setting of progressively worsening constipation.", "3. He complains of epigastric pain that waxes and wanes.", "4. He has not defecated for the past 5 days.", "5. He has been taking three of his wife's multivitamins each day for the past three weeks.", "6. Vital signs are within normal limits.", "7. Physical exam reveals an abdomen with nonspecific tenderness to deep palpation.", "8. There is no rebound tenderness, hyperpercussion, or flank tenderness." ]

[ "1. Patient complains of epigastric pain", "2. Pain waxes and wanes", "3. Patient has not defecated for the past 5 days", "4. Patient has been taking three of his wife's multivitamins each day for the past three weeks", "5. Patient took multivitamins to combat a cold", "6. Vital signs are within normal limits", "7. Physical exam reveals nonspecific tenderness in the abdomen to deep palpation", "8. No rebound tenderness, hyperpercussion, or flank tenderness" ]

[ "Two days after undergoing transsphenoidal removal of a pituitary macroadenoma, a 35-year-old woman reports increased thirst and frequent urination.", "The surgery was uncomplicated.", "Neurologic examination shows no abnormalities.", "Her serum sodium concentration is 153 mEq/L and serum glucose concentration is 92 mg/dL." ]

[ "1. A 35-year-old woman underwent transsphenoidal removal of a pituitary macroadenoma.", "2. Two days after the surgery, the woman reported increased thirst and frequent urination.", "3. The surgery was uncomplicated.", "4. Neurologic examination showed no abnormalities.", "5. The woman's serum sodium concentration was 153 mEq/L.", "6. The woman's serum glucose concentration was 92 mg/dL." ]

[ "1. The surgery was uncomplicated.", "2. Neurologic examination shows no abnormalities.", "3. Her serum sodium concentration is 153 mEq/L.", "4. Her serum glucose concentration is 92 mg/dL." ]

[ "A 67-year-old woman comes to the physician because of a 5-day history of episodic abdominal pain, nausea, and vomiting.", "She has coronary artery disease and type 2 diabetes mellitus.", "She takes aspirin, metoprolol, and metformin.", "She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2.", "Her temperature is 38.1°C (100.6°F).", "Physical examination shows dry mucous membranes, abdominal distension, and hyperactive bowel sounds.", "Ultrasonography of the abdomen shows air in the biliary tract." ]

[ "1. A 67-year-old woman comes to the physician.", "2. She has a 5-day history of episodic abdominal pain, nausea, and vomiting.", "3. She has coronary artery disease and type 2 diabetes mellitus.", "4. She takes aspirin, metoprolol, and metformin.", "5. She is 163 cm (5 ft 4 in) tall.", "6. She weighs 91 kg (200 lb).", "7. Her BMI is 34 kg/m2.", "8. Her temperature is 38.1°C (100.6°F).", "9. Physical examination shows dry mucous membranes.", "10. Physical examination shows abdominal distension.", "11. Physical examination shows hyperactive bowel sounds.", "12. Ultrasonography of the abdomen shows air in the biliary tract." ]

[ "1. She has coronary artery disease.", "2. She has type 2 diabetes mellitus.", "3. She takes aspirin.", "4. She takes metoprolol.", "5. She takes metformin.", "6. She is 163 cm (5 ft 4 in) tall.", "7. She weighs 91 kg (200 lb).", "8. Her BMI is 34 kg/m2.", "9. Her temperature is 38.1°C (100.6°F).", "10. Physical examination shows dry mucous membranes.", "11. Physical examination shows abdominal distension.", "12. Physical examination shows hyperactive bowel sounds.", "13. Ultrasonography of the abdomen shows air in the biliary tract." ]

[ "A 47-year-old man presents to his ophthalmologist for abnormal vision.", "The patient was discharged from the hospital 2 weeks ago after a motor vehicle accident where he was given 1L of blood.", "He also underwent several surgical procedures including enucleation of the right globe and exploratory abdominal laparotomy to stop internal bleeding.", "Currently, he states that he has noticed decreased vision in his left eye.", "The patient has a past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.", "His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 97% on room air.", "Physical exam is notable for 20/200 vision in the patient's left eye, which is worse than usual.", "The patient's left eye appears red and irritated." ]

[ "1. Patient is 47 years old.", "2. Patient was discharged from hospital 2 weeks ago after motor vehicle accident.", "3. Patient was given 1L of blood.", "4. Patient underwent enucleation of right globe and exploratory abdominal laparotomy.", "5. Patient has noticed decreased vision in left eye.", "6. Patient has past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.", "7. Patient's temperature is 98.9°F (37.2°C).", "8. Patient's blood pressure is 167/108 mmHg.", "9. Patient's pulse is 90/min.", "10. Patient's respirations are 14/min.", "11. Patient's oxygen saturation is 97% on room air.", "12. Patient's vision in left eye is 20/200.", "13. Patient's left eye appears red and irritated." ]

[ "1. The patient was discharged from the hospital 2 weeks ago after a motor vehicle accident.", "2. The patient was given 1L of blood.", "3. The patient underwent enucleation of the right globe.", "4. The patient underwent exploratory abdominal laparotomy to stop internal bleeding.", "5. The patient has noticed decreased vision in his left eye.", "6. The patient has a past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.", "7. The patient's temperature is 98.9°F (37.2°C).", "8. The patient's blood pressure is 167/108 mmHg.", "9. The patient's pulse is 90/min.", "10. The patient's respirations are 14/min.", "11. The patient's oxygen saturation is 97% on room air.", "12. The patient's physical exam is notable for 20/200 vision in the left eye.", "13. The patient's left eye appears red and irritated." ]

[ "A 26-year-old female presents to her primary care physician with several months of mood swings, which she feels are affecting her work and personal relationships.", "She states that on roughly a quarter of days each month, she feels highly irritable, sensitive to criticism and rejection, and easily saddened.", "She also feels that her appetite varies greatly, and on the days when she is particularly emotional, she also feels especially hungry.", "As a result of these symptoms, her performance at work has suffered, and her boyfriend has been complaining that she is difficult to live with.", "She is anxious that she cannot “get my mood under control.” The patient has no past medical history, regular periods every 28 days, and no obstetric history.", "She uses condoms for contraception.", "Her mother has major depressive disorder, and her father has hypertension and coronary artery disease.", "At this visit, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 130/76 mmHg, and respirations are 13/min.", "She appears slightly anxious but has overall normal affect and is pleasantly conversational.", "Physical exam is unremarkable." ]

[ "1. Patient is a 26-year-old female.", "2. Patient has been experiencing mood swings for several months.", "3. Patient feels highly irritable, sensitive to criticism and rejection, and easily saddened on roughly a quarter of days each month.", "4. Patient's appetite varies greatly on days when she is particularly emotional.", "5. Patient's performance at work has suffered.", "6. Patient's boyfriend has been complaining that she is difficult to live with.", "7. Patient is anxious that she cannot \"get my mood under control.\"", "8. Patient has no past medical history.", "9. Patient has regular periods every 28 days.", "10. Patient has no obstetric history.", "11. Patient uses condoms for contraception.", "12. Patient's mother has major depressive disorder.", "13. Patient's father has hypertension and coronary artery disease.", "14. Patient's temperature is 98.4°F (36.9°C).", "15. Patient's pulse is 75/min.", "16. Patient's blood pressure is 130/76 mmHg.", "17. Patient's respirations are 13/min.", "18. Patient appears slightly anxious but has overall normal affect.", "19. Patient is pleasantly conversational.", "20. Patient's physical exam is unremarkable." ]

[ "1. The patient experiences irritability, sensitivity to criticism and rejection, and sadness on roughly a quarter of days each month.", "2. She also experiences varying appetite and increased hunger on emotional days.", "3. Her work performance has suffered due to these symptoms.", "4. Her boyfriend has complained about her being difficult to live with.", "5. The patient is anxious about not being able to control her mood.", "6. She has no past medical history, regular 28-day periods, and no obstetric history.", "7. She uses condoms for contraception.", "8. Her mother has major depressive disorder, and her father has hypertension and coronary artery disease.", "9. At the visit, her temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 130/76 mmHg, and respirations are 13/min.", "10. She appears slightly anxious but has overall normal affect and is pleasantly conversational.", "11. The physical exam is unremarkable." ]

[ "A 63-year-old male presents to the emergency department complaining of worsening nausea.", "He reports that the nausea began several months ago and is accompanied by occasional bloating and heartburn.", "He reports that he frequently feels full even after eating only a little at each meal, and occasionally he will vomit if he eats too much.", "The vomit is non-bloody and contains bits of undigested food.", "A review of systems is notable for occasional headaches, tingling in his distal extremities, and constipation.", "His medical history is significant for Parkinson’s disease diagnosed 3 years ago, hypertension diagnosed 8 years ago, and type II diabetes mellitus diagnosed 10 years ago.", "The patient reports that he was given prescriptions for both his blood pressure and diabetes medications, but he has not taken either for months because one of them was causing erectile dysfunction.", "He reports he regularly takes his levodopa.", "An endoscopy is performed, which rules out cancer." ]

[ "1. Patient is 63 years old.", "2. Patient is male.", "3. Patient presents to emergency department with worsening nausea.", "4. Nausea began several months ago.", "5. Symptoms include occasional bloating and heartburn.", "6. Patient frequently feels full after eating only a little.", "7. Patient occasionally vomits if he eats too much.", "8. Vomit is non-bloody and contains bits of undigested food.", "9. Review of systems is notable for occasional headaches, tingling in distal extremities, and constipation.", "10. Medical history is significant for Parkinson's disease diagnosed 3 years ago.", "11. Medical history is significant for hypertension diagnosed 8 years ago.", "12. Medical history is significant for type II diabetes mellitus diagnosed 10 years ago.", "13. Patient was given prescriptions for blood pressure and diabetes medications, but has not taken either for months.", "14. Patient regularly takes levodopa.", "15. Endoscopy is performed, which rules out cancer." ]

[ "1. The patient reports nausea that began several months ago.", "2. The nausea is accompanied by occasional bloating and heartburn.", "3. The patient frequently feels full even after eating only a little at each meal.", "4. Occasionally, the patient will vomit if he eats too much.", "5. The vomit is non-bloody and contains bits of undigested food.", "6. A review of systems is notable for occasional headaches, tingling in distal extremities, and constipation.", "7. The patient has a medical history significant for Parkinson’s disease diagnosed 3 years ago, hypertension diagnosed 8 years ago, and type II diabetes mellitus diagnosed 10 years ago.", "8. The patient was given prescriptions for both blood pressure and diabetes medications but has not taken either for months due to one of them causing erectile dysfunction.", "9. The patient regularly takes his levodopa.", "10. An endoscopy is performed, which rules out cancer." ]

[ "A 27-year-old Japanese man presents to the emergency department with diarrhea.", "The patient states that whenever he goes out to eat he experiences bloating, flatulence, abdominal cramps, and watery diarrhea.", "Today, his symptoms started after he went out for frozen yogurt.", "The patient is otherwise healthy and is not currently taking any medications.", "His temperature is 98.0°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 81/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "Physical exam demonstrates a nontender abdomen and an unremarkable rectal exam with guaiac-negative stools." ]

[ "1. Patient is 27-year-old Japanese man.", "2. Patient presents to emergency department with diarrhea.", "3. Patient experiences bloating, flatulence, abdominal cramps, and watery diarrhea when going out to eat.", "4. Symptoms started today after going out for frozen yogurt.", "5. Patient is otherwise healthy and not taking any medications.", "6. Patient's temperature is 98.0°F (36.7°C).", "7. Patient's blood pressure is 122/80 mmHg.", "8. Patient's pulse is 81/min.", "9. Patient's respirations are 13/min.", "10. Patient's oxygen saturation is 99% on room air.", "11. Physical exam demonstrates a nontender abdomen.", "12. Rectal exam is unremarkable with guaiac-negative stools." ]

[ "1. The patient experiences bloating, flatulence, abdominal cramps, and watery diarrhea when going out to eat.", "2. Symptoms started after the patient went out for frozen yogurt.", "3. The patient is otherwise healthy.", "4. The patient is not currently taking any medications.", "5. The patient's temperature is 98.0°F (36.7°C).", "6. The patient's blood pressure is 122/80 mmHg.", "7. The patient's pulse is 81/min.", "8. The patient's respirations are 13/min.", "9. The patient's oxygen saturation is 99% on room air.", "10. Physical exam demonstrates a nontender abdomen.", "11. Physical exam demonstrates an unremarkable rectal exam with guaiac-negative stools." ]

[ "A 29-year-old woman presents to her primary care physician with worsening fatigue and lightheadedness over the past several months.", "She states that she has felt easily fatigued and has experienced several falls during this time frame as well.", "She drinks 5 to 8 drinks per day and works as a waitress.", "Her temperature is 98.2°F (36.8°C), blood pressure is 114/64 mmHg, pulse is 98/min, respirations are 12/min, and oxygen saturation is 98% on room air.", "Laboratory studies are ordered as seen below. | | Hemoglobin: 9.0 g/dL | Hematocrit: 29% | Leukocyte count: 6,700/mm^3 with normal differential | Platelet count: 199,400/mm^3 | Methylymalonic acid: 1.0 umol/L (normal < 0.40 umol/L) | | ." ]

[ "1. Patient is a 29-year-old female.", "2. Patient has been experiencing worsening fatigue and lightheadedness over the past several months.", "3. Patient has felt easily fatigued and has experienced several falls during this time frame.", "4. Patient drinks 5 to 8 drinks per day and works as a waitress.", "5. Patient's temperature is 98.2°F (36.8°C).", "6. Patient's blood pressure is 114/64 mmHg.", "7. Patient's pulse is 98/min.", "8. Patient's respirations are 12/min.", "9. Patient's oxygen saturation is 98% on room air.", "10. Laboratory studies show hemoglobin of 9.0 g/dL.", "11. Laboratory studies show hematocrit of 29%.", "12. Laboratory studies show leukocyte count of 6,700/mm^3 with normal differential.", "13. Laboratory studies show platelet count of 199,400/mm^3.", "14. Laboratory studies show methylymalonic acid of 1.0 umol/L (normal < 0.40 umol/L)." ]

[ "1. The patient has felt easily fatigued.", "2. The patient has experienced several falls.", "3. The patient drinks 5 to 8 drinks per day.", "4. The patient works as a waitress.", "5. The patient's temperature is 98.2°F (36.8°C).", "6. The patient's blood pressure is 114/64 mmHg.", "7. The patient's pulse is 98/min.", "8. The patient's respirations are 12/min.", "9. The patient's oxygen saturation is 98% on room air.", "10. The patient's hemoglobin level is 9.0 g/dL.", "11. The patient's hematocrit level is 29%.", "12. The patient's leukocyte count is 6,700/mm^3 with normal differential.", "13. The patient's platelet count is 199,400/mm^3.", "14. The patient's methylymalonic acid level is 1.0 umol/L (normal < 0.40 umol/L)." ]

[ "A 32-year-old man from the Czech Republic is brought to the emergency department by his girlfriend with a 2-day history of yellowing of the skin.", "His girlfriend also reports a several-week history of anorexia, nausea without vomiting, and diffuse low-grade abdominal pain.", "He is a frequent injection drug user.", "His temperature is 38.1°C (100.6°F).", "He is grossly confused and somnolent.", "Physical examination is notable for scleral icterus and diffuse jaundice; when asked to hold his hands in wrist extension, a flapping movement is observed.", "Liver function tests show alanine aminotransferase 1,830 U/L, aspartate aminotransferase 1,377 U/L, and direct bilirubin 15 mg/dL.", "Coagulation studies reveal an international normalized ratio of 3.8.", "On serological testing, HBsAg is positive, and HBsAb is negative." ]

[ "1. A 32-year-old man from the Czech Republic is brought to the emergency department by his girlfriend. ", "2. His girlfriend reports a 2-day history of yellowing of the skin and a several-week history of anorexia, nausea without vomiting, and diffuse low-grade abdominal pain. ", "3. He is a frequent injection drug user. ", "4. His temperature is 38.1°C (100.6°F). ", "5. He is grossly confused and somnolent. ", "6. Physical examination is notable for scleral icterus and diffuse jaundice. ", "7. When asked to hold his hands in wrist extension, a flapping movement is observed. ", "8. Liver function tests show alanine aminotransferase 1,830 U/L, aspartate aminotransferase 1,377 U/L, and direct bilirubin 15 mg/dL. ", "9. Coagulation studies reveal an international normalized ratio of 3.8. ", "10. On serological testing, HBsAg is positive, and HBsAb is negative." ]

[ "1. His girlfriend reports a several-week history of anorexia.", "2. His girlfriend reports a several-week history of nausea without vomiting.", "3. His girlfriend reports a several-week history of diffuse low-grade abdominal pain.", "4. He is a frequent injection drug user.", "5. His temperature is 38.1°C (100.6°F).", "6. He is grossly confused and somnolent.", "7. Physical examination is notable for scleral icterus.", "8. Physical examination is notable for diffuse jaundice.", "9. A flapping movement is observed when asked to hold his hands in wrist extension.", "10. Liver function tests show alanine aminotransferase 1,830 U/L.", "11. Liver function tests show aspartate aminotransferase 1,377 U/L.", "12. Liver function tests show direct bilirubin 15 mg/dL.", "13. Coagulation studies reveal an international normalized ratio of 3.8.", "14. On serological testing, HBsAg is positive.", "15. On serological testing, HBsAb is negative." ]

[ "A 63-year-old woman with a history of adult polycystic kidney disease and COPD presents to her optometrist after having difficulty watching a movie.", "She has no other complaints.", "She is accompanied by her daughter, who notes that her mother hasn’t been able to look at her since the previous day.", "On exam, her right eye has full range of motion, but her left eye is fixed in a down and outward position." ]

[ "1. A 63-year-old woman presents to her optometrist.", "2. She has a history of adult polycystic kidney disease and COPD.", "3. She has difficulty watching a movie.", "4. She has no other complaints.", "5. She is accompanied by her daughter.", "6. Her daughter notes that her mother hasn't been able to look at her since the previous day.", "7. On exam, her right eye has full range of motion.", "8. Her left eye is fixed in a down and outward position." ]

[ "1. She has no other complaints.", "2. She is accompanied by her daughter.", "3. Her daughter notes that her mother hasn’t been able to look at her since the previous day.", "4. On exam, her right eye has full range of motion.", "5. Her left eye is fixed in a down and outward position." ]

[ "An 11-year-old boy presents to the office with his mother for the evaluation of weight loss, rash, and several weeks of bloating and diarrhea.", "The mother states that the patient’s father had similar symptoms at his age.", "On physical examination, the patient is pale with dry mucous membranes.", "There is a vesicular rash on the bilateral lower extremities which he says is ‘very itchy’." ]

[ "1. An 11-year-old boy presents to the office with his mother.", "2. The evaluation is for weight loss, rash, and several weeks of bloating and diarrhea.", "3. The mother states that the patient's father had similar symptoms at his age.", "4. On physical examination, the patient is pale with dry mucous membranes.", "5. There is a vesicular rash on the bilateral lower extremities.", "6. The patient says the rash is 'very itchy'." ]

[ "1. The mother states that the patient’s father had similar symptoms at his age.", "2. On physical examination, the patient is pale with dry mucous membranes.", "3. There is a vesicular rash on the bilateral lower extremities.", "4. The patient says the rash is ‘very itchy’." ]

[ "A 23-year-old African American G1P0 woman at 18 weeks estimated gestational age presents with fatigue and lethargy.", "She says the symptoms onset gradually about 1 week ago and have progressively worsened.", "She has been otherwise healthy.", "Past medical history is unremarkable.", "She denies smoking, drug or alcohol use.", "The patient is afebrile and vital signs are within normal limits.", "Her physical examination is unremarkable.", "Her blood count shows the following: | Hemoglobin 10.8 g/dL | Red blood cell count 5.7 million/mm3 | Mean corpuscular volume (MCV) 76 μm3 | Red cell distribution width 12.4% (ref: 11.5–14.5%) | She is empirically started on ferrous gluconate tablets.", "Five weeks later, she shows no improvement in her hemoglobin level.", "Hemoglobin electrophoresis is normal." ]

[ "1. Patient is a 23-year-old African American G1P0 woman.", "2. Patient is at 18 weeks estimated gestational age.", "3. Patient presents with fatigue and lethargy.", "4. Symptoms onset gradually about 1 week ago and have progressively worsened.", "5. Patient has been otherwise healthy.", "6. Past medical history is unremarkable.", "7. Patient denies smoking, drug or alcohol use.", "8. Patient is afebrile and vital signs are within normal limits.", "9. Physical examination is unremarkable.", "10. Hemoglobin is 10.8 g/dL.", "11. Red blood cell count is 5.7 million/mm3.", "12. Mean corpuscular volume (MCV) is 76 μm3.", "13. Red cell distribution width is 12.4% (ref: 11.5–14.5%).", "14. Patient is empirically started on ferrous gluconate tablets.", "15. Five weeks later, patient shows no improvement in her hemoglobin level.", "16. Hemoglobin electrophoresis is normal." ]

[ "1. Symptoms onset gradually about 1 week ago", "2. Symptoms have progressively worsened", "3. Patient has been otherwise healthy", "4. Past medical history is unremarkable", "5. Patient denies smoking, drug, or alcohol use", "6. Patient is afebrile", "7. Vital signs are within normal limits", "8. Physical examination is unremarkable", "9. Blood count shows: Hemoglobin 10.8 g/dL", "10. Blood count shows: Red blood cell count 5.7 million/mm3", "11. Blood count shows: Mean corpuscular volume (MCV) 76 μm3", "12. Blood count shows: Red cell distribution width 12.4% (ref: 11.5–14.5%)", "13. Patient is empirically started on ferrous gluconate tablets", "14. Five weeks later, no improvement in hemoglobin level", "15. Hemoglobin electrophoresis is normal" ]

[ "A 26-year-old woman comes to the physician for a follow-up examination 1 week after undergoing rotator cuff repair surgery.", "Physical examination of the right shoulder shows decreased sensation to pinprick and light touch over the lateral shoulder.", "There is normal passive range of motion of the shoulder, but she has difficulty externally rotating and abducting her right arm." ]

[ "1. A 26-year-old woman comes to the physician for a follow-up examination.", "2. The follow-up examination is 1 week after undergoing rotator cuff repair surgery.", "3. Physical examination of the right shoulder shows decreased sensation to pinprick and light touch over the lateral shoulder.", "4. There is normal passive range of motion of the shoulder.", "5. She has difficulty externally rotating her right arm.", "6. She has difficulty abducting her right arm." ]

[ "1. Physical examination of the right shoulder shows decreased sensation to pinprick.", "2. Physical examination of the right shoulder shows decreased sensation to light touch over the lateral shoulder.", "3. There is normal passive range of motion of the shoulder.", "4. She has difficulty externally rotating her right arm.", "5. She has difficulty abducting her right arm." ]

[ "A 25-year-old man presents to his primary care physician with complaints of coughing up blood in his sputum and dark-colored urine for 1 week.", "There are streaks of blood intermixed with phlegm.", "He also expresses concerns about his urine being grossly dark brown.", "He denies any history of major bleeding from minor injuries.", "He is currently not taking any medications.", "His family history is negative for bleeding disorders.", "The vital signs include blood pressure 160/100 mm Hg, pulse 88/min, temperature 36.8°C (98.2°F), and respiratory rate 11/min.", "On physical examination, there are no significant clinical findings.", "The urinalysis results are as follows: | pH 6.7 | Color dark brown | Red blood cell (RBC) count 12–14/HPF | White blood cell (WBC) count 3–4/HPF | Protein absent | Cast RBC and granular casts | Glucose absent | Crystal none | Ketone absent | Nitrite absent | 24 hours of urine protein excretion 1 g | His renal function test showed: | Sodium 136 mEq/L | Potassium 5.1 mEq/L | Chloride 101 mEq/L | Bicarbonate 22 mEq/L | Albumin 3.5 mg/ dL | Urea nitrogen 28 mg/dL | Creatinine 2.5 mg/dL | Uric Acid 6.8 mg/ dL | Calcium 8.7 mg/ dL | Glucose 111 mg/dL | HPF: high-power field | A kidney biopsy is obtained and the immunofluorescence shows linear immunoglobulin G (IgG) deposition in the glomeruli." ]

[ "1. A 25-year-old man presents to his primary care physician with complaints of coughing up blood in his sputum and dark-colored urine for 1 week.", "2. There are streaks of blood intermixed with phlegm.", "3. He also expresses concerns about his urine being grossly dark brown.", "4. He denies any history of major bleeding from minor injuries.", "5. He is currently not taking any medications.", "6. His family history is negative for bleeding disorders.", "7. The vital signs include blood pressure 160/100 mm Hg, pulse 88/min, temperature 36.8°C (98.2°F), and respiratory rate 11/min.", "8. On physical examination, there are no significant clinical findings.", "9. The urinalysis results show a pH of 6.7, color dark brown, RBC count 12–14/HPF, WBC count 3–4/HPF, protein absent, RBC and granular casts, glucose absent, crystal none, ketone absent, and nitrite absent.", "10. 24 hours of urine protein excretion is 1 g.", "11. His renal function test shows sodium 136 mEq/L, potassium 5.1 mEq/L, chloride 101 mEq/L, bicarbonate 22 mEq/L, albumin 3.5 mg/dL, urea nitrogen 28 mg/dL, creatinine 2.5 mg/dL, uric acid 6.8 mg/dL, calcium 8.7 mg/dL, and glucose 111 mg/dL.", "12. A kidney biopsy is obtained and the immunofluorescence shows linear immunoglobulin G (IgG) deposition in the glomeruli." ]

[ "1. Streaks of blood intermixed with phlegm", "2. Concerns about urine being grossly dark brown", "3. Denial of history of major bleeding from minor injuries", "4. Not taking any medications", "5. Family history negative for bleeding disorders", "6. Vital signs: blood pressure 160/100 mm Hg, pulse 88/min, temperature 36.8°C (98.2°F), respiratory rate 11/min", "7. No significant clinical findings on physical examination", "8. Urinalysis results: pH 6.7, color dark brown, RBC count 12–14/HPF, WBC count 3–4/HPF, protein absent, cast RBC and granular casts, glucose absent, crystal none, ketone absent, nitrite absent, 24 hours of urine protein excretion 1 g", "9. Renal function test results: sodium 136 mEq/L, potassium 5.1 mEq/L, chloride 101 mEq/L, bicarbonate 22 mEq/L, albumin 3.5 mg/dL, urea nitrogen 28 mg/dL, creatinine 2.5 mg/dL, uric acid 6.8 mg/dL, calcium 8.7 mg/dL, glucose 111 mg/dL", "10. Kidney biopsy obtained", "11. Immunofluorescence shows linear IgG deposition in the glomeruli" ]

[ "The lung of a 45-year-old Caucasian male who died from Mycobacterium tuberculosis infection reveals the following at autopsy (Image A)." ]

[ "1. The lung belongs to a 45-year-old Caucasian male.", "2. The cause of death was Mycobacterium tuberculosis infection.", "3. Autopsy was performed on the lung.", "4. Image A was taken during the autopsy." ]

[ "1. The lung belongs to a 45-year-old Caucasian male.", "2. The male died from Mycobacterium tuberculosis infection.", "3. The autopsy revealed specific findings in the lung." ]

[ "A 57-year-old man comes to the physician because of a 3-month history of bloating and nausea after eating food.", "He has also had episodic abdominal pain during this period.", "He has osteoarthritis of the left knee.", "There is no family history of serious illness.", "He has smoked one pack of cigarettes daily for 21 years.", "He drinks two to three beers daily.", "Current medications include ibuprofen.", "He is allergic to amoxicillin and latex.", "Vital signs are within normal limits.", "The lungs are clear to auscultation.", "Cardiac examination shows no abnormalities.", "The abdomen is soft; there is mild tenderness to palpation over the epigastrium.", "Rectal examination shows no abnormalities.", "An esophagogastroduodenoscopy is performed and shows 3 shallow ulcers of the gastric mucosa.", "Biopsy shows chronic inflammation of the gastric mucosa and Helicobacter pylori.", "He is prescribed a 2-week course of antibiotics and omeprazole to treat the H.", "pylori infection." ]

[ "1. A 57-year-old man comes to the physician.", "2. He has a 3-month history of bloating and nausea after eating food.", "3. He has had episodic abdominal pain during this period.", "4. He has osteoarthritis of the left knee.", "5. There is no family history of serious illness.", "6. He has smoked one pack of cigarettes daily for 21 years.", "7. He drinks two to three beers daily.", "8. His current medications include ibuprofen.", "9. He is allergic to amoxicillin and latex.", "10. Vital signs are within normal limits.", "11. The lungs are clear to auscultation.", "12. Cardiac examination shows no abnormalities.", "13. The abdomen is soft; there is mild tenderness to palpation over the epigastrium.", "14. Rectal examination shows no abnormalities.", "15. An esophagogastroduodenoscopy is performed.", "16. It shows 3 shallow ulcers of the gastric mucosa.", "17. Biopsy shows chronic inflammation of the gastric mucosa and Helicobacter pylori.", "18. He is prescribed a 2-week course of antibiotics and omeprazole to treat the H. pylori infection." ]

[ "1. He has episodic abdominal pain.", "2. He has osteoarthritis of the left knee.", "3. There is no family history of serious illness.", "4. He has smoked one pack of cigarettes daily for 21 years.", "5. He drinks two to three beers daily.", "6. Current medications include ibuprofen.", "7. He is allergic to amoxicillin and latex.", "8. Vital signs are within normal limits.", "9. The lungs are clear to auscultation.", "10. Cardiac examination shows no abnormalities.", "11. The abdomen is soft; there is mild tenderness to palpation over the epigastrium.", "12. Rectal examination shows no abnormalities.", "13. An esophagogastroduodenoscopy is performed and shows 3 shallow ulcers of the gastric mucosa.", "14. Biopsy shows chronic inflammation of the gastric mucosa and Helicobacter pylori.", "15. He is prescribed a 2-week course of antibiotics and omeprazole to treat the H. pylori infection." ]

[ "A 72-year-old man presents to his physician’s office with difficulty breathing and chronic fatigue.", "Over the past few months, he has felt that it is difficult to retain his energy throughout the day.", "He is disturbed because he has to skip many social events because of his inability to participate.", "He also says that lately, he has had difficulty catching his breath after walking for just a few blocks.", "Other than well-controlled diabetes, his past medical history is insignificant.", "On physical examination, moderate conjunctival pallor is noted.", "His recent blood count shows a hemoglobin level of 10.3 g/dl, hematocrit of 24%, serum ferritin level of 10 ng/ml, and a red cell distribution width of 16.5%." ]

[ "1. A 72-year-old man presents to his physician's office with difficulty breathing and chronic fatigue.", "2. Over the past few months, he has felt that it is difficult to retain his energy throughout the day.", "3. He is disturbed because he has to skip many social events because of his inability to participate.", "4. He also says that lately, he has had difficulty catching his breath after walking for just a few blocks.", "5. Other than well-controlled diabetes, his past medical history is insignificant.", "6. On physical examination, moderate conjunctival pallor is noted.", "7. His recent blood count shows a hemoglobin level of 10.3 g/dl.", "8. His recent blood count shows a hematocrit of 24%.", "9. His recent blood count shows a serum ferritin level of 10 ng/ml.", "10. His recent blood count shows a red cell distribution width of 16.5%." ]

[ "1. Over the past few months, he has felt that it is difficult to retain his energy throughout the day.", "2. He is disturbed because he has to skip many social events because of his inability to participate.", "3. He also says that lately, he has had difficulty catching his breath after walking for just a few blocks.", "4. Other than well-controlled diabetes, his past medical history is insignificant.", "5. On physical examination, moderate conjunctival pallor is noted.", "6. His recent blood count shows a hemoglobin level of 10.3 g/dl.", "7. His recent blood count shows a hematocrit of 24%.", "8. His recent blood count shows a serum ferritin level of 10 ng/ml.", "9. His recent blood count shows a red cell distribution width of 16.5%." ]

[ "A 17-year-old rugby player limped into the emergency room and says he “rolled his ankle” while running during a game.", "You conclude that the mechanism involved ankle plantar flexion and inversion.", "There is no medial or lateral malleolus point tenderness.", "Anterior drawer test of the ankle is positive.", "Talar tilt test is negative." ]

[ "1. A 17-year-old rugby player limped into the emergency room.", "2. The player said he \"rolled his ankle\" while running during a game.", "3. The mechanism involved ankle plantar flexion and inversion.", "4. There is no medial or lateral malleolus point tenderness.", "5. Anterior drawer test of the ankle is positive.", "6. Talar tilt test is negative." ]

[ "1. Mechanism involved ankle plantar flexion and inversion.", "2. No medial or lateral malleolus point tenderness.", "3. Anterior drawer test of the ankle is positive.", "4. Talar tilt test is negative." ]

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[ "A 32-year-old man presents to the emergency department with fever, weight loss, and right upper quadrant pain.", "He says that he started experiencing nausea and fatigue after he returned from a honeymoon trip to Asia with his wife.", "Notably, she is 5 months pregnant with their first child.", "On presentation, his temperature is 100.8°F (38.2°C), blood pressure is 118/79 mmHg, pulse is 81/min, and respirations are 14/min.", "Physical exam reveals a jaundiced patient with a palpable liver edge as well as splenomegaly.", "Labs are sent in order to confirm the diagnosis.", "After confirmation, the patient's wife is immediately tested as well because she is at a much higher risk of fatal complications from this infection." ]

[ "1. A 32-year-old man presents to the emergency department.", "2. He has fever, weight loss, and right upper quadrant pain.", "3. He started experiencing nausea and fatigue after returning from a honeymoon trip to Asia with his wife.", "4. His wife is 5 months pregnant with their first child.", "5. On presentation, his temperature is 100.8°F (38.2°C).", "6. His blood pressure is 118/79 mmHg.", "7. His pulse is 81/min.", "8. His respirations are 14/min.", "9. Physical exam reveals a jaundiced patient with a palpable liver edge.", "10. Physical exam reveals splenomegaly.", "11. Labs are sent in order to confirm the diagnosis.", "12. After confirmation, the patient's wife is immediately tested as well.", "13. She is at a much higher risk of fatal complications from this infection." ]

[ "1. The patient started experiencing nausea and fatigue after returning from a honeymoon trip to Asia with his wife.", "2. The patient's wife is 5 months pregnant with their first child.", "3. On presentation, the patient's temperature is 100.8°F (38.2°C).", "4. On presentation, the patient's blood pressure is 118/79 mmHg.", "5. On presentation, the patient's pulse is 81/min.", "6. On presentation, the patient's respirations are 14/min.", "7. Physical exam reveals a jaundiced patient.", "8. Physical exam reveals a palpable liver edge.", "9. Physical exam reveals splenomegaly.", "10. Labs are sent to confirm the diagnosis.", "11. The patient's wife is immediately tested due to a higher risk of fatal complications from the infection." ]

[ "A 59-year-old man presents to the emergency room with shortness of breath and swelling of his feet and legs.", "He denies any past medical problems, surgeries, medications, or illicit drug use.", "He reports drinking a few beers each night.", "He is diagnosed with a first episode of congestive heart failure and is admitted to the hospital.", "The next day, the nurse notices that his hands are shaky when he extends his arms.", "The patient says that he couldn’t sleep the night before and that he feels restless, anxious, and slightly nauseated.", "On the second night of admission the patient becomes agitated.", "He is disoriented, cannot remember where he is, and appears globally confused.", "His pulse is 125/min, blood pressure is 170/110 mmHg, and temperature is 101.7°F (38.7°C).", "He is diaphoretic and his hands are shaking at rest.", "He cries out in fear reporting voices whispering in his room and strange shadows passing over the walls." ]

[ "1. A 59-year-old man presents to the emergency room with shortness of breath and swelling of his feet and legs.", "2. He denies any past medical problems, surgeries, medications, or illicit drug use.", "3. He reports drinking a few beers each night.", "4. He is diagnosed with a first episode of congestive heart failure and is admitted to the hospital.", "5. The next day, the nurse notices that his hands are shaky when he extends his arms.", "6. The patient says that he couldn’t sleep the night before and that he feels restless, anxious, and slightly nauseated.", "7. On the second night of admission the patient becomes agitated.", "8. He is disoriented, cannot remember where he is, and appears globally confused.", "9. His pulse is 125/min, blood pressure is 170/110 mmHg, and temperature is 101.7°F (38.7°C).", "10. He is diaphoretic and his hands are shaking at rest.", "11. He cries out in fear reporting voices whispering in his room and strange shadows passing over the walls." ]

[ "1. The patient denies any past medical problems, surgeries, medications, or illicit drug use.", "2. The patient reports drinking a few beers each night.", "3. The patient is diagnosed with a first episode of congestive heart failure and is admitted to the hospital.", "4. The nurse notices that the patient's hands are shaky when he extends his arms.", "5. The patient says that he couldn’t sleep the night before and that he feels restless, anxious, and slightly nauseated.", "6. On the second night of admission, the patient becomes agitated.", "7. The patient is disoriented, cannot remember where he is, and appears globally confused.", "8. The patient's pulse is 125/min, blood pressure is 170/110 mmHg, and temperature is 101.7°F (38.7°C).", "9. The patient is diaphoretic and his hands are shaking at rest.", "10. The patient cries out in fear reporting voices whispering in his room and strange shadows passing over the walls." ]

[ "A 49-year-old woman otherwise healthy presents to the outpatient department with swelling of the neck.", "Family history is negative for any thyroid disorders.", "Physical examination shows a nontender thyroid gland with a nodule on the right side.", "The thyroid gland is mobile on deglutition.", "Cervical lymphadenopathy is present.", "Fine needle aspiration and cytology show empty appearing nuclei with central clearing, nuclear grooves and branching structures interspersed with calcific bodies." ]

[ "1. A 49-year-old woman is presenting to the outpatient department.", "2. The woman is otherwise healthy.", "3. Family history is negative for any thyroid disorders.", "4. Physical examination shows a nontender thyroid gland.", "5. There is a nodule on the right side of the thyroid gland.", "6. The thyroid gland is mobile on deglutition.", "7. Cervical lymphadenopathy is present.", "8. Fine needle aspiration and cytology show empty appearing nuclei.", "9. The nuclei have central clearing.", "10. The nuclei have nuclear grooves.", "11. The nuclei have branching structures.", "12. The nuclei have calcific bodies." ]

[ "1. Family history is negative for any thyroid disorders.", "2. Physical examination shows a nontender thyroid gland with a nodule on the right side.", "3. The thyroid gland is mobile on deglutition.", "4. Cervical lymphadenopathy is present.", "5. Fine needle aspiration and cytology show empty appearing nuclei with central clearing, nuclear grooves and branching structures interspersed with calcific bodies." ]

[ "A 33-year-old woman comes to the physician because of a 2-year history of intermittent episodes of pain in all her fingers bilaterally.", "The episodes are worse during the winter.", "The fingers become white when exposed to cold weather, then severely painful and numb once they warm up.", "She has started wearing gloves at all times to prevent these episodes.", "She has generalized anxiety disorder.", "Her mother has systemic lupus erythematosus.", "Current medications include lorazepam and fluoxetine.", "She appears anxious.", "Her temperature is 37.3°C (99.1°F), pulse is 92/min, and blood pressure is 116/72 mm Hg.", "Examination of both hands shows no abnormalities.", "Allen's test is negative.", "Her hemoglobin concentration is 14.4 g/dL, leukocyte count is 9,800/mm3, and platelet count is 156,000/mm3.", "Serum electrolyte concentrations are within normal limits.", "Nailfold capillary microscopy is normal." ]

[ "1. Patient is a 33-year-old woman.", "2. Patient has a 2-year history of intermittent episodes of pain in all her fingers bilaterally.", "3. Episodes are worse during the winter.", "4. Fingers become white when exposed to cold weather, then severely painful and numb once they warm up.", "5. Patient has started wearing gloves at all times to prevent these episodes.", "6. Patient has generalized anxiety disorder.", "7. Patient's mother has systemic lupus erythematosus.", "8. Current medications include lorazepam and fluoxetine.", "9. Patient appears anxious.", "10. Patient's temperature is 37.3°C (99.1°F).", "11. Patient's pulse is 92/min.", "12. Patient's blood pressure is 116/72 mm Hg.", "13. Examination of both hands shows no abnormalities.", "14. Allen's test is negative.", "15. Patient's hemoglobin concentration is 14.4 g/dL.", "16. Patient's leukocyte count is 9,800/mm3.", "17. Patient's platelet count is 156,000/mm3.", "18. Serum electrolyte concentrations are within normal limits.", "19. Nailfold capillary microscopy is normal." ]

[ "1. The episodes are worse during the winter.", "2. The fingers become white when exposed to cold weather.", "3. The fingers then become severely painful and numb once they warm up.", "4. She has started wearing gloves at all times to prevent these episodes.", "5. She has generalized anxiety disorder.", "6. Her mother has systemic lupus erythematosus.", "7. Current medications include lorazepam and fluoxetine.", "8. She appears anxious.", "9. Her temperature is 37.3°C (99.1°F).", "10. Her pulse is 92/min.", "11. Her blood pressure is 116/72 mm Hg.", "12. Examination of both hands shows no abnormalities.", "13. Allen's test is negative.", "14. Her hemoglobin concentration is 14.4 g/dL.", "15. Her leukocyte count is 9,800/mm3.", "16. Her platelet count is 156,000/mm3.", "17. Serum electrolyte concentrations are within normal limits.", "18. Nailfold capillary microscopy is normal." ]

[ "A 43-year-old man comes to the physician because of redness and swelling of his right leg.", "He reports that it is very painful to touch.", "He has had fever and chills.", "He has no chest pain or shortness of breath.", "He has a history of type 2 diabetes mellitus and underwent saphenous vein stripping and ligation in his right leg 3 years ago.", "He works as a security guard.", "He does not smoke or drink alcohol.", "His medications include metformin and sitagliptin.", "His temperature is 38.7°C (101.7°F), pulse is 99/min, and blood pressure is 138/72 mm Hg.", "Examination shows an 8-cm, indurated, tender, warm, erythematous skin lesion with sharply demarcated margins.", "There is no inguinal lymphadenopathy.", "Toe web intertrigo is noted." ]

[ "1. A 43-year-old man comes to the physician.", "2. He has redness and swelling of his right leg.", "3. It is very painful to touch.", "4. He has had fever and chills.", "5. He has no chest pain or shortness of breath.", "6. He has a history of type 2 diabetes mellitus.", "7. He underwent saphenous vein stripping and ligation in his right leg 3 years ago.", "8. He works as a security guard.", "9. He does not smoke or drink alcohol.", "10. His medications include metformin and sitagliptin.", "11. His temperature is 38.7°C (101.7°F).", "12. His pulse is 99/min.", "13. His blood pressure is 138/72 mm Hg.", "14. Examination shows an 8-cm, indurated, tender, warm, erythematous skin lesion with sharply demarcated margins.", "15. There is no inguinal lymphadenopathy.", "16. Toe web intertrigo is noted." ]

[ "1. He reports that it is very painful to touch.", "2. He has had fever and chills.", "3. He has no chest pain or shortness of breath.", "4. He has a history of type 2 diabetes mellitus.", "5. He underwent saphenous vein stripping and ligation in his right leg 3 years ago.", "6. He works as a security guard.", "7. He does not smoke or drink alcohol.", "8. His medications include metformin and sitagliptin.", "9. His temperature is 38.7°C (101.7°F).", "10. His pulse is 99/min.", "11. His blood pressure is 138/72 mm Hg.", "12. Examination shows an 8-cm, indurated, tender, warm, erythematous skin lesion with sharply demarcated margins.", "13. There is no inguinal lymphadenopathy.", "14. Toe web intertrigo is noted." ]

[ "A 52-year-old thoracic surgeon presents to his primary care physician with an eczematous dermatitis overlying his hands and forearms.", "He notes that he has recently started using a new type of surgical gloves.", "He notes that he washes his hands frequently, but he has never had issues with skin irritation before.", "On physical examination, there are erythematous plaques with areas of vesicles on his bilateral hands and dorsal forearms." ]

[ "1. A 52-year-old thoracic surgeon presents to his primary care physician.", "2. He has an eczematous dermatitis overlying his hands and forearms.", "3. He recently started using a new type of surgical gloves.", "4. He washes his hands frequently.", "5. He has never had issues with skin irritation before.", "6. On physical examination, there are erythematous plaques.", "7. There are areas of vesicles on his bilateral hands and dorsal forearms." ]

[ "1. The patient has recently started using a new type of surgical gloves.", "2. The patient washes his hands frequently.", "3. The patient has never had issues with skin irritation before.", "4. On physical examination, there are erythematous plaques on the patient's bilateral hands and dorsal forearms.", "5. There are areas of vesicles on the patient's bilateral hands and dorsal forearms." ]

[ "A 43-year-old woman presents to a new primary care physician complaining of anxiety.", "She has been worrying non-stop recently about the possibility that her husband will lose his job as a teacher.", "Her husband, who is present, assures the physician that his job is entirely secure and states that she has \"fretted\" for their entire marriage, though the exact topic causing her anxiety varies over time.", "She also worries excessively about everyday tasks, such as whether she will catch the train on time and whether their house in Southern California is sufficiently earthquake-proof.", "She has no way to overcome these worries.", "She endorses other symptoms including poor sleep (associated with racing thoughts about her various worries), fatigue, and impaired concentration at work, all of which have been present for at least the past year.", "Her vital signs are within normal limits and there are no abnormalities on physical exam." ]

[ "1. Patient is a 43-year-old female.", "2. Patient is presenting to a new primary care physician with anxiety.", "3. Patient's husband is present and states that she has \"fretted\" for their entire marriage.", "4. Patient worries excessively about everyday tasks, such as catching the train on time and whether their house is earthquake-proof.", "5. Patient has no way to overcome these worries.", "6. Patient endorses other symptoms including poor sleep, fatigue, and impaired concentration at work.", "7. Symptoms have been present for at least the past year.", "8. Patient's vital signs are within normal limits.", "9. No abnormalities on physical exam." ]

[ "1. She has been worrying non-stop recently about the possibility of her husband losing his job as a teacher.", "2. Her husband assures the physician that his job is entirely secure.", "3. Her husband states that she has \"fretted\" for their entire marriage.", "4. The exact topic causing her anxiety varies over time.", "5. She worries excessively about everyday tasks, such as catching the train on time and the earthquake-proofing of their house in Southern California.", "6. She has no way to overcome these worries.", "7. She endorses other symptoms including poor sleep associated with racing thoughts about her worries.", "8. She experiences fatigue and impaired concentration at work.", "9. These symptoms have been present for at least the past year.", "10. Her vital signs are within normal limits.", "11. There are no abnormalities on physical exam." ]

[ "A 60-year-old woman comes to the physician because of palpitations and a 5.4-kg (11.9-lb) weight loss over the past 3 months.", "She appears anxious.", "Her pulse is 104/min and blood pressure is 148/101 mm Hg.", "Physical examination shows warm skin, mild tremor, and an enlarged thyroid gland.", "A thyroid scintigraphy scan shows several focal areas with increased uptake." ]

[ "1. A 60-year-old woman comes to the physician.", "2. She has experienced a 5.4-kg (11.9-lb) weight loss over the past 3 months.", "3. She appears anxious.", "4. Her pulse is 104/min.", "5. Her blood pressure is 148/101 mm Hg.", "6. Physical examination shows warm skin, mild tremor, and an enlarged thyroid gland.", "7. A thyroid scintigraphy scan shows several focal areas with increased uptake." ]

[ "1. She appears anxious.", "2. Her pulse is 104/min.", "3. Her blood pressure is 148/101 mm Hg.", "4. Physical examination shows warm skin.", "5. Physical examination shows mild tremor.", "6. Physical examination shows an enlarged thyroid gland.", "7. A thyroid scintigraphy scan shows several focal areas with increased uptake." ]

[ "A 47-year-old man is brought to the emergency department 1 hour after his neighbor found him collapsed on his front porch in a pool of vomitus.", "On arrival, he is oriented only to self.", "His pulse is 103/min and respirations are 30/min.", "Neurologic examination shows muscle spasms in the arms and jaw.", "Serum studies show: | Na+ 137 mEq/L | Cl- 99 mEq/L | HCO3- 8 mEq/L | Osmolality 328 mOsm/kg | The difference between the calculated and observed serum osmolality is 32 mOsm/kg.", "Urinalysis shows oxalate crystals." ]

[ "1. A 47-year-old man is brought to the emergency department.", "2. His neighbor found him collapsed on his front porch in a pool of vomitus 1 hour prior.", "3. On arrival, he is oriented only to self.", "4. His pulse is 103/min.", "5. Respirations are 30/min.", "6. Neurologic examination shows muscle spasms in the arms and jaw.", "7. Serum studies show Na+ 137 mEq/L.", "8. Serum studies show Cl- 99 mEq/L.", "9. Serum studies show HCO3- 8 mEq/L.", "10. Serum studies show Osmolality 328 mOsm/kg.", "11. The difference between the calculated and observed serum osmolality is 32 mOsm/kg.", "12. Urinalysis shows oxalate crystals." ]

[ "1. On arrival, the patient is oriented only to self.", "2. The patient's pulse is 103/min.", "3. The patient's respirations are 30/min.", "4. Neurologic examination shows muscle spasms in the arms and jaw.", "5. Serum studies show: Na+ 137 mEq/L, Cl- 99 mEq/L, HCO3- 8 mEq/L, Osmolality 328 mOsm/kg.", "6. The difference between the calculated and observed serum osmolality is 32 mOsm/kg.", "7. Urinalysis shows oxalate crystals." ]

[ "A 13-year-old boy presents to the clinic for evaluation of pain, swelling, and redness in the left knee.", "This began a month ago and has been progressively worsening.", "He thinks his pain is due to playing soccer.", "He is frustrated that the pain does not respond to Tylenol.", "History is non-contributory.", "The vital signs are unremarkable.", "On examination, there is tenderness and warmth present over the knee with limitation of movement.", "The laboratory values show a normal white blood cell (WBC) count and elevated alkaline phosphatase.", "A radiograph of the knee shows mixed lytic and blastic lesions." ]

[ "1. A 13-year-old boy presents to the clinic for evaluation of pain, swelling, and redness in the left knee.", "2. This began a month ago and has been progressively worsening.", "3. He thinks his pain is due to playing soccer.", "4. He is frustrated that the pain does not respond to Tylenol.", "5. History is non-contributory.", "6. The vital signs are unremarkable.", "7. On examination, there is tenderness and warmth present over the knee with limitation of movement.", "8. The laboratory values show a normal white blood cell (WBC) count.", "9. The laboratory values show an elevated alkaline phosphatase.", "10. A radiograph of the knee shows mixed lytic and blastic lesions." ]

[ "1. The symptoms began a month ago.", "2. The symptoms have been progressively worsening.", "3. The patient attributes the pain to playing soccer.", "4. The patient is frustrated that the pain does not respond to Tylenol.", "5. The patient's medical history is non-contributory.", "6. The vital signs are unremarkable.", "7. On examination, there is tenderness and warmth present over the knee.", "8. On examination, there is limitation of movement in the knee.", "9. Laboratory values show a normal white blood cell (WBC) count.", "10. Laboratory values show elevated alkaline phosphatase.", "11. A radiograph of the knee shows mixed lytic and blastic lesions." ]

[ "A 55-year-old woman presents to the emergency department because of palpitations and generalized weakness.", "She has a history of type 2 diabetes, for which she has been receiving medication for the past 15 years.", "Consequently, her recent medical history involves diabetic retinopathy as well as end-stage renal disease.", "She is advised dialysis; however, she does not attend her regular dialysis sessions.", "The physical examination shows motor strength of 3/5 in the upper limbs and 4/5 in the lower limbs.", "Cranial nerve capacity is intact.", "Her electrocardiogram (ECG) is shown.", "Medical management is initiated for the patient." ]

[ "1. A 55-year-old woman presents to the emergency department because of palpitations and generalized weakness.", "2. She has a history of type 2 diabetes, for which she has been receiving medication for the past 15 years.", "3. Her recent medical history involves diabetic retinopathy.", "4. Her recent medical history also involves end-stage renal disease.", "5. She is advised dialysis; however, she does not attend her regular dialysis sessions.", "6. The physical examination shows motor strength of 3/5 in the upper limbs and 4/5 in the lower limbs.", "7. Cranial nerve capacity is intact.", "8. Her electrocardiogram (ECG) is shown.", "9. Medical management is initiated for the patient." ]

[ "1. She has a history of type 2 diabetes.", "2. She has been receiving medication for the past 15 years.", "3. Her recent medical history involves diabetic retinopathy.", "4. Her recent medical history involves end-stage renal disease.", "5. She is advised dialysis.", "6. She does not attend her regular dialysis sessions.", "7. The physical examination shows motor strength of 3/5 in the upper limbs.", "8. The physical examination shows motor strength of 4/5 in the lower limbs.", "9. Cranial nerve capacity is intact.", "10. Her electrocardiogram (ECG) is shown.", "11. Medical management is initiated for the patient." ]

[ "A 59-year-old man presents to the emergency department with diffuse abdominal pain that radiates to his back, nausea, and vomiting.", "The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min.", "The laboratory evaluation on admission is significant for a serum glucose 241 mg/dL, aspartate aminotransferase (AST) 321 IU/dL, and leukocyte count 21,200/mL.", "Within 3 days of admission with supportive care in the intensive care unit, the patient’s clinical condition begins to improve." ]

[ "1. A 59-year-old man presents to the emergency department with diffuse abdominal pain that radiates to his back, nausea, and vomiting.", "2. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min.", "3. The laboratory evaluation on admission is significant for a serum glucose 241 mg/dL.", "4. The laboratory evaluation on admission is significant for an aspartate aminotransferase (AST) 321 IU/dL.", "5. The laboratory evaluation on admission is significant for a leukocyte count 21,200/mL.", "6. Within 3 days of admission with supportive care in the intensive care unit, the patient’s clinical condition begins to improve." ]

[ "1. Vital signs: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, respiratory rate 14/min.", "2. Laboratory evaluation on admission: serum glucose 241 mg/dL, aspartate aminotransferase (AST) 321 IU/dL, leukocyte count 21,200/mL.", "3. Patient admitted to intensive care unit.", "4. Patient's clinical condition begins to improve within 3 days of admission." ]

[ "A 68-year-old male presents to your office for his annual physical exam.", "He has no complaints at this time and his chronic hypertension is well controlled.", "You notice a .5cm papule on the patient's eyelid that has a pink pearly appearance, rolled borders, and overlying telangiectasias.", "On further questioning, you find out the patient was a door-to-door salesman and spent a lot of time outdoors, and he did not wear sunscreen.", "He has fair skin and blonde hair.", "The patient states that he first noticed the lesion about 6 months prior, and it has grown slightly since then." ]

[ "1. A 68-year-old male presents to your office for his annual physical exam.", "2. He has no complaints at this time.", "3. His chronic hypertension is well controlled.", "4. You notice a .5cm papule on the patient's eyelid.", "5. The papule has a pink pearly appearance.", "6. The papule has rolled borders.", "7. The papule has overlying telangiectasias.", "8. The patient was a door-to-door salesman.", "9. The patient spent a lot of time outdoors.", "10. The patient did not wear sunscreen.", "11. The patient has fair skin.", "12. The patient has blonde hair.", "13. The patient first noticed the lesion about 6 months prior.", "14. The lesion has grown slightly since then." ]

[ "1. The patient has no complaints at this time.", "2. The patient's chronic hypertension is well controlled.", "3. There is a .5cm papule on the patient's eyelid.", "4. The papule has a pink pearly appearance.", "5. The papule has rolled borders.", "6. The papule has overlying telangiectasias.", "7. The patient was a door-to-door salesman.", "8. The patient spent a lot of time outdoors.", "9. The patient did not wear sunscreen.", "10. The patient has fair skin.", "11. The patient has blonde hair.", "12. The patient first noticed the lesion about 6 months prior.", "13. The lesion has grown slightly since then." ]

[ "A 67-year-old woman is brought to the emergency room after complaining of back pain with a gradual loss of sensation in her lower extremities.", "She was recently diagnosed with radiosensitive metastatic breast cancer and was scheduled to receive chemotherapy and palliative surgery.", "Her temperature is 99.0°F (37.2°C), blood pressure is 133/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for decreased sensation bilaterally over the patient's lower extremities.", "She demonstrates 2/5 strength of leg extension on the left and 1/5 on the right which is slightly worse than her baseline neurological exam taken 2 months ago.", "Pain to her lumbar region worsens with coughing.", "An initial CT scan of the spine does not demonstrate any unstable fractures of the spine.", "A MRI of the spine is ordered and pending." ]

[ "1. A 67-year-old woman is brought to the emergency room.", "2. She is complaining of back pain with a gradual loss of sensation in her lower extremities.", "3. She was recently diagnosed with radiosensitive metastatic breast cancer.", "4. She was scheduled to receive chemotherapy and palliative surgery.", "5. Her temperature is 99.0°F (37.2°C).", "6. Her blood pressure is 133/81 mmHg.", "7. Her pulse is 82/min.", "8. Her respirations are 15/min.", "9. Her oxygen saturation is 98% on room air.", "10. Physical exam is notable for decreased sensation bilaterally over the patient's lower extremities.", "11. She demonstrates 2/5 strength of leg extension on the left.", "12. She demonstrates 1/5 strength of leg extension on the right.", "13. Her neurological exam taken 2 months ago was slightly better than her current exam.", "14. Pain to her lumbar region worsens with coughing.", "15. An initial CT scan of the spine does not demonstrate any unstable fractures of the spine.", "16. A MRI of the spine is ordered and pending." ]

[ "1. Patient diagnosed with radiosensitive metastatic breast cancer", "2. Scheduled to receive chemotherapy and palliative surgery", "3. Temperature is 99.0°F (37.2°C)", "4. Blood pressure is 133/81 mmHg", "5. Pulse is 82/min", "6. Respirations are 15/min", "7. Oxygen saturation is 98% on room air", "8. Physical exam notable for decreased sensation bilaterally over lower extremities", "9. Demonstrates 2/5 strength of leg extension on the left", "10. Demonstrates 1/5 strength of leg extension on the right", "11. Strength is slightly worse than baseline neurological exam taken 2 months ago", "12. Pain to lumbar region worsens with coughing", "13. Initial CT scan of the spine does not demonstrate any unstable fractures", "14. MRI of the spine is ordered and pending" ]

[ "An obese 50-year-old woman presents to the emergency department of a rural hospital due to chest pain for the last 12 hours.", "The pain is substernal, crushing in nature, radiating into her neck, and accompanied by profuse sweating.", "Her history is significant for hypertension, and she admits poor compliance with her medications.", "An ECG done at the clinic confirmed the presence of STEMI, and the patient was given aspirin.", "The ambulance was in an accident on the way to the hospital and by the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation.", "Also, the patient’s pain has improved.", "The patient is admitted and is stable for 3 nights with no dyspnea or edema.", "Her blood pressure is kept under control while in the hospital.", "On the fourth night, the patient becomes quite agitated and soon thereafter she is unresponsive.", "Her pulse cannot be palpated.", "She has an elevated JVP and upon auscultation, heart sounds are distant." ]

[ "1. Patient is a 50-year-old woman.", "2. Patient is obese.", "3. Patient presents to the emergency department of a rural hospital.", "4. Patient has had chest pain for the last 12 hours.", "5. Pain is substernal, crushing in nature, radiating into her neck, and accompanied by profuse sweating.", "6. Patient has a history of hypertension.", "7. Patient admits poor compliance with her medications.", "8. ECG done at the clinic confirmed the presence of STEMI.", "9. Patient was given aspirin.", "10. Ambulance was in an accident on the way to the hospital.", "11. By the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation.", "12. Patient's pain has improved.", "13. Patient is admitted and is stable for 3 nights with no dyspnea or edema.", "14. Patient's blood pressure is kept under control while in the hospital.", "15. On the fourth night, the patient becomes quite agitated.", "16. Soon thereafter, the patient is unresponsive.", "17. Pulse cannot be palpated.", "18. Patient has an elevated JVP.", "19. Upon auscultation, heart sounds are distant." ]

[ "1. The pain is substernal", "2. The pain is crushing in nature", "3. The pain is radiating into her neck", "4. The pain is accompanied by profuse sweating", "5. Her history is significant for hypertension", "6. She admits poor compliance with her medications", "7. An ECG done at the clinic confirmed the presence of STEMI", "8. The patient was given aspirin", "9. The ambulance was in an accident on the way to the hospital", "10. By the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation", "11. The patient’s pain has improved", "12. The patient is admitted", "13. The patient is stable for 3 nights with no dyspnea or edema", "14. Her blood pressure is kept under control while in the hospital", "15. On the fourth night, the patient becomes quite agitated", "16. Soon thereafter she is unresponsive", "17. Her pulse cannot be palpated", "18. She has an elevated JVP", "19. Upon auscultation, heart sounds are distant" ]

[ "A 20-year-old woman presents to the emergency department with painful swelling in the middle of her neck for the past 3 days.", "She is not experiencing pain during swallowing, difficulty in breathing, or changes in her voice.", "On examination, a red, 5 x 5 cm, exquisitely tender, non-pulsatile, fluctuating mass is present in the midline on the anterior aspect of the neck.", "The patient is prepared for an incision and drainage of the neck abscess." ]

[ "1. A 20-year-old woman presents to the emergency department.", "2. She has had painful swelling in the middle of her neck for the past 3 days.", "3. She is not experiencing pain during swallowing, difficulty in breathing, or changes in her voice.", "4. On examination, a red, 5 x 5 cm, exquisitely tender, non-pulsatile, fluctuating mass is present in the midline on the anterior aspect of the neck.", "5. The patient is prepared for an incision and drainage of the neck abscess." ]

[ "1. The patient is not experiencing pain during swallowing.", "2. The patient is not experiencing difficulty in breathing.", "3. The patient is not experiencing changes in her voice.", "4. On examination, a red, 5 x 5 cm mass is present in the midline on the anterior aspect of the neck.", "5. The mass is exquisitely tender.", "6. The mass is non-pulsatile.", "7. The mass is fluctuating.", "8. The patient is prepared for an incision and drainage of the neck abscess." ]

[ "A 45-year-old G2P2 presents with episodes of urgency accompanied by an involuntary passage of urine.", "These symptoms take place during the day and night.", "The symptoms are not linked with physical exertion, laughing, or coughing.", "Her occupation does not involve weight lifting, but she says that sometimes it is very stressful for her.", "She denies any other genitourinary symptoms.", "She had 1 vaginal delivery and 1 cesarean section.", "She does not have a history of genitourinary or neurologic disorders.", "The weight is 91 kg (200.6 lb) and the height is 172 cm (5 ft 60 in).", "The vital signs are as follows: blood pressure, 128/75 mmHg; heart rate, 77/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉).", "The physical examination shows no abdominal masses and no costovertebral angle or suprapubic tenderness.", "On gynecologic examination, there are no vulvar lesions.", "The external urethral orifice appears normal.", "A Q-tip test is negative.", "The cervix is normally positioned, non-tender, movable, and without visible lesions.", "The uterus is not enlarged and the ovaries are not palpable.", "A urinalysis, urine culture, and ultrasound examination of the bladder were all normal.", "Cystometric studies show the following findings: | Measured value Normal range | Residual volume 10 ml < 50 ml | Sensation-of-fullness volume 190 ml 200–225 ml | Urge-to-void volume 700 ml 400–500 ml | Involuntary contractions present absent | ." ]

[ "1. Patient is 45 years old.", "2. Patient is G2P2.", "3. Patient has episodes of urgency accompanied by an involuntary passage of urine.", "4. Symptoms take place during the day and night.", "5. Symptoms are not linked with physical exertion, laughing, or coughing.", "6. Patient's occupation does not involve weight lifting.", "7. Patient says occupation is sometimes very stressful.", "8. Patient denies any other genitourinary symptoms.", "9. Patient had 1 vaginal delivery and 1 cesarean section.", "10. Patient does not have a history of genitourinary or neurologic disorders.", "11. Patient's weight is 91 kg (200.6 lb).", "12. Patient's height is 172 cm (5 ft 60 in).", "13. Patient's blood pressure is 128/75 mmHg.", "14. Patient's heart rate is 77/min.", "15. Patient's respiratory rate is 13/min.", "16. Patient's temperature is 36.6℃ (97.9℉).", "17. Physical examination shows no abdominal masses.", "18. Physical examination shows no costovertebral angle or suprapubic tenderness.", "19. Gynecologic examination shows no vulvar lesions.", "20. External urethral orifice appears normal.", "21. Q-tip test is negative.", "22. Cervix is normally positioned, non-tender, movable, and without visible lesions.", "23. Uterus is not enlarged.", "24. Ovaries are not palpable.", "25. Urinalysis, urine culture, and ultrasound examination of the bladder were all normal.", "26. Cystometric studies show residual volume of 10 ml (normal range < 50 ml).", "27. Cystometric studies show sensation-of-fullness volume of 190 ml (normal range 200–225 ml).", "28. Cystometric studies show urge-to-void volume of 700 ml (normal range 400–500 ml).", "29. Cystometric studies show presence of involuntary contractions (normal range absent)." ]

[ "1. Symptoms occur during the day and night.", "2. Symptoms are not linked with physical exertion, laughing, or coughing.", "3. Occupation does not involve weight lifting, but is sometimes stressful.", "4. Denies any other genitourinary symptoms.", "5. Had 1 vaginal delivery and 1 cesarean section.", "6. No history of genitourinary or neurologic disorders.", "7. Weight is 91 kg (200.6 lb) and height is 172 cm (5 ft 60 in).", "8. Vital signs: blood pressure 128/75 mmHg, heart rate 77/min, respiratory rate 13/min, temperature 36.6℃ (97.9℉).", "9. Physical examination shows no abdominal masses, costovertebral angle tenderness, or suprapubic tenderness.", "10. Gynecologic examination shows no vulvar lesions, normal external urethral orifice, and negative Q-tip test.", "11. Cervix is normally positioned, non-tender, movable, and without visible lesions.", "12. Uterus is not enlarged and ovaries are not palpable.", "13. Urinalysis, urine culture, and ultrasound examination of the bladder were all normal.", "14. Cystometric studies show specific measured values and normal ranges for residual volume, sensation-of-fullness volume, urge-to-void volume, and presence of involuntary contractions." ]

[ "A 4-year-old girl is brought to the physician with progressively worsening fever, malaise, and a sore throat.", "Her parents say “Our daughter has not received vaccinations because her body has to learn how to fight infections.” Her temperature is 38.5˚C (101.3 F).", "Physical examination shows marked cervical lymphadenopathy.", "There are gray-white membranes over the tonsils and posterior pharynx that bleed when scraped off." ]

[ "1. A 4-year-old girl is brought to the physician.", "2. She has progressively worsening fever, malaise, and a sore throat.", "3. Her parents say she has not received vaccinations because her body has to learn how to fight infections.", "4. Her temperature is 38.5˚C (101.3 F).", "5. Physical examination shows marked cervical lymphadenopathy.", "6. There are gray-white membranes over the tonsils and posterior pharynx.", "7. The gray-white membranes bleed when scraped off." ]

[ "1. Her parents say \"Our daughter has not received vaccinations because her body has to learn how to fight infections.\"", "2. Her temperature is 38.5˚C (101.3 F).", "3. Physical examination shows marked cervical lymphadenopathy.", "4. There are gray-white membranes over the tonsils and posterior pharynx that bleed when scraped off." ]

[ "A 56-year-old man presents to his family physician for issues with his back that have persisted since he was in his 20’s.", "For the last 6 months, his neck has been very stiff and he has been unable to tilt his head backwards.", "He also has severe kyphosis and feels limited in his range of motion.", "He tries to get at least 8 hours of sleep each night, but he says he rarely feels rested.", "On examination, the patient has no pain on active and passive movements.", "His cervical spine is moderately stiff; limitations are in extension, flexion, and rotation.", "There is also evidence of mild swelling of his wrist joints.", "The patient is sent for an X-ray of his lumbar spine.", "Unfortunately, he did not seek medical care for years due to financial hardships." ]

[ "1. Patient is 56 years old.", "2. Patient has had back issues since his 20's.", "3. Patient has had a stiff neck for the last 6 months.", "4. Patient has severe kyphosis.", "5. Patient has limited range of motion.", "6. Patient tries to get 8 hours of sleep each night.", "7. Patient has no pain on active and passive movements.", "8. Patient's cervical spine is moderately stiff.", "9. Limitations in extension, flexion, and rotation.", "10. Patient has mild swelling of his wrist joints.", "11. Patient is sent for an X-ray of his lumbar spine.", "12. Patient did not seek medical care for years due to financial hardships." ]

[ "1. His neck has been very stiff for the last 6 months.", "2. He has been unable to tilt his head backwards.", "3. He has severe kyphosis.", "4. He feels limited in his range of motion.", "5. He tries to get at least 8 hours of sleep each night.", "6. He rarely feels rested despite getting 8 hours of sleep.", "7. On examination, the patient has no pain on active and passive movements.", "8. His cervical spine is moderately stiff.", "9. Limitations are in extension, flexion, and rotation.", "10. There is evidence of mild swelling of his wrist joints.", "11. The patient is sent for an X-ray of his lumbar spine.", "12. He did not seek medical care for years due to financial hardships." ]

[ "A 24-year-old woman visits the health services of her university for vaginal itching, dysuria, pelvic discomfort, and foul-smelling vaginal discharge.", "She states this is the eighth time she has had such symptoms within the last year, for which she and her sexual partners have received multiple courses of doxycycline and ceftriaxone or azithromycin and ceftriaxone.", "A pelvic examination showed a mucopurulent cervical discharge with cervical friability.", "A vaginal wet-mount showed an elevated number of polymorphonuclear leukocytes." ]

[ "1. A 24-year-old woman visited the health services of her university.", "2. She had vaginal itching, dysuria, pelvic discomfort, and foul-smelling vaginal discharge.", "3. This was the eighth time she had these symptoms in the last year.", "4. She and her sexual partners had received multiple courses of doxycycline and ceftriaxone or azithromycin and ceftriaxone.", "5. A pelvic examination showed a mucopurulent cervical discharge with cervical friability.", "6. A vaginal wet-mount showed an elevated number of polymorphonuclear leukocytes." ]

[ "1. The patient has experienced similar symptoms eight times in the past year.", "2. The patient and her sexual partners have received multiple courses of doxycycline and ceftriaxone or azithromycin and ceftriaxone.", "3. A pelvic examination revealed mucopurulent cervical discharge.", "4. The cervical discharge showed cervical friability.", "5. A vaginal wet-mount showed an elevated number of polymorphonuclear leukocytes." ]

[ "A previously healthy 11-month-old boy is brought to the emergency department for the evaluation of abdominal pain and vomiting.", "His mother states that over the past 6 hours he has been having intermittent episodes of inconsolable crying, during which he “grabs his abdomen and draws up his legs.” These episodes have been accompanied by nonbloody, nonbilious vomiting and reddish, mucoid bowel movements.", "He appears sleepy.", "His temperature is 38.1°C (100.6°F), blood pressure 100/60 mm Hg, pulse is 110/min, and respirations are 24/min.", "He cries when his abdomen is palpated.", "The remainder of the examination shows no abnormalities.", "A complete blood count shows a leukocyte count of 12,000/mm3.", "Serum electrolyte levels are within normal limits.", "An abdominal x-ray shows no free air.", "An abdominal ultrasonography is shown." ]

[ "1. A previously healthy 11-month-old boy is brought to the emergency department for the evaluation of abdominal pain and vomiting.", "2. His mother states that over the past 6 hours he has been having intermittent episodes of inconsolable crying, during which he “grabs his abdomen and draws up his legs.”", "3. These episodes have been accompanied by nonbloody, nonbilious vomiting and reddish, mucoid bowel movements.", "4. He appears sleepy.", "5. His temperature is 38.1°C (100.6°F), blood pressure 100/60 mm Hg, pulse is 110/min, and respirations are 24/min.", "6. He cries when his abdomen is palpated.", "7. The remainder of the examination shows no abnormalities.", "8. A complete blood count shows a leukocyte count of 12,000/mm3.", "9. Serum electrolyte levels are within normal limits.", "10. An abdominal x-ray shows no free air.", "11. An abdominal ultrasonography is shown." ]

[ "1. His mother reports intermittent episodes of inconsolable crying over the past 6 hours.", "2. During the episodes, he grabs his abdomen and draws up his legs.", "3. The episodes are accompanied by nonbloody, nonbilious vomiting and reddish, mucoid bowel movements.", "4. He appears sleepy.", "5. His temperature is 38.1°C (100.6°F).", "6. His blood pressure is 100/60 mm Hg.", "7. His pulse is 110/min.", "8. His respirations are 24/min.", "9. He cries when his abdomen is palpated.", "10. The remainder of the examination shows no abnormalities.", "11. A complete blood count shows a leukocyte count of 12,000/mm3.", "12. Serum electrolyte levels are within normal limits.", "13. An abdominal x-ray shows no free air.", "14. An abdominal ultrasonography is shown." ]

[ "A 68-year-old man comes to the physician because of a 4-month history of bad breath and progressive difficulty swallowing solid food.", "Physical examination shows no abnormalities.", "An upper endoscopy is performed and a photomicrograph of a biopsy specimen obtained from the mid-esophagus is shown." ]

[ "1. A 68-year-old man comes to the physician.", "2. He has a 4-month history of bad breath.", "3. He has progressive difficulty swallowing solid food.", "4. Physical examination shows no abnormalities.", "5. An upper endoscopy is performed.", "6. A photomicrograph of a biopsy specimen is obtained from the mid-esophagus." ]

[ "1. Physical examination shows no abnormalities.", "2. An upper endoscopy is performed.", "3. A photomicrograph of a biopsy specimen is obtained from the mid-esophagus." ]

[ "A 43-year-old woman comes to the physician because of a 2-month history of progressive muscle pain and stiffness that worsens with exercise.", "She also has difficulty climbing stairs, getting out of chairs, and putting things on shelves or in cupboards.", "She has had constipation, occasional headaches, and a 9-kg (20-lb) weight gain during the past year.", "She has hypertension controlled with atenolol and amlodipine.", "She has used calamine lotion for the past 6 months for dry skin.", "Her pulse is 80/min and her blood pressure is 138/76 mm Hg.", "Physical examination shows weakness of the proximal muscle groups.", "She has delayed tendon reflex relaxation, with a mounding of the muscle surface occurring just before relaxation.", "Creatine kinase level is 3,120 U/L." ]

[ "1. Patient is a 43-year-old woman.", "2. Patient has a 2-month history of progressive muscle pain and stiffness that worsens with exercise.", "3. Patient has difficulty climbing stairs, getting out of chairs, and putting things on shelves or in cupboards.", "4. Patient has had constipation, occasional headaches, and a 9-kg (20-lb) weight gain during the past year.", "5. Patient has hypertension controlled with atenolol and amlodipine.", "6. Patient has used calamine lotion for the past 6 months for dry skin.", "7. Patient's pulse is 80/min.", "8. Patient's blood pressure is 138/76 mm Hg.", "9. Physical examination shows weakness of the proximal muscle groups.", "10. Patient has delayed tendon reflex relaxation, with a mounding of the muscle surface occurring just before relaxation.", "11. Patient's creatine kinase level is 3,120 U/L." ]

[ "1. She has difficulty climbing stairs.", "2. She has difficulty getting out of chairs.", "3. She has difficulty putting things on shelves or in cupboards.", "4. She has had constipation.", "5. She has occasional headaches.", "6. She has had a 9-kg (20-lb) weight gain during the past year.", "7. She has hypertension controlled with atenolol and amlodipine.", "8. She has used calamine lotion for the past 6 months for dry skin.", "9. Her pulse is 80/min.", "10. Her blood pressure is 138/76 mm Hg.", "11. Physical examination shows weakness of the proximal muscle groups.", "12. She has delayed tendon reflex relaxation.", "13. She has a mounding of the muscle surface occurring just before relaxation.", "14. Creatine kinase level is 3,120 U/L." ]

[ "A 34-year-old woman comes to the physician because of a rapidly growing lump in her right breast.", "Eight months ago, she underwent excision of a liposarcoma from the dorsum of her right forearm.", "Her brother was diagnosed with osteosarcoma of the maxilla at the age of 22 years.", "Her mother died at the age of 43 years from complications of acute myeloid leukemia.", "She has smoked a pack of cigarettes daily for 7 years.", "Examination shows a fixed, firm mass in the right breast with axillary lymphadenopathy.", "A biopsy of the mass confirms the diagnosis of invasive ductal carcinoma." ]

[ "1. A 34-year-old woman comes to the physician.", "2. She has a rapidly growing lump in her right breast.", "3. Eight months ago, she underwent excision of a liposarcoma from the dorsum of her right forearm.", "4. Her brother was diagnosed with osteosarcoma of the maxilla at the age of 22 years.", "5. Her mother died at the age of 43 years from complications of acute myeloid leukemia.", "6. She has smoked a pack of cigarettes daily for 7 years.", "7. Examination shows a fixed, firm mass in the right breast with axillary lymphadenopathy.", "8. A biopsy of the mass confirms the diagnosis of invasive ductal carcinoma." ]

[ "1. Eight months ago, she underwent excision of a liposarcoma from the dorsum of her right forearm.", "2. Her brother was diagnosed with osteosarcoma of the maxilla at the age of 22 years.", "3. Her mother died at the age of 43 years from complications of acute myeloid leukemia.", "4. She has smoked a pack of cigarettes daily for 7 years.", "5. Examination shows a fixed, firm mass in the right breast with axillary lymphadenopathy.", "6. A biopsy of the mass confirms the diagnosis of invasive ductal carcinoma." ]

[ "A 31-year-old woman comes to the doctor because of episodic nosebleeds and gingival bleeding for the past 2 weeks.", "She has no history of serious illness and takes no medications.", "She is sexually active with two male partners and uses condoms inconsistently.", "Vital signs are within normal limits.", "Examination shows punctate, non-blanching macules on the chest.", "The remainder of the examination shows no abnormalities.", "The hemoglobin concentration is 13.1 g/dL, leukocyte count is 6600/mm3, and platelet count is 28,000/mm3.", "A peripheral blood smear shows reduced platelets with normal morphology.", "HIV test is negative." ]

[ "1. Patient is a 31-year-old woman.", "2. Patient has had episodic nosebleeds and gingival bleeding for the past 2 weeks.", "3. Patient has no history of serious illness.", "4. Patient takes no medications.", "5. Patient is sexually active with two male partners.", "6. Patient uses condoms inconsistently.", "7. Vital signs are within normal limits.", "8. Examination shows punctate, non-blanching macules on the chest.", "9. The remainder of the examination shows no abnormalities.", "10. Hemoglobin concentration is 13.1 g/dL.", "11. Leukocyte count is 6600/mm3.", "12. Platelet count is 28,000/mm3.", "13. Peripheral blood smear shows reduced platelets with normal morphology.", "14. HIV test is negative." ]

[ "1. She has no history of serious illness and takes no medications.", "2. She is sexually active with two male partners and uses condoms inconsistently.", "3. Vital signs are within normal limits.", "4. Examination shows punctate, non-blanching macules on the chest.", "5. The remainder of the examination shows no abnormalities.", "6. The hemoglobin concentration is 13.1 g/dL, leukocyte count is 6600/mm3, and platelet count is 28,000/mm3.", "7. A peripheral blood smear shows reduced platelets with normal morphology.", "8. HIV test is negative." ]

[ "A 40-year-old woman presents to the clinic for hair loss.", "She was in her usual state of health until earlier this month when she started noticing more and more hair on her pillow in the morning.", "The problem has only been getting worse since then; she's even started pulling out clumps of hair when she shampoos in the morning.", "She has no other symptoms, and her past medical history is unremarkable.", "The physical exam is notable for smooth, circular, non-scarring, hairless patches across her scalp.", "A firm tug on a bundle of hair causes almost all of the hair to be removed." ]

[ "1. A 40-year-old woman presents to the clinic for hair loss.", "2. She was in her usual state of health until earlier this month.", "3. She started noticing more and more hair on her pillow in the morning.", "4. The problem has only been getting worse since then.", "5. She's even started pulling out clumps of hair when she shampoos in the morning.", "6. She has no other symptoms.", "7. Her past medical history is unremarkable.", "8. The physical exam is notable for smooth, circular, non-scarring, hairless patches across her scalp.", "9. A firm tug on a bundle of hair causes almost all of the hair to be removed." ]

[ "1. She was in her usual state of health until earlier this month.", "2. She started noticing more and more hair on her pillow in the morning.", "3. The problem has only been getting worse since then.", "4. She's even started pulling out clumps of hair when she shampoos in the morning.", "5. She has no other symptoms.", "6. Her past medical history is unremarkable.", "7. The physical exam is notable for smooth, circular, non-scarring, hairless patches across her scalp.", "8. A firm tug on a bundle of hair causes almost all of the hair to be removed." ]

[ "A 2-day-old girl born at 32 weeks gestation to a 42-year-old woman is being examined by a resident.", "The examination reveals a very small head circumference with low set ears, a prominent occiput, and a comparatively small mandible.", "A picture of the infant’s fist is given below.", "A bilateral foot deformity is present." ]

[ "1. A 2-day-old girl was born at 32 weeks gestation.", "2. The girl's mother is 42 years old.", "3. The girl is being examined by a resident.", "4. The examination reveals a very small head circumference.", "5. The examination reveals low set ears.", "6. The examination reveals a prominent occiput.", "7. The examination reveals a comparatively small mandible.", "8. A picture of the infant's fist is given.", "9. A bilateral foot deformity is present." ]

[ "1. The examination reveals a very small head circumference.", "2. The examination reveals low set ears.", "3. The examination reveals a prominent occiput.", "4. The examination reveals a comparatively small mandible.", "5. A picture of the infant’s fist is given below.", "6. A bilateral foot deformity is present." ]

[ "A 44-year-old male is brought to the physician by his father.", "Over the past year, the patient has become progressively forgetful and withdrawn.", "He frequently has trouble remembering names of acquaintances, and has been requiring increasing amounts of assistance with getting dressed, cooking, and personal hygiene.", "He was diagnosed with a genetic disorder during infancy.", "Physical examination shows prominent epicanthal folds, low-set small ears, and a protruding tongue.", "Mental examination shows significant deficits in short- and long-term memory." ]

[ "1. A 44-year-old male is brought to the physician by his father.", "2. Over the past year, the patient has become progressively forgetful and withdrawn.", "3. He frequently has trouble remembering names of acquaintances.", "4. He has been requiring increasing amounts of assistance with getting dressed, cooking, and personal hygiene.", "5. He was diagnosed with a genetic disorder during infancy.", "6. Physical examination shows prominent epicanthal folds.", "7. Physical examination shows low-set small ears.", "8. Physical examination shows a protruding tongue.", "9. Mental examination shows significant deficits in short-term memory.", "10. Mental examination shows significant deficits in long-term memory." ]

[ "1. The patient has become progressively forgetful over the past year.", "2. The patient has become progressively withdrawn over the past year.", "3. The patient frequently has trouble remembering names of acquaintances.", "4. The patient has been requiring increasing amounts of assistance with getting dressed.", "5. The patient has been requiring increasing amounts of assistance with cooking.", "6. The patient has been requiring increasing amounts of assistance with personal hygiene.", "7. The patient was diagnosed with a genetic disorder during infancy.", "8. Physical examination shows prominent epicanthal folds.", "9. Physical examination shows low-set small ears.", "10. Physical examination shows a protruding tongue.", "11. Mental examination shows significant deficits in short-term memory.", "12. Mental examination shows significant deficits in long-term memory." ]

[ "A previously healthy 75-year-old man comes to the physician with a 6-month history of fatigue, weight loss, and abdominal pain.", "He drinks 2 oz of alcohol on the weekends and does not smoke.", "He is retired but previously worked in a factory that produces plastic pipes.", "Abdominal examination shows right upper quadrant tenderness; the liver edge is palpable 2 cm below the ribs.", "A liver biopsy specimen shows pleomorphic spindle cells that express PECAM-1 on their surface." ]

[ "1. A 75-year-old man comes to the physician.", "2. He has a 6-month history of fatigue, weight loss, and abdominal pain.", "3. He drinks 2 oz of alcohol on the weekends.", "4. He does not smoke.", "5. He previously worked in a factory that produces plastic pipes.", "6. Abdominal examination shows right upper quadrant tenderness.", "7. The liver edge is palpable 2 cm below the ribs.", "8. A liver biopsy specimen shows pleomorphic spindle cells.", "9. The spindle cells express PECAM-1 on their surface." ]

[ "1. He drinks 2 oz of alcohol on the weekends.", "2. He does not smoke.", "3. He is retired.", "4. He previously worked in a factory that produces plastic pipes.", "5. Abdominal examination shows right upper quadrant tenderness.", "6. The liver edge is palpable 2 cm below the ribs.", "7. A liver biopsy specimen shows pleomorphic spindle cells.", "8. The pleomorphic spindle cells express PECAM-1 on their surface." ]

[ "A 28-year-old man is brought to the emergency department 20 minutes after being involved in a bicycling accident.", "He complains of severe pain over the front of his right shoulder.", "He refuses to move his right arm.", "Physical examination shows supraclavicular swelling and bruising.", "The shoulder's range of motion is limited by pain.", "An x-ray of the shoulder shows a fracture of the middle third of the clavicle with complete superior displacement of the medial clavicular segment." ]

[ "1. A 28-year-old man is brought to the emergency department.", "2. He was involved in a bicycling accident 20 minutes prior.", "3. He complains of severe pain over the front of his right shoulder.", "4. He refuses to move his right arm.", "5. Physical examination shows supraclavicular swelling and bruising.", "6. The shoulder's range of motion is limited by pain.", "7. An x-ray of the shoulder shows a fracture of the middle third of the clavicle.", "8. The x-ray shows complete superior displacement of the medial clavicular segment." ]

[ "1. Patient complains of severe pain over the front of his right shoulder.", "2. Patient refuses to move his right arm.", "3. Physical examination shows supraclavicular swelling and bruising.", "4. Shoulder's range of motion is limited by pain.", "5. X-ray of the shoulder shows a fracture of the middle third of the clavicle.", "6. X-ray shows complete superior displacement of the medial clavicular segment." ]

[ "A 49-year-old woman presents to her oncologist with progressive difficulty breathing at rest, decreased exercise tolerance, and ankle swelling bilaterally for the past 2 weeks.", "She was diagnosed with breast cancer 4 years ago which was treated with radical mastectomy, radiation, and aggressive chemotherapy.", "She does not smoke or drink alcohol.", "Her family history is positive for breast cancer in her elder sister.", "Vital signs include: blood pressure 85/50 mm Hg, temperature 36.7°C (98.1°F), and a regular pulse of 110/min.", "The physician notices that, with inspiration, the radial pulse becomes weak.", "On physical examination, she looks anxious and tachypneic.", "Jugular venous pressure is 14 cm and heart sounds are distant.", "Lungs are clear and 1+ pedal edema is noted.", "Her chest X-ray is shown in the exhibit." ]

[ "1. A 49-year-old woman presents to her oncologist with progressive difficulty breathing at rest, decreased exercise tolerance, and ankle swelling bilaterally for the past 2 weeks.", "2. She was diagnosed with breast cancer 4 years ago which was treated with radical mastectomy, radiation, and aggressive chemotherapy.", "3. She does not smoke or drink alcohol.", "4. Her family history is positive for breast cancer in her elder sister.", "5. Vital signs include: blood pressure 85/50 mm Hg, temperature 36.7°C (98.1°F), and a regular pulse of 110/min.", "6. The physician notices that, with inspiration, the radial pulse becomes weak.", "7. On physical examination, she looks anxious and tachypneic.", "8. Jugular venous pressure is 14 cm and heart sounds are distant.", "9. Lungs are clear and 1+ pedal edema is noted.", "10. Her chest X-ray is shown in the exhibit." ]

[ "1. Diagnosed with breast cancer 4 years ago", "2. Treated with radical mastectomy, radiation, and aggressive chemotherapy", "3. Does not smoke or drink alcohol", "4. Family history positive for breast cancer in elder sister", "5. Blood pressure 85/50 mm Hg", "6. Temperature 36.7°C (98.1°F)", "7. Regular pulse of 110/min", "8. Radial pulse becomes weak with inspiration", "9. Looks anxious and tachypneic", "10. Jugular venous pressure is 14 cm", "11. Distant heart sounds", "12. Lungs are clear", "13. 1+ pedal edema noted", "14. Chest X-ray is shown in the exhibit" ]

[ "A 5-year-old boy is brought to the physician because of high-grade fever and generalized fatigue for 5 days.", "Two days ago, he developed a rash on his trunk.", "He returned from a family hiking trip to Montana 1 week ago.", "His immunization records are unavailable.", "His temperature is 39.8°C (103.6°F), pulse is 111/min, and blood pressure is 96/60 mm Hg.", "Examination shows injection of the conjunctivae bilaterally.", "The tongue and pharynx are erythematous.", "Tender cervical lymphadenopathy is present on the left.", "There is a macular rash over the trunk and extremities.", "Bilateral knee joints are swollen and tender; range of motion is limited by pain.", "Cardiopulmonary examination shows no abnormalities." ]

[ "1. A 5-year-old boy is brought to the physician.", "2. He has had high-grade fever and generalized fatigue for 5 days.", "3. Two days ago, he developed a rash on his trunk.", "4. He returned from a family hiking trip to Montana 1 week ago.", "5. His immunization records are unavailable.", "6. His temperature is 39.8°C (103.6°F).", "7. His pulse is 111/min.", "8. His blood pressure is 96/60 mm Hg.", "9. Examination shows injection of the conjunctivae bilaterally.", "10. The tongue and pharynx are erythematous.", "11. Tender cervical lymphadenopathy is present on the left.", "12. There is a macular rash over the trunk and extremities.", "13. Bilateral knee joints are swollen and tender.", "14. Range of motion is limited by pain.", "15. Cardiopulmonary examination shows no abnormalities." ]

[ "1. Two days ago, he developed a rash on his trunk.", "2. He returned from a family hiking trip to Montana 1 week ago.", "3. His immunization records are unavailable.", "4. His temperature is 39.8°C (103.6°F), pulse is 111/min, and blood pressure is 96/60 mm Hg.", "5. Examination shows injection of the conjunctivae bilaterally.", "6. The tongue and pharynx are erythematous.", "7. Tender cervical lymphadenopathy is present on the left.", "8. There is a macular rash over the trunk and extremities.", "9. Bilateral knee joints are swollen and tender; range of motion is limited by pain.", "10. Cardiopulmonary examination shows no abnormalities." ]

[ "A 61-year-old female presents to the emergency room for a headache and vision loss.", "She reports a 3-hour history of acute-onset dull headache.", "She also says she cannot see out of part of her eye.", "Her past medical history is notable for hypertension, hyperlipidemia, and a prior myocardial infarction.", "She takes enalapril, atorvastatin, aspirin, and metoprolol.", "On exam, she is alert and oriented to person, place, and time.", "She has 5/5 strength and full sensation to light touch in her bilateral upper and lower extremities.", "Her brachioradialis, triceps, patellar, and Achilles reflexes are symmetric and 2+ bilaterally.", "Fundoscopic examination reveals a normal retina.", "Visual field examination demonstrates an inability to see in the superior right visual field." ]

[ "1. Patient is a 61-year-old female.", "2. Patient presents to the emergency room for a headache and vision loss.", "3. Patient has a 3-hour history of acute-onset dull headache.", "4. Patient cannot see out of part of her eye.", "5. Patient's past medical history is notable for hypertension, hyperlipidemia, and a prior myocardial infarction.", "6. Patient takes enalapril, atorvastatin, aspirin, and metoprolol.", "7. Patient is alert and oriented to person, place, and time.", "8. Patient has 5/5 strength and full sensation to light touch in her bilateral upper and lower extremities.", "9. Patient's brachioradialis, triceps, patellar, and Achilles reflexes are symmetric and 2+ bilaterally.", "10. Fundoscopic examination reveals a normal retina.", "11. Visual field examination demonstrates an inability to see in the superior right visual field." ]

[ "1. She reports a 3-hour history of acute-onset dull headache.", "2. She cannot see out of part of her eye.", "3. Her past medical history includes hypertension, hyperlipidemia, and a prior myocardial infarction.", "4. She takes enalapril, atorvastatin, aspirin, and metoprolol.", "5. On exam, she is alert and oriented to person, place, and time.", "6. She has 5/5 strength and full sensation to light touch in her bilateral upper and lower extremities.", "7. Her brachioradialis, triceps, patellar, and Achilles reflexes are symmetric and 2+ bilaterally.", "8. Fundoscopic examination reveals a normal retina.", "9. Visual field examination demonstrates an inability to see in the superior right visual field." ]

[ "A 37-year-old G2P1001 presents to her obstetrician’s office at 31 weeks gestation for decreased fetal movement over the last day.", "She states that although she occasionally feels some movement, it is decreased from baseline.", "She denies any gush of fluid, vaginal bleeding, or painful contractions.", "This pregnancy has been complicated by gestational diabetes for which the patient was prescribed insulin.", "She reports not always taking postprandial fingersticks; therefore, she infrequently uses her insulin.", "She also had a urinary tract infection in the first trimester that was successfully treated with nitrofurantoin.", "The patient has a past medical history of obesity and rosacea, and she had an uncomplicated spontaneous vaginal delivery six years ago.", "At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 148/71 mmHg, pulse is 75/min, and respirations are 14/min.", "The patient appears comfortable and has a fundal height of 33 centimeters.", "An initial attempt with Doppler ultrasound is unable to detect fetal heart tones." ]

[ "1. Patient is 37 years old.", "2. Patient is G2P1001.", "3. Patient is 31 weeks gestation.", "4. Patient has decreased fetal movement over the last day.", "5. Patient occasionally feels some movement, but it is decreased from baseline.", "6. Patient denies any gush of fluid, vaginal bleeding, or painful contractions.", "7. Patient has gestational diabetes.", "8. Patient was prescribed insulin.", "9. Patient does not always take postprandial fingersticks.", "10. Patient infrequently uses her insulin.", "11. Patient had a urinary tract infection in the first trimester.", "12. Patient was successfully treated with nitrofurantoin.", "13. Patient has a past medical history of obesity and rosacea.", "14. Patient had an uncomplicated spontaneous vaginal delivery six years ago.", "15. Patient's temperature is 98.6°F (37.0°C).", "16. Patient's blood pressure is 148/71 mmHg.", "17. Patient's pulse is 75/min.", "18. Patient's respirations are 14/min.", "19. Patient appears comfortable.", "20. Patient has a fundal height of 33 centimeters.", "21. Initial attempt with Doppler ultrasound is unable to detect fetal heart tones." ]

[ "1. The patient occasionally feels some movement, but it is decreased from baseline.", "2. The patient denies any gush of fluid, vaginal bleeding, or painful contractions.", "3. The pregnancy has been complicated by gestational diabetes, and the patient was prescribed insulin.", "4. The patient reports not always taking postprandial fingersticks and infrequently uses her insulin.", "5. The patient had a urinary tract infection in the first trimester, successfully treated with nitrofurantoin.", "6. The patient has a past medical history of obesity and rosacea.", "7. The patient had an uncomplicated spontaneous vaginal delivery six years ago.", "8. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 148/71 mmHg, pulse is 75/min, and respirations are 14/min.", "9. The patient appears comfortable and has a fundal height of 33 centimeters.", "10. An initial attempt with Doppler ultrasound is unable to detect fetal heart tones." ]

[ "A 59-year-old man is brought to the emergency department by his wife because of fever, chills, night sweats, and generalized fatigue for 2 weeks.", "His temperature is 39.1°C (102.4°F).", "He appears ill.", "Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border, and crackles at both lung bases.", "A transesophageal echocardiography shows a 12 mm vegetation on the aortic valve.", "Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains that are unable to grow in a 6.5% NaCl medium." ]

[ "1. A 59-year-old man is brought to the emergency department by his wife.", "2. He has been experiencing fever, chills, night sweats, and generalized fatigue for 2 weeks.", "3. His temperature is 39.1°C (102.4°F).", "4. He appears ill.", "5. Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border.", "6. Physical examination also shows crackles at both lung bases.", "7. A transesophageal echocardiography shows a 12 mm vegetation on the aortic valve.", "8. Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains.", "9. The cocci are unable to grow in a 6.5% NaCl medium." ]

[ "1. His temperature is 39.1°C (102.4°F).", "2. He appears ill.", "3. Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border.", "4. Physical examination shows crackles at both lung bases.", "5. A transesophageal echocardiography shows a 12 mm vegetation on the aortic valve.", "6. Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains.", "7. The blood cultures are unable to grow in a 6.5% NaCl medium." ]

[ "A 65-year-old woman presents to her family doctor to reestablish care since her retirement from her corporate job and loss of her employer-sponsored health insurance.", "She states that she has not had time for regular check-ups.", "She exercises 3-4 times a week and consumes red meat sparingly.", "She drank and smoked cigarettes socially with coworkers but never at home or on vacation.", "She wakes up with achy wrists and elbows that she suspects is from years of using a computer keyboard.", "She completed menopause at age 52.", "Her family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.", "She last had a colonoscopy 5 years ago that revealed no abnormal findings.", "Her vital signs are within normal limits and her physical exam is grossly unremarkable." ]

[ "1. Patient is 65 years old.", "2. Patient recently retired from a corporate job and lost employer-sponsored health insurance.", "3. Patient has not had time for regular check-ups.", "4. Patient exercises 3-4 times a week.", "5. Patient consumes red meat sparingly.", "6. Patient drank and smoked cigarettes socially with coworkers, but not at home or on vacation.", "7. Patient wakes up with achy wrists and elbows, which she suspects is from years of using a computer keyboard.", "8. Patient completed menopause at age 52.", "9. Patient's family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.", "10. Patient last had a colonoscopy 5 years ago that revealed no abnormal findings.", "11. Patient's vital signs are within normal limits.", "12. Patient's physical exam is grossly unremarkable." ]

[ "1. She has not had time for regular check-ups.", "2. She exercises 3-4 times a week.", "3. She consumes red meat sparingly.", "4. She drank and smoked cigarettes socially with coworkers.", "5. She never drank or smoked at home or on vacation.", "6. She wakes up with achy wrists and elbows.", "7. She suspects it is from years of using a computer keyboard.", "8. She completed menopause at age 52.", "9. Her family history includes coronary artery disease on her father's side.", "10. Her family history includes colon cancer on her mother's side.", "11. She had a colonoscopy 5 years ago.", "12. The colonoscopy revealed no abnormal findings.", "13. Her vital signs are within normal limits.", "14. Her physical exam is grossly unremarkable." ]

[ "A 52-year-old woman comes to the physician because of mild fatigue and dizziness for the past 2 days.", "She has not been to work since yesterday due to her symptoms.", "She says she has \"\"very high blood sugar” and has had similar episodes often in the past 2 years, for which she has visited multiple doctors around the city.", "She has also purchased a home glucose monitoring device, which she uses daily.", "Since the symptoms began, she has become socially withdrawn and spends much of her time at home researching diabetes on the internet.", "One week ago, she took a day off work because of her symptoms.", "She is not on any treatment.", "She has had 3 laboratory test reports that all show normal fasting and post-meal blood glucose levels.", "Her father and brother have diabetes mellitus type 2.", "She appears anxious.", "Vital signs are normal.", "Physical examination shows no abnormalities.", "Random serum glucose is 128 mg/dL." ]

[ "1. A 52-year-old woman comes to the physician.", "2. She has mild fatigue and dizziness for the past 2 days.", "3. She has not been to work since yesterday due to her symptoms.", "4. She says she has \"very high blood sugar\".", "5. She has had similar episodes often in the past 2 years.", "6. She has visited multiple doctors around the city.", "7. She has purchased a home glucose monitoring device.", "8. She uses the device daily.", "9. Since the symptoms began, she has become socially withdrawn.", "10. She spends much of her time at home researching diabetes on the internet.", "11. One week ago, she took a day off work because of her symptoms.", "12. She is not on any treatment.", "13. She has had 3 laboratory test reports.", "14. All show normal fasting and post-meal blood glucose levels.", "15. Her father and brother have diabetes mellitus type 2.", "16. She appears anxious.", "17. Vital signs are normal.", "18. Physical examination shows no abnormalities.", "19. Random serum glucose is 128 mg/dL." ]

[ "1. She has not been to work since yesterday due to her symptoms.", "2. She says she has \"very high blood sugar” and has had similar episodes often in the past 2 years.", "3. She has visited multiple doctors around the city for her symptoms.", "4. She has purchased a home glucose monitoring device, which she uses daily.", "5. Since the symptoms began, she has become socially withdrawn and spends much of her time at home researching diabetes on the internet.", "6. One week ago, she took a day off work because of her symptoms.", "7. She is not on any treatment.", "8. She has had 3 laboratory test reports that all show normal fasting and post-meal blood glucose levels.", "9. Her father and brother have diabetes mellitus type 2.", "10. She appears anxious.", "11. Vital signs are normal.", "12. Physical examination shows no abnormalities.", "13. Random serum glucose is 128 mg/dL." ]

[ "A 4800 g (10.6 lb) male newborn is delivered at term to a 35-year-old woman, gravida 1, para 1.", "Significant lateral neck traction is required during delivery.", "Apgar scores are 9 and 9 at 1 and 5 minutes, respectively.", "Vital signs are within normal limits.", "At rest, his right shoulder is adducted and internally rotated.", "The baby cries with passive movement of the arm.", "Laboratory studies show: | Hematocrit 66% | Leukocyte count 9000/mm3 | Serum | Na+ 142 mEq/L | Cl- 103 mEq/L | K+ 5.1 mEq/L | HCO3- 20 mEq/L | Urea nitrogen 8 mg/dL | Glucose 34 mg/dL | Creatinine 0.6 mg/dL | ." ]

[ "1. A 4800 g male newborn is delivered at term.", "2. The mother is 35 years old and gravida 1, para 1.", "3. Significant lateral neck traction is required during delivery.", "4. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively.", "5. Vital signs are within normal limits.", "6. At rest, the baby's right shoulder is adducted and internally rotated.", "7. The baby cries with passive movement of the arm.", "8. Hematocrit is 66%.", "9. Leukocyte count is 9000/mm3.", "10. Serum Na+ is 142 mEq/L.", "11. Serum Cl- is 103 mEq/L.", "12. Serum K+ is 5.1 mEq/L.", "13. Serum HCO3- is 20 mEq/L.", "14. Serum urea nitrogen is 8 mg/dL.", "15. Serum glucose is 34 mg/dL.", "16. Serum creatinine is 0.6 mg/dL." ]

[ "1. Significant lateral neck traction is required during delivery.", "2. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively.", "3. Vital signs are within normal limits.", "4. At rest, his right shoulder is adducted and internally rotated.", "5. The baby cries with passive movement of the arm.", "6. Laboratory studies show: Hematocrit 66%", "7. Laboratory studies show: Leukocyte count 9000/mm3", "8. Laboratory studies show: Serum Na+ 142 mEq/L", "9. Laboratory studies show: Serum Cl- 103 mEq/L", "10. Laboratory studies show: Serum K+ 5.1 mEq/L", "11. Laboratory studies show: Serum HCO3- 20 mEq/L", "12. Laboratory studies show: Serum Urea nitrogen 8 mg/dL", "13. Laboratory studies show: Serum Glucose 34 mg/dL", "14. Laboratory studies show: Serum Creatinine 0.6 mg/dL" ]

[ "A 30-year-old woman comes to the physician for evaluation of successful conception.", "She and her husband are trying to conceive, and they have had frequent sexual intercourse over the past month.", "Her menstrual cycles occur at regular 28-day intervals, and her last menstrual period began 25 days ago." ]

[ "1. A 30-year-old woman comes to the physician for evaluation of successful conception.", "2. She and her husband are trying to conceive.", "3. They have had frequent sexual intercourse over the past month.", "4. Her menstrual cycles occur at regular 28-day intervals.", "5. Her last menstrual period began 25 days ago." ]

[ "1. She and her husband are trying to conceive.", "2. They have had frequent sexual intercourse over the past month.", "3. Her menstrual cycles occur at regular 28-day intervals.", "4. Her last menstrual period began 25 days ago." ]

[ "A 25-year-old healthy man presents to the physician for an annual checkup.", "He doesn’t have any concerns and feels completely healthy.", "He recently started a new job and has been working out at a gym regularly.", "He does not smoke cigarettes, drinks occasionally, and does not use illicit substances.", "His vital signs include: pulse 80/min, respirations 14/min, and blood pressure 120/80 mm Hg.", "Physical examination is significant for a splitting of the second heart sound heard on inspiration but not on expiration." ]

[ "1. A 25-year-old man presents to the physician for an annual checkup.", "2. He does not have any concerns and feels completely healthy.", "3. He recently started a new job.", "4. He has been working out at a gym regularly.", "5. He does not smoke cigarettes.", "6. He drinks occasionally.", "7. He does not use illicit substances.", "8. His pulse is 80/min.", "9. His respirations are 14/min.", "10. His blood pressure is 120/80 mm Hg.", "11. Physical examination is significant for a splitting of the second heart sound heard on inspiration but not on expiration." ]

[ "1. The patient doesn't have any concerns.", "2. The patient feels completely healthy.", "3. The patient recently started a new job.", "4. The patient has been working out at a gym regularly.", "5. The patient does not smoke cigarettes.", "6. The patient drinks occasionally.", "7. The patient does not use illicit substances.", "8. The patient's pulse is 80/min.", "9. The patient's respirations are 14/min.", "10. The patient's blood pressure is 120/80 mm Hg.", "11. The physical examination is significant for a splitting of the second heart sound heard on inspiration but not on expiration." ]

[ "A 79-year-old man presents to his primary care physician complaining of progressive shortness of breath on exertion for the past 2 months.", "He was first aware of having to catch his breath while gardening, and he is now unable to walk up the stairs in his house without stopping.", "He has had type 2 diabetes mellitus for 30 years, for which he takes metformin and sitagliptin.", "His blood pressure is 110/50 mm Hg, the temperature is 37.1°C (98.8°F), and the radial pulse is 80/min and regular.", "On physical examination, there is a loud systolic murmur at the right upper sternal border with radiation to the carotid arteries." ]

[ "1. Patient is 79 years old.", "2. Patient is complaining of progressive shortness of breath on exertion for the past 2 months.", "3. Patient first noticed shortness of breath while gardening.", "4. Patient is unable to walk up stairs without stopping.", "5. Patient has type 2 diabetes mellitus for 30 years.", "6. Patient takes metformin and sitagliptin for diabetes.", "7. Patient's blood pressure is 110/50 mm Hg.", "8. Patient's temperature is 37.1°C (98.8°F).", "9. Patient's radial pulse is 80/min and regular.", "10. Physical examination reveals loud systolic murmur at right upper sternal border with radiation to carotid arteries." ]

[ "1. He first noticed difficulty catching his breath while gardening.", "2. He is unable to walk up the stairs in his house without stopping.", "3. He has had type 2 diabetes mellitus for 30 years.", "4. He takes metformin and sitagliptin for his diabetes.", "5. His blood pressure is 110/50 mm Hg.", "6. His temperature is 37.1°C (98.8°F).", "7. His radial pulse is 80/min and regular.", "8. On physical examination, there is a loud systolic murmur at the right upper sternal border with radiation to the carotid arteries." ]

[ "A 47-year-old woman presents with intermittent throbbing headaches.", "She says that she has had at least 1–2 every week for the last 3 months.", "She describes the pain as severe, pulsatile, and localized to the right frontotemporal and periorbital areas.", "She says the headaches usually last for several hours and are made worse by the presence of light.", "She endorses nausea with occasional vomiting during the most severe episodes.", "She denies any seizures, loss of consciousness, or focal neurologic deficits.", "Her past medical history is significant for myocardial infarction (MI) 1 year ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina, and severe asthma, managed medically.", "The patient is afebrile, and the vital signs are within normal limits.", "A physical examination is unremarkable.", "A noncontrast computed tomography (CT) scan of the head appears normal." ]

[ "1. Patient is a 47-year-old woman.", "2. Patient has had intermittent throbbing headaches for the last 3 months, 1-2 per week.", "3. Pain is severe, pulsatile, and localized to the right frontotemporal and periorbital areas.", "4. Headaches usually last for several hours and are made worse by the presence of light.", "5. Patient endorses nausea with occasional vomiting during the most severe episodes.", "6. Patient denies any seizures, loss of consciousness, or focal neurologic deficits.", "7. Patient's past medical history is significant for MI 1 year ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina, and severe asthma, managed medically.", "8. Patient is afebrile, and vital signs are within normal limits.", "9. Physical examination is unremarkable.", "10. Noncontrast CT scan of the head appears normal." ]

[ "1. The patient reports having at least 1–2 headaches every week for the last 3 months.", "2. She describes the pain as severe, pulsatile, and localized to the right frontotemporal and periorbital areas.", "3. The headaches usually last for several hours and are exacerbated by the presence of light.", "4. She experiences nausea with occasional vomiting during the most severe episodes.", "5. The patient denies any seizures, loss of consciousness, or focal neurologic deficits.", "6. Her past medical history includes myocardial infarction (MI) 1 year ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina, and severe asthma, managed medically.", "7. The patient is afebrile, and the vital signs are within normal limits.", "8. A physical examination is unremarkable.", "9. A noncontrast computed tomography (CT) scan of the head appears normal." ]

[ "A 37-year-old 11-week primigravida will soon undergo a prenatal evaluation.", "The doctor wants to exclude chromosomal abnormalities with a test.", "He tells her that the test includes extracting a blood sample to determine the chances of having certain genetic conditions.", "This process involves analyzing fetal DNA in the mother’s blood." ]

[ "1. A 37-year-old 11-week primigravida will soon undergo a prenatal evaluation.", "2. The doctor wants to exclude chromosomal abnormalities with a test.", "3. The test includes extracting a blood sample.", "4. The blood sample is used to determine the chances of having certain genetic conditions.", "5. This process involves analyzing fetal DNA in the mother’s blood." ]

[ "1. The doctor wants to exclude chromosomal abnormalities with a test.", "2. The test includes extracting a blood sample.", "3. The blood sample is used to determine the chances of having certain genetic conditions.", "4. The process involves analyzing fetal DNA in the mother’s blood." ]

[ "A 41-year-old man presents with progressive fatigue, pain in the front of the chest, and difficulty breathing with minimal exertion while trying to sleep.", "He reports having a flu-like illness consisting of fatigue, muscle pain, and cough 10 days ago that resolved spontaneously without seeking a medical help.", "He has no past medical history.", "He does not smoke cigarettes or drink alcohol.", "His vital signs include a blood pressure of 100/70 mm Hg, a temperature of 37.5°C (99.5°F), and a regular radial pulse of 105/min.", "On physical examination, the patient looks tired, the jugular venous pressure is elevated, pulmonary rales are present on both sides, and an S3 gallop is audible.", "His ECG shows nonspecific ST-segment and T-wave abnormalities.", "A 2-dimensional echocardiogram shows global left ventricular motion abnormalities and dilatation of the left ventricle.", "Troponin I and Creatine Kinase-MB are elevated." ]

[ "1. Patient is a 41-year-old man.", "2. Patient has progressive fatigue, pain in the front of the chest, and difficulty breathing with minimal exertion while trying to sleep.", "3. Patient had a flu-like illness consisting of fatigue, muscle pain, and cough 10 days ago that resolved spontaneously without seeking a medical help.", "4. Patient has no past medical history.", "5. Patient does not smoke cigarettes or drink alcohol.", "6. Patient's blood pressure is 100/70 mm Hg.", "7. Patient's temperature is 37.5°C (99.5°F).", "8. Patient's radial pulse is 105/min.", "9. Patient looks tired on physical examination.", "10. Patient's jugular venous pressure is elevated.", "11. Pulmonary rales are present on both sides.", "12. An S3 gallop is audible.", "13. Patient's ECG shows nonspecific ST-segment and T-wave abnormalities.", "14. 2-dimensional echocardiogram shows global left ventricular motion abnormalities and dilatation of the left ventricle.", "15. Troponin I is elevated.", "16. Creatine Kinase-MB is elevated." ]

[ "1. He had a flu-like illness 10 days ago with fatigue, muscle pain, and cough.", "2. The flu-like illness resolved spontaneously without seeking medical help.", "3. He has no past medical history.", "4. He does not smoke cigarettes or drink alcohol.", "5. His blood pressure is 100/70 mm Hg.", "6. His temperature is 37.5°C (99.5°F).", "7. His radial pulse is regular and 105/min.", "8. On physical examination, the patient looks tired.", "9. The jugular venous pressure is elevated.", "10. Pulmonary rales are present on both sides.", "11. An S3 gallop is audible.", "12. His ECG shows nonspecific ST-segment and T-wave abnormalities.", "13. A 2-dimensional echocardiogram shows global left ventricular motion abnormalities and dilatation of the left ventricle.", "14. Troponin I and Creatine Kinase-MB are elevated." ]

[ "A group of epidemiologists is studying the rates of cardiac surgeries performed in several Southeast Asian countries compared to the United States.", "Results show a significant increase in the number of mitral valve replacements performed in Vietnam in adults aged 30–50 years compared to the same age group in the United States." ]

[ "1. A group of epidemiologists is studying the rates of cardiac surgeries performed in several Southeast Asian countries compared to the United States.", "2. Results show a significant increase in the number of mitral valve replacements performed in Vietnam.", "3. The increase is in adults aged 30–50 years.", "4. The same age group in the United States is being compared." ]

[ "1. Results show a significant increase in the number of mitral valve replacements performed in Vietnam.", "2. The increase is in adults aged 30–50 years.", "3. The increase is compared to the same age group in the United States." ]

[ "A 31-year-old male presents to his primary care physician complaining of low back pain and fevers.", "He reports a four-day history of intermittent fevers, chills, and low back pain.", "He denies trauma or recent illness.", "His past medical history is notable for recurrent renal stones, diabetes mellitus, and alcohol abuse.", "He takes metformin but admits to missing several doses.", "He has had multiple sexual partners and uses condoms intermittently.", "His temperature is 100.6°F (38.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 21/min.", "On examination, he demonstrates mild tenderness to palpation along his lower back.", "Sensation to touch is intact in the bilateral lower extremities.", "Strength in leg and hip flexion and extension is 5/5 bilaterally.", "The physician is unable to perform a digital rectal examination due to pain.", "A urinalysis demonstrates leukocytes." ]

[ "1. Patient is a 31-year-old male.", "2. Patient is complaining of low back pain and fevers.", "3. Patient has a four-day history of intermittent fevers, chills, and low back pain.", "4. Patient denies trauma or recent illness.", "5. Patient's past medical history is notable for recurrent renal stones, diabetes mellitus, and alcohol abuse.", "6. Patient takes metformin but admits to missing several doses.", "7. Patient has had multiple sexual partners and uses condoms intermittently.", "8. Patient's temperature is 100.6°F (38.1°C).", "9. Patient's blood pressure is 110/70 mmHg.", "10. Patient's pulse is 110/min.", "11. Patient's respirations are 21/min.", "12. On examination, patient demonstrates mild tenderness to palpation along his lower back.", "13. Sensation to touch is intact in the bilateral lower extremities.", "14. Strength in leg and hip flexion and extension is 5/5 bilaterally.", "15. Physician is unable to perform a digital rectal examination due to pain.", "16. Urinalysis demonstrates leukocytes." ]

[ "1. He reports a four-day history of intermittent fevers, chills, and low back pain.", "2. He denies trauma or recent illness.", "3. His past medical history is notable for recurrent renal stones, diabetes mellitus, and alcohol abuse.", "4. He takes metformin but admits to missing several doses.", "5. He has had multiple sexual partners and uses condoms intermittently.", "6. His temperature is 100.6°F (38.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 21/min.", "7. On examination, he demonstrates mild tenderness to palpation along his lower back.", "8. Sensation to touch is intact in the bilateral lower extremities.", "9. Strength in leg and hip flexion and extension is 5/5 bilaterally.", "10. The physician is unable to perform a digital rectal examination due to pain.", "11. A urinalysis demonstrates leukocytes." ]

[ "A 12-year-old boy is brought to his pediatrician in order to be medically cleared for playing baseball.", "On presentation, the boy’s only complaint is that he has never been able to completely keep up with his classmates during gym or on the playground because he feels fatigued and short of breath.", "A review of his prior medical history reveals that he hit all his developmental milestones as expected and has otherwise been healthy.", "He lives with his parents and eats a diet consisting of mostly fast food and soda.", "Physical exam reveals a thin, pale boy with decreased color under his eyelids.", "A panel of hematologic tests are obtained with the following results: | | Hemoglobin: 11 g/dL | Leukocyte count: 4,250/mm^3 | Platelet count: 185,000/mm^3 | Mean corpuscular volume: 116 µm^3 | Blood smear: neutrophils with extra lobes | | Crystals are also found within this patient's urine." ]

[ "1. A 12-year-old boy is brought to his pediatrician in order to be medically cleared for playing baseball.", "2. The boy's only complaint is that he has never been able to completely keep up with his classmates during gym or on the playground because he feels fatigued and short of breath.", "3. A review of his prior medical history reveals that he hit all his developmental milestones as expected and has otherwise been healthy.", "4. He lives with his parents and eats a diet consisting of mostly fast food and soda.", "5. Physical exam reveals a thin, pale boy with decreased color under his eyelids.", "6. A panel of hematologic tests are obtained with the following results: Hemoglobin: 11 g/dL, Leukocyte count: 4,250/mm^3, Platelet count: 185,000/mm^3, Mean corpuscular volume: 116 µm^3, Blood smear: neutrophils with extra lobes.", "7. Crystals are also found within this patient's urine." ]

[ "1. The boy complains of feeling fatigued and short of breath during physical activities.", "2. The boy has hit all his developmental milestones as expected.", "3. The boy lives with his parents and consumes a diet consisting mostly of fast food and soda.", "4. Physical exam reveals a thin, pale boy with decreased color under his eyelids.", "5. Hemoglobin level is 11 g/dL.", "6. Leukocyte count is 4,250/mm^3.", "7. Platelet count is 185,000/mm^3.", "8. Mean corpuscular volume is 116 µm^3.", "9. Blood smear shows neutrophils with extra lobes.", "10. Crystals are found in the patient's urine." ]

[ "A 27-year-old woman presents to her primary care physician for a follow-up appointment.", "At her previous visit she had missed her previous two menses and also had a blood pressure of 147/100 mmHg.", "The patient has a past medical history of anxiety, depression, bulimia nervosa and irritable bowel syndrome.", "Her physician prescribed her an exercise program as well as started her on hydrochlorothiazide and ordered lab work.", "The results of the patient's lab work are below: | | Serum: | Na+: 145 mEq/L | K+: 2.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 30 mEq/L | BUN: 18 mg/dL | Ca2+: 10.9 mg/dL | Mg2+: 2.0 mEq/L | Creatinine: 1.2 mg/dL | Glucose: 110 mg/dL | | The patient's blood pressure at this visit is 145/100 mmHg and she has still not experienced her menses.", "Her cardiac, abdominal, and pulmonary exams are within normal limits.", "Inspection of the patient's oropharynx is unremarkable as is inspection of her extremities.", "The patient is started on furosemide and sent home." ]

[ "1. A 27-year-old woman presents to her primary care physician for a follow-up appointment.", "2. At her previous visit she had missed her previous two menses and also had a blood pressure of 147/100 mmHg.", "3. The patient has a past medical history of anxiety, depression, bulimia nervosa and irritable bowel syndrome.", "4. Her physician prescribed her an exercise program as well as started her on hydrochlorothiazide and ordered lab work.", "5. The results of the patient's lab work are: Na+: 145 mEq/L, K+: 2.9 mEq/L, Cl-: 100 mEq/L, HCO3-: 30 mEq/L, BUN: 18 mg/dL, Ca2+: 10.9 mg/dL, Mg2+: 2.0 mEq/L, Creatinine: 1.2 mg/dL, Glucose: 110 mg/dL.", "6. The patient's blood pressure at this visit is 145/100 mmHg and she has still not experienced her menses.", "7. Her cardiac, abdominal, and pulmonary exams are within normal limits.", "8. Inspection of the patient's oropharynx is unremarkable as is inspection of her extremities.", "9. The patient is started on furosemide and sent home." ]

[ "1. The patient missed her previous two menses.", "2. The patient had a blood pressure of 147/100 mmHg.", "3. The patient has a past medical history of anxiety, depression, bulimia nervosa, and irritable bowel syndrome.", "4. The physician prescribed an exercise program for the patient.", "5. The physician started the patient on hydrochlorothiazide.", "6. The physician ordered lab work for the patient.", "7. The results of the patient's lab work are as follows: ", "8. Serum: Na+: 145 mEq/L, K+: 2.9 mEq/L, Cl-: 100 mEq/L, HCO3-: 30 mEq/L, BUN: 18 mg/dL, Ca2+: 10.9 mg/dL, Mg2+: 2.0 mEq/L, Creatinine: 1.2 mg/dL, Glucose: 110 mg/dL.", "9. The patient's blood pressure at this visit is 145/100 mmHg.", "10. The patient has still not experienced her menses.", "11. The patient's cardiac, abdominal, and pulmonary exams are within normal limits.", "12. Inspection of the patient's oropharynx is unremarkable.", "13. Inspection of the patient's extremities is unremarkable.", "14. The patient is started on furosemide and sent home." ]

[ "A 59-year-old man is brought to the emergency room by his wife.", "Thirty minutes ago, he was carrying heavy moving boxes from his house to a truck when he felt short of breath and suddenly lost consciousness.", "His wife states that he fell to the ground and was unresponsive for 15 seconds before he regained consciousness.", "He was not confused after this episode.", "He does not have chest pain.", "On questioning, he recalls experiencing episodic shortness of breath and chest tightness while playing tennis over the past year.", "These symptoms resolved with rest.", "He has no personal history of serious illness and takes no medication.", "Vital signs are within normal limits.", "His temperature is 36.7°C (98°F), heart rate is 95/min and pulse is delayed but regular, respirations are 20/min, and blood pressure is 104/80 mm Hg." ]

[ "1. A 59-year-old man is brought to the emergency room by his wife.", "2. Thirty minutes ago, he was carrying heavy moving boxes from his house to a truck.", "3. He felt short of breath and suddenly lost consciousness.", "4. His wife states that he fell to the ground and was unresponsive for 15 seconds before he regained consciousness.", "5. He was not confused after this episode.", "6. He does not have chest pain.", "7. On questioning, he recalls experiencing episodic shortness of breath and chest tightness while playing tennis over the past year.", "8. These symptoms resolved with rest.", "9. He has no personal history of serious illness and takes no medication.", "10. Vital signs are within normal limits.", "11. His temperature is 36.7°C (98°F).", "12. Heart rate is 95/min.", "13. Pulse is delayed but regular.", "14. Respirations are 20/min.", "15. Blood pressure is 104/80 mm Hg." ]

[ "1. Thirty minutes ago, he was carrying heavy moving boxes from his house to a truck.", "2. He felt short of breath and suddenly lost consciousness.", "3. His wife states that he fell to the ground and was unresponsive for 15 seconds before he regained consciousness.", "4. He was not confused after this episode.", "5. He does not have chest pain.", "6. On questioning, he recalls experiencing episodic shortness of breath and chest tightness while playing tennis over the past year.", "7. These symptoms resolved with rest.", "8. He has no personal history of serious illness and takes no medication.", "9. Vital signs are within normal limits.", "10. His temperature is 36.7°C (98°F).", "11. Heart rate is 95/min and pulse is delayed but regular.", "12. Respirations are 20/min.", "13. Blood pressure is 104/80 mm Hg." ]

[ "A previously healthy 2-year-old girl is brought to the physician by her mother because of a dry, harsh cough for 2 days that worsens at night.", "She has also had mild rhinorrhea and fever.", "Her older brother has asthma and had a cold last week.", "Immunizations are up-to-date.", "She appears to be in mild distress.", "Her temperature is 38.1°C (100.5°F), pulse is 140/min, respirations are 35/min, and blood pressure is 99/56 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 96%.", "Examination shows clear rhinorrhea and a dry, hoarse cough.", "There is mild inspiratory stridor upon agitation that resolves with rest.", "The remainder of the examination shows no abnormalities." ]

[ "1. Patient is a 2-year-old girl.", "2. Patient is brought to the physician by her mother.", "3. Patient has a dry, harsh cough for 2 days that worsens at night.", "4. Patient has mild rhinorrhea and fever.", "5. Patient's older brother has asthma and had a cold last week.", "6. Patient's immunizations are up-to-date.", "7. Patient appears to be in mild distress.", "8. Patient's temperature is 38.1°C (100.5°F).", "9. Patient's pulse is 140/min.", "10. Patient's respirations are 35/min.", "11. Patient's blood pressure is 99/56 mm Hg.", "12. Pulse oximetry on room air shows an oxygen saturation of 96%.", "13. Examination shows clear rhinorrhea and a dry, hoarse cough.", "14. Examination shows mild inspiratory stridor upon agitation that resolves with rest.", "15. Examination shows no other abnormalities." ]

[ "1. She has mild rhinorrhea.", "2. She has fever.", "3. Her older brother has asthma.", "4. Her older brother had a cold last week.", "5. Her immunizations are up-to-date.", "6. She appears to be in mild distress.", "7. Her temperature is 38.1°C (100.5°F).", "8. Her pulse is 140/min.", "9. Her respirations are 35/min.", "10. Her blood pressure is 99/56 mm Hg.", "11. Pulse oximetry on room air shows an oxygen saturation of 96%.", "12. Examination shows clear rhinorrhea.", "13. Examination shows a dry, hoarse cough.", "14. There is mild inspiratory stridor upon agitation.", "15. The inspiratory stridor resolves with rest.", "16. The remainder of the examination shows no abnormalities." ]

[ "A 78-year-old man comes to the physician for evaluation of progressive hearing loss in both ears over the past year.", "He has difficulties understanding conversations in crowded places and when more than one person talks at the same time.", "He has no dizziness, ear discharge, ringing noise, or ear pain.", "He has a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus.", "Medications include enalapril, metformin, and atorvastatin.", "Vital signs are within normal limits.", "Otoscopic examination shows pearly gray, translucent tympanic membranes with a normal light reflex.", "A vibrating 512 Hz tuning fork is placed on the left mastoid process.", "Once the patient no longer hears a tone, the fork is held over the ipsilateral ear and the patient reports to hear the tone again.", "The same test is repeated on the right side with similar results.", "There is no lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead." ]

[ "1. Patient is 78 years old.", "2. Patient has progressive hearing loss in both ears over the past year.", "3. Patient has difficulties understanding conversations in crowded places and when more than one person talks at the same time.", "4. Patient has no dizziness, ear discharge, ringing noise, or ear pain.", "5. Patient has a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus.", "6. Patient is taking enalapril, metformin, and atorvastatin.", "7. Vital signs are within normal limits.", "8. Otoscopic examination shows pearly gray, translucent tympanic membranes with a normal light reflex.", "9. A vibrating 512 Hz tuning fork is placed on the left mastoid process.", "10. Patient no longer hears a tone when the fork is placed on the left mastoid process.", "11. Patient reports to hear the tone again when the fork is held over the ipsilateral ear.", "12. Similar results when the same test is repeated on the right side.", "13. No lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead." ]

[ "1. He has difficulties understanding conversations in crowded places and when more than one person talks at the same time.", "2. He has no dizziness, ear discharge, ringing noise, or ear pain.", "3. He has a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus.", "4. Medications include enalapril, metformin, and atorvastatin.", "5. Vital signs are within normal limits.", "6. Otoscopic examination shows pearly gray, translucent tympanic membranes with a normal light reflex.", "7. A vibrating 512 Hz tuning fork is placed on the left mastoid process.", "8. Once the patient no longer hears a tone, the fork is held over the ipsilateral ear and the patient reports to hear the tone again.", "9. The same test is repeated on the right side with similar results.", "10. There is no lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead." ]

[ "A 35-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit.", "She feels well.", "She states that she did not follow up with her gynecologist on a regular basis due to a busy work schedule.", "Pregnancy and delivery of her first two children were uncomplicated.", "Her blood pressure was 127/75 mm Hg at her initial obstetrics appointment.", "Her temperature is 37.2°C (99°F), pulse is 90/min, and blood pressure is 145/95 mm Hg.", "Pelvic examination shows a uterus consistent in size with a 37-week gestation.", "Physical examination shows 2+ edema in the lower extremities.", "Urinalysis shows: | Blood negative | Protein 3+ | RBC 1–2/hpf | RBC casts negative | After four hours of observation, her vital signs are unchanged." ]

[ "1. A 35-year-old woman is gravida 3, para 2, at 37 weeks' gestation.", "2. She feels well.", "3. She did not follow up with her gynecologist on a regular basis due to a busy work schedule.", "4. Pregnancy and delivery of her first two children were uncomplicated.", "5. Her blood pressure was 127/75 mm Hg at her initial obstetrics appointment.", "6. Her temperature is 37.2°C (99°F).", "7. Her pulse is 90/min.", "8. Her blood pressure is 145/95 mm Hg.", "9. Pelvic examination shows a uterus consistent in size with a 37-week gestation.", "10. Physical examination shows 2+ edema in the lower extremities.", "11. Urinalysis shows: Blood negative, Protein 3+, RBC 1–2/hpf, RBC casts negative.", "12. After four hours of observation, her vital signs are unchanged." ]

[ "1. She feels well.", "2. She did not follow up with her gynecologist on a regular basis due to a busy work schedule.", "3. Pregnancy and delivery of her first two children were uncomplicated.", "4. Her blood pressure was 127/75 mm Hg at her initial obstetrics appointment.", "5. Her temperature is 37.2°C (99°F), pulse is 90/min, and blood pressure is 145/95 mm Hg.", "6. Pelvic examination shows a uterus consistent in size with a 37-week gestation.", "7. Physical examination shows 2+ edema in the lower extremities.", "8. Urinalysis shows: | Blood negative | Protein 3+ | RBC 1–2/hpf | RBC casts negative.", "9. After four hours of observation, her vital signs are unchanged." ]

[ "A 31-year-old presents with self-described complaints of being \"fidgety and irritable\" that is unlike his \"calm personality a few years ago\".", "What is concerning to him is that his father was diagnosed with a similar condition at the age of 38.", "His father began a progressive decline - losing interest in his life and family, becoming messy, experiencing involuntary movements, and worsening dementia as he grew older.", "Genetic tests were performed on the patient which confirmed that he has a larger number of repeats than his father.", "He is concerned that the disease may begin earlier for him or may have already started." ]

[ "1. A 31-year-old presents with self-described complaints of being \"fidgety and irritable\".", "2. This is unlike his \"calm personality a few years ago\".", "3. His father was diagnosed with a similar condition at the age of 38.", "4. His father began a progressive decline.", "5. His father's decline included losing interest in his life and family, becoming messy, experiencing involuntary movements, and worsening dementia as he grew older.", "6. Genetic tests were performed on the patient.", "7. The genetic tests confirmed that he has a larger number of repeats than his father.", "8. He is concerned that the disease may begin earlier for him or may have already started." ]

[ "1. His father was diagnosed with a similar condition at the age of 38.", "2. His father began a progressive decline.", "3. His father lost interest in his life and family.", "4. His father became messy.", "5. His father experienced involuntary movements.", "6. His father's dementia worsened as he grew older.", "7. Genetic tests were performed on the patient.", "8. The genetic tests confirmed that he has a larger number of repeats than his father.", "9. He is concerned that the disease may begin earlier for him or may have already started." ]

[ "A 48-year-old woman comes to the physician because of a 3-month history of low-grade fever, unintentional weight loss, night sweats, and a right-sided neck mass.", "Examination shows pallor.", "There is a non-tender and immobile right-sided cervical mass and enlarged axillary and inguinal lymph nodes.", "The liver is palpated 4 cm below the right costal margin, and the spleen is palpated 3 cm below the left costal margin.", "Histopathologic examination of a cervical lymph node biopsy specimen shows a nodular proliferation of centrocytes and centroblasts that stain positive for CD20.", "Genetic analysis shows a reciprocal translocation of chromosomes 14 and 18." ]

[ "1. A 48-year-old woman comes to the physician.", "2. She has a 3-month history of low-grade fever.", "3. She has a 3-month history of unintentional weight loss.", "4. She has a 3-month history of night sweats.", "5. She has a right-sided neck mass.", "6. Examination shows pallor.", "7. There is a non-tender and immobile right-sided cervical mass.", "8. There are enlarged axillary and inguinal lymph nodes.", "9. The liver is palpated 4 cm below the right costal margin.", "10. The spleen is palpated 3 cm below the left costal margin.", "11. Histopathologic examination of a cervical lymph node biopsy specimen shows a nodular proliferation of centrocytes and centroblasts.", "12. The nodular proliferation stains positive for CD20.", "13. Genetic analysis shows a reciprocal translocation of chromosomes 14 and 18." ]

[ "1. Examination shows pallor.", "2. There is a non-tender and immobile right-sided cervical mass.", "3. Enlarged axillary and inguinal lymph nodes are present.", "4. The liver is palpated 4 cm below the right costal margin.", "5. The spleen is palpated 3 cm below the left costal margin.", "6. Histopathologic examination of a cervical lymph node biopsy specimen shows a nodular proliferation of centrocytes and centroblasts.", "7. The centrocytes and centroblasts stain positive for CD20.", "8. Genetic analysis shows a reciprocal translocation of chromosomes 14 and 18." ]

[ "A 59-year-old man is brought to the emergency department for changes in mental status.", "His wife noticed that since lunch time today, he has been “zoning out” and forgetting simple things such as where the bathroom is.", "She decided to call the ambulance as he got uncharacteristically violent during dinner when he threw his plate to the floor.", "The patient denies fevers, weight loss, chills, chest pain, or shortness of breath, but reports mild abdominal discomfort and some dark stools that he attributes to iron supplements.", "A physical examination demonstrates a moderate fluid wave of the abdomen and shaking of the hands while the wrists are extended." ]

[ "1. A 59-year-old man is brought to the emergency department for changes in mental status.", "2. His wife noticed that since lunch time today, he has been “zoning out” and forgetting simple things such as where the bathroom is.", "3. She decided to call the ambulance as he got uncharacteristically violent during dinner when he threw his plate to the floor.", "4. The patient denies fevers, weight loss, chills, chest pain, or shortness of breath.", "5. The patient reports mild abdominal discomfort and some dark stools that he attributes to iron supplements.", "6. A physical examination demonstrates a moderate fluid wave of the abdomen.", "7. A physical examination demonstrates shaking of the hands while the wrists are extended." ]

[ "1. His wife noticed that since lunch time today, he has been “zoning out” and forgetting simple things such as where the bathroom is.", "2. She decided to call the ambulance as he got uncharacteristically violent during dinner when he threw his plate to the floor.", "3. The patient denies fevers, weight loss, chills, chest pain, or shortness of breath.", "4. The patient reports mild abdominal discomfort and some dark stools that he attributes to iron supplements.", "5. A physical examination demonstrates a moderate fluid wave of the abdomen.", "6. A physical examination demonstrates shaking of the hands while the wrists are extended." ]

[ "An otherwise healthy 49-year-old man presents to his primary care doctor for routine screening.", "He does not have any symptoms and take no medications.", "He has smoked 15–20 cigarettes daily for the past 9 years.", "His father died of diabetes complications and his mother has been recently diagnosed with proliferative diabetic retinopathy.", "His blood pressure is 160/95 mm Hg, temperature is 36.9°C (98.4°F), pulse is 90/min, body mass index is 36 kg/m², fasting blood sugar 170 mg/dL, and A1c is 9%." ]

[ "1. An otherwise healthy 49-year-old man presents to his primary care doctor for routine screening.", "2. He does not have any symptoms and take no medications.", "3. He has smoked 15–20 cigarettes daily for the past 9 years.", "4. His father died of diabetes complications.", "5. His mother has been recently diagnosed with proliferative diabetic retinopathy.", "6. His blood pressure is 160/95 mm Hg.", "7. His temperature is 36.9°C (98.4°F).", "8. His pulse is 90/min.", "9. His body mass index is 36 kg/m².", "10. His fasting blood sugar is 170 mg/dL.", "11. His A1c is 9%." ]

[ "1. The patient does not have any symptoms.", "2. The patient takes no medications.", "3. The patient has smoked 15–20 cigarettes daily for the past 9 years.", "4. The patient's father died of diabetes complications.", "5. The patient's mother has been recently diagnosed with proliferative diabetic retinopathy.", "6. The patient's blood pressure is 160/95 mm Hg.", "7. The patient's temperature is 36.9°C (98.4°F).", "8. The patient's pulse is 90/min.", "9. The patient's body mass index is 36 kg/m².", "10. The patient's fasting blood sugar is 170 mg/dL.", "11. The patient's A1c is 9%." ]

[ "A 30-year-old woman is brought to the emergency department because of severe headache and vomiting that started after she was hiking in the mountains at high altitude.", "She normally lives in a city that is close to sea level.", "Therapy is initiated with a drug that alkalinizes the urine." ]

[ "1. A 30-year-old woman is brought to the emergency department.", "2. She has severe headache and vomiting.", "3. Her symptoms started after she was hiking in the mountains at high altitude.", "4. She normally lives in a city that is close to sea level.", "5. Therapy is initiated with a drug that alkalinizes the urine." ]

[ "1. She normally lives in a city.", "2. The city is close to sea level.", "3. Therapy is initiated.", "4. The therapy involves a drug.", "5. The drug alkalinizes the urine." ]

[ "A 35-year-old woman comes to employee health services 30 minutes after a work-related incident.", "She works as a phlebotomist and reports that blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.", "Immediately following the incident, she flushed her eye with water for several minutes.", "The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats.", "He is an intravenous drug user and is sexually active with several male and female partners.", "The phlebotomist has no history of serious illness and takes no medications.", "Her immunizations are up-to-date.", "Physical examination shows no abnormalities." ]

[ "1. A 35-year-old woman came to employee health services 30 minutes after a work-related incident.", "2. She works as a phlebotomist.", "3. Blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.", "4. Immediately following the incident, she flushed her eye with water for several minutes.", "5. The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats.", "6. He is an intravenous drug user.", "7. He is sexually active with several male and female partners.", "8. The phlebotomist has no history of serious illness.", "9. She takes no medications.", "10. Her immunizations are up-to-date.", "11. Physical examination shows no abnormalities." ]

[ "1. She works as a phlebotomist.", "2. Blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.", "3. She flushed her eye with water for several minutes immediately following the incident.", "4. The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats.", "5. The patient is an intravenous drug user and is sexually active with several male and female partners.", "6. The phlebotomist has no history of serious illness.", "7. The phlebotomist takes no medications.", "8. Her immunizations are up-to-date.", "9. Physical examination shows no abnormalities." ]

[ "A 65-year-old Asian woman comes to the physician for a routine health maintenance examination.", "On questioning, she has had occasional night sweats during the past 2 months.", "She has not had fevers or weight loss.", "Seven months ago, she had an acute myocardial infarction and was treated with percutaneous coronary intervention.", "She has hypertension, hyperlipidemia, and gastroesophageal reflux disease.", "She has smoked one pack of cigarettes daily for 37 years.", "Current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.", "She is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.", "Her temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.", "The lungs are clear to auscultation.", "Cardiac examination shows an S4.", "There is a nontender skin lesion near the right large toenail.", "A photograph of the lesion is shown.", "The remainder of the examination shows no abnormalities." ]

[ "1. Patient is a 65-year-old Asian woman.", "2. Patient has had occasional night sweats during the past 2 months.", "3. Patient has not had fevers or weight loss.", "4. Patient had an acute myocardial infarction 7 months ago and was treated with percutaneous coronary intervention.", "5. Patient has hypertension, hyperlipidemia, and gastroesophageal reflux disease.", "6. Patient has smoked one pack of cigarettes daily for 37 years.", "7. Patient's current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.", "8. Patient is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.", "9. Patient's temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.", "10. Lungs are clear to auscultation.", "11. Cardiac examination shows an S4.", "12. Patient has a nontender skin lesion near the right large toenail.", "13. Photograph of the lesion is shown.", "14. No other abnormalities found on examination." ]

[ "1. She has had occasional night sweats during the past 2 months.", "2. She has not had fevers or weight loss.", "3. Seven months ago, she had an acute myocardial infarction and was treated with percutaneous coronary intervention.", "4. She has hypertension, hyperlipidemia, and gastroesophageal reflux disease.", "5. She has smoked one pack of cigarettes daily for 37 years.", "6. Current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.", "7. She is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.", "8. Her temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.", "9. The lungs are clear to auscultation.", "10. Cardiac examination shows an S4.", "11. There is a nontender skin lesion near the right large toenail.", "12. A photograph of the lesion is shown.", "13. The remainder of the examination shows no abnormalities." ]

[ "A 12-year-old girl brought to the clinic by her mother has a 3-day history of fever and sore throat and hematuria since this morning.", "The patient’s mother says she had a fever up to 39.5℃ (103.1℉) for the last 3 days and a severe sore throat, which has improved slightly.", "The mother states that she noticed her daughter had red urine today.", "The patient’s temperature is 39.3℃ (102.8℉), pulse is 89/min, respiratory rate is 25/min, and blood pressure is 109/69 mm Hg.", "On physical examination, her pharynx is erythematous.", "There is significant swelling of the tonsils bilaterally, and there is a white exudate covering them.", "Ophthalmologic examination reveals evidence of conjunctivitis bilaterally.", "Otoscopic examination is significant for gray-white tympanic membranes bilaterally.", "The remainder of the exam is unremarkable.", "A urine dipstick is performed and shows the following results: | Urine Dipstick | Specific Gravity 1.019 | Glucose None | Ketones None | Nitrites Negative | Leukocyte Esterase Negative | Protein None | Blood 3+ | ." ]

[ "1. A 12-year-old girl was brought to the clinic by her mother.", "2. The patient has a 3-day history of fever and sore throat.", "3. The patient has had hematuria since this morning.", "4. The patient's mother says the fever has been up to 39.5℃ (103.1℉) for the last 3 days.", "5. The patient's mother says the sore throat has improved slightly.", "6. The patient's mother noticed her daughter had red urine today.", "7. The patient's temperature is 39.3℃ (102.8℉).", "8. The patient's pulse is 89/min.", "9. The patient's respiratory rate is 25/min.", "10. The patient's blood pressure is 109/69 mm Hg.", "11. On physical examination, the patient's pharynx is erythematous.", "12. There is significant swelling of the tonsils bilaterally.", "13. There is a white exudate covering the tonsils bilaterally.", "14. Ophthalmologic examination reveals evidence of conjunctivitis bilaterally.", "15. Otoscopic examination is significant for gray-white tympanic membranes bilaterally.", "16. The remainder of the exam is unremarkable.", "17. A urine dipstick was performed.", "18. The urine dipstick showed a specific gravity of 1.019.", "19. The urine dipstick showed no glucose.", "20. The urine dipstick showed no ketones.", "21. The urine dipstick showed negative nitrites.", "22. The urine dipstick showed negative leukocyte esterase.", "23. The urine dipstick showed no protein.", "24. The urine dipstick showed 3+ blood." ]

[ "1. The patient's mother reports a fever up to 39.5℃ (103.1℉) for the last 3 days and a severe sore throat.", "2. The patient's mother noticed her daughter had red urine today.", "3. The patient's temperature is 39.3℃ (102.8℉), pulse is 89/min, respiratory rate is 25/min, and blood pressure is 109/69 mm Hg.", "4. On physical examination, the patient's pharynx is erythematous.", "5. There is significant swelling of the tonsils bilaterally, and there is a white exudate covering them.", "6. Ophthalmologic examination reveals evidence of conjunctivitis bilaterally.", "7. Otoscopic examination is significant for gray-white tympanic membranes bilaterally.", "8. The remainder of the exam is unremarkable.", "9. A urine dipstick test shows the following results: Specific Gravity 1.019, Glucose None, Ketones None, Nitrites Negative, Leukocyte Esterase Negative, Protein None, Blood 3+." ]

[ "A 73-year-old woman with a past medical history of diabetes, hypertension, and hyperlipidemia presents to the emergency department with swelling in her left neck.", "The onset was a few months ago.", "She has lost 6.8 kg (15.0 lb) over the same duration.", "She denies any fever, night sweats or itching.", "Physical examination reveals a painless swelling in front of her left ear.", "There is painless lymphadenopathy below the ear.", "Biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland.", "Surgery is planned and the tumor is removed while trying to preserve a nerve that could be involved." ]

[ "1. A 73-year-old woman presents to the emergency department with swelling in her left neck.", "2. The onset of the swelling was a few months ago.", "3. The woman has lost 6.8 kg (15.0 lb) over the same duration.", "4. The woman denies any fever, night sweats or itching.", "5. Physical examination reveals a painless swelling in front of her left ear.", "6. There is painless lymphadenopathy below the ear.", "7. Biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland.", "8. Surgery is planned to remove the tumor while trying to preserve a nerve that could be involved.", "9. The woman has a past medical history of diabetes, hypertension, and hyperlipidemia." ]

[ "1. The onset of symptoms was a few months ago.", "2. She has lost 6.8 kg (15.0 lb) over the same duration.", "3. She denies any fever, night sweats, or itching.", "4. Physical examination reveals a painless swelling in front of her left ear.", "5. There is painless lymphadenopathy below the ear.", "6. Biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland.", "7. Surgery is planned.", "8. The tumor is removed while trying to preserve a nerve that could be involved." ]

[ "A 43-year-old man is brought to the emergency department by his wife after a near-syncopal episode.", "He was doing yard work when he began feeling dizzy and had to lie down.", "Earlier in the day, he was started on lisinopril.", "On arrival, he is fully oriented.", "His pulse is 100/min and blood pressure is 92/60 mm Hg.", "Serum electrolytes are within normal limits.", "An ECG shows no evidence of ischemia." ]

[ "1. A 43-year-old man is brought to the emergency department by his wife.", "2. He had a near-syncopal episode.", "3. He was doing yard work when he began feeling dizzy and had to lie down.", "4. He was started on lisinopril earlier in the day.", "5. On arrival, he is fully oriented.", "6. His pulse is 100/min.", "7. His blood pressure is 92/60 mm Hg.", "8. His serum electrolytes are within normal limits.", "9. An ECG shows no evidence of ischemia." ]

[ "1. He was doing yard work.", "2. He began feeling dizzy.", "3. He had to lie down.", "4. Earlier in the day, he was started on lisinopril.", "5. On arrival, he is fully oriented.", "6. His pulse is 100/min.", "7. His blood pressure is 92/60 mm Hg.", "8. Serum electrolytes are within normal limits.", "9. An ECG shows no evidence of ischemia." ]

[ "A 4-year-old Caucasian girl previously diagnosed with asthma presents with recurrent sinusitis, otitis media, and clubbing of the nail bed.", "Family history is significant for a distant cousin with cystic fibrosis.", "A \"sweat test\" is performed and comes back normal." ]

[ "1. Patient is a 4-year-old Caucasian girl.", "2. Patient has a previous diagnosis of asthma.", "3. Patient presents with recurrent sinusitis.", "4. Patient presents with otitis media.", "5. Patient has clubbing of the nail bed.", "6. Patient has a family history of a distant cousin with cystic fibrosis.", "7. A \"sweat test\" was performed.", "8. The \"sweat test\" came back normal." ]

[ "1. Family history is significant for a distant cousin with cystic fibrosis.", "2. A \"sweat test\" is performed.", "3. The sweat test comes back normal." ]

[ "A 35-year-old woman presents with a complaint of oral ulcers.", "It is the third recurrence of ulcers in the last 8 months.", "She is sexually active and complains of dyspareunia.", "Examination shows the presence of a uveitis." ]

[ "1. A 35-year-old woman presents with a complaint of oral ulcers.", "2. It is the third recurrence of ulcers in the last 8 months.", "3. She is sexually active.", "4. She complains of dyspareunia.", "5. Examination shows the presence of a uveitis." ]

[ "1. It is the third recurrence of ulcers", "2. The ulcers have recurred in the last 8 months", "3. She is sexually active", "4. She complains of dyspareunia", "5. Examination shows the presence of a uveitis" ]

[ "A 22-year-old female software analyst presents to a medical clinic for evaluation of tingling and numbness in both hands for the past 2 months.", "Her symptoms are usually aggravated by the end of the work day and absent on most off days.", "She has been a type I diabetic for 2 years and is currently on insulin.", "She admits to being sexually active but has had irregular periods for the past 3 months.", "A urine pregnancy test is negative." ]

[ "1. A 22-year-old female software analyst presents to a medical clinic.", "2. She has tingling and numbness in both hands for the past 2 months.", "3. Her symptoms are usually aggravated by the end of the work day.", "4. Her symptoms are absent on most off days.", "5. She has been a type I diabetic for 2 years.", "6. She is currently on insulin.", "7. She admits to being sexually active.", "8. She has had irregular periods for the past 3 months.", "9. A urine pregnancy test is negative." ]

[ "1. Her symptoms are usually aggravated by the end of the work day.", "2. Her symptoms are absent on most off days.", "3. She has been a type I diabetic for 2 years.", "4. She is currently on insulin.", "5. She admits to being sexually active.", "6. She has had irregular periods for the past 3 months.", "7. A urine pregnancy test is negative." ]

[ "A 60-year-old male presents to his primary care physician complaining of fatigue.", "He reports a six-month history of gradually worsening tiredness.", "More recently, he has experienced intermittent fevers and night sweats.", "His temperature is 99.5°F (37.5°C), blood pressure is 115/80 mmHg, pulse is 80/min, and respirations are 18/min.", "On examination, painless cervical lymphadenopathy is noted.", "A lymph node biopsy is performed and karyotypic analysis of the biopsy reveals an 11;14 translocation." ]

[ "1. A 60-year-old male presents to his primary care physician.", "2. He complains of fatigue.", "3. He has a six-month history of gradually worsening tiredness.", "4. He has experienced intermittent fevers and night sweats.", "5. His temperature is 99.5°F (37.5°C).", "6. His blood pressure is 115/80 mmHg.", "7. His pulse is 80/min.", "8. His respirations are 18/min.", "9. On examination, painless cervical lymphadenopathy is noted.", "10. A lymph node biopsy is performed.", "11. Karyotypic analysis of the biopsy reveals an 11;14 translocation." ]

[ "1. The patient reports a six-month history of gradually worsening tiredness.", "2. The patient has experienced intermittent fevers and night sweats.", "3. The patient's temperature is 99.5°F (37.5°C).", "4. The patient's blood pressure is 115/80 mmHg.", "5. The patient's pulse is 80/min.", "6. The patient's respirations are 18/min.", "7. On examination, painless cervical lymphadenopathy is noted.", "8. A lymph node biopsy is performed.", "9. Karyotypic analysis of the biopsy reveals an 11;14 translocation." ]

[ "An 8-year-old boy presents with abdominal pain and constipation.", "The patient’s mother says that the symptoms gradually onset 2 months ago.", "The patient describes the pain as moderate to severe, gnawing and diffusely localized.", "No significant past medical history and no current medications.", "The patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.", "His mother mentioned that he is a good student but has been irritable lately, and his homework has been full of careless mistakes.", "The vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.", "On physical examination, the patient is alert and cooperative.", "The abdomen is diffusely tender to palpation with no rebound or guarding.", "There is a left wrist drop.", "A nontender, flat bluish line above the gums is noted.", "Laboratory results are significant for the following: | Sodium 141 mEq/L | Potassium 4.1 mEq/L | Chloride 101 mEq/L | Bicarbonate 25 mEq/L | Blood urea nitrogen (BUN) 27 mg/dL | Creatinine 1.7 mg/dL | Glucose (fasting) 80 mg/dL | White blood cell (WBC) count 8,700/mm3 | Red blood cell (RBC) count 4.20 x 106/mm3 | Hematocrit 41.5% | Hemoglobin 10.3 g/dL | Platelet count 190,000/mm3 | Mean corpuscular volume (MCV) 65 mm3 | Lead 72 mcg/dL. " ]

[ "1. Patient is 8 years old.", "2. Patient presents with abdominal pain and constipation.", "3. Symptoms gradually onset 2 months ago.", "4. Patient describes pain as moderate to severe, gnawing and diffusely localized.", "5. No significant past medical history and no current medications.", "6. Patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.", "7. Patient is a good student but has been irritable lately, and his homework has been full of careless mistakes.", "8. Vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.", "9. Patient is alert and cooperative on physical examination.", "10. Abdomen is diffusely tender to palpation with no rebound or guarding.", "11. Left wrist drop is present.", "12. Nontender, flat bluish line above the gums is noted.", "13. Laboratory results are significant for sodium 141 mEq/L, potassium 4.1 mEq/L, chloride 101 mEq/L, bicarbonate 25 mEq/L, BUN 27 mg/dL, creatinine 1.7 mg/dL, and glucose (fasting) 80 mg/dL, White blood cell (WBC) count 8,700/mm3, Red blood cell (RBC) count 4.20 x 106/mm3, Hematocrit 41.5%, Hemoglobin 10.3 g/dL, Platelet count 190,000/mm3, Mean corpuscular volume (MCV) 65 mm3, Lead 72 mcg/dL." ]

[ "1. The patient's symptoms gradually onset 2 months ago.", "2. The patient describes the pain as moderate to severe, gnawing, and diffusely localized.", "3. The patient has no significant past medical history and is not taking any current medications.", "4. The patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.", "5. The patient's mother mentioned that he is a good student but has been irritable lately, and his homework has been full of careless mistakes.", "6. The patient's vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.", "7. On physical examination, the patient is alert and cooperative.", "8. The patient's abdomen is diffusely tender to palpation with no rebound or guarding.", "9. The patient has a left wrist drop.", "10. A nontender, flat bluish line above the gums is noted.", "11. Laboratory results show: Sodium 141 mEq/L, Potassium 4.1 mEq/L, Chloride 101 mEq/L, Bicarbonate 25 mEq/L, Blood urea nitrogen (BUN) 27 mg/dL, Creatinine 1.7 mg/dL, Glucose (fasting) 80 mg/dL, White blood cell (WBC) count 8,700/mm3, Red blood cell (RBC) count 4.20 x 106/mm3, Hematocrit 41.5%, Hemoglobin 10.3 g/dL, Platelet count 190,000/mm3, Mean corpuscular volume (MCV) 65 mm3, and Lead 72 mcg/dL." ]

[ "Two days after undergoing a left total hip replacement, a 68-year-old man has increasing shortness of breath and chest pain for 30 minutes.", "He has type 2 diabetes mellitus and bilateral osteoarthritis of the hips.", "Prior to admission to the hospital, his medications were metformin and naproxen.", "His temperature is 37.8°C (100°F), pulse is 110/min, respirations are 30/min, and blood pressure is 106/70 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 89%.", "The lungs are clear to auscultation.", "Cardiac examination shows no abnormalities.", "The right lower extremity is swollen.", "Right foot flexion in an upward direction causes pain in the right calf.", "Pedal pulses are palpable.", "Supplemental oxygen and intravenous fluid resuscitation are begun.", "His hematocrit is 30%.", "Arterial blood gas analysis on room air shows: | pH 7.48 | pCO2 27 mm Hg | pO2 68 mm Hg | HCO3- 23 mEq/L | An electrocardiogram shows sinus tachycardia and right axis deviation." ]

[ "1. Patient is 68 years old.", "2. Patient has type 2 diabetes mellitus and bilateral osteoarthritis of the hips.", "3. Patient's medications prior to admission were metformin and naproxen.", "4. Patient's temperature is 37.8°C (100°F).", "5. Patient's pulse is 110/min.", "6. Patient's respirations are 30/min.", "7. Patient's blood pressure is 106/70 mm Hg.", "8. Pulse oximetry on room air shows an oxygen saturation of 89%.", "9. Lungs are clear to auscultation.", "10. Cardiac examination shows no abnormalities.", "11. Right lower extremity is swollen.", "12. Right foot flexion in an upward direction causes pain in the right calf.", "13. Pedal pulses are palpable.", "14. Supplemental oxygen and intravenous fluid resuscitation are begun.", "15. Patient's hematocrit is 30%.", "16. Arterial blood gas analysis on room air shows: pH 7.48, pCO2 27 mm Hg, pO2 68 mm Hg, HCO3- 23 mEq/L.", "17. An electrocardiogram shows sinus tachycardia and right axis deviation.", "18. Patient has increasing shortness of breath and chest pain for 30 minutes, two days after undergoing a left total hip replacement." ]

[ "1. He has type 2 diabetes mellitus.", "2. He has bilateral osteoarthritis of the hips.", "3. Prior to admission to the hospital, his medications were metformin and naproxen.", "4. His temperature is 37.8°C (100°F).", "5. His pulse is 110/min.", "6. His respirations are 30/min.", "7. His blood pressure is 106/70 mm Hg.", "8. Pulse oximetry on room air shows an oxygen saturation of 89%.", "9. The lungs are clear to auscultation.", "10. Cardiac examination shows no abnormalities.", "11. The right lower extremity is swollen.", "12. Right foot flexion in an upward direction causes pain in the right calf.", "13. Pedal pulses are palpable.", "14. Supplemental oxygen and intravenous fluid resuscitation are begun.", "15. His hematocrit is 30%.", "16. Arterial blood gas analysis on room air shows: pH 7.48, pCO2 27 mm Hg, pO2 68 mm Hg, HCO3- 23 mEq/L.", "17. An electrocardiogram shows sinus tachycardia and right axis deviation." ]

[ "An 11-month-old male presents to the emergency department with his father after “passing out” at home.", "His father reports that the patient started crying after his older brother took a toy away from him.", "The patient was difficult to soothe and then suddenly stopped breathing.", "His father reports that his lips turned slightly blue, and the patient’s entire body became limp.", "The episode lasted a few seconds, and the patient seemed to act normally afterwards.", "The patient’s father notes that the patient’s older brother had similar episodes as a child.", "He denies any family history of neurological disease.", "The patient’s temperature is 98.5°F (36.9°C), blood pressure is 86/64 mmHg, pulse is 98/min, and respirations are 26/min.", "On physical exam, the patient is in no acute distress playing on his father’s lap.", "The patient's neurological exam is unremarkable." ]

[ "1. An 11-month-old male presents to the emergency department with his father.", "2. His father reports that the patient started crying after his older brother took a toy away from him.", "3. The patient was difficult to soothe and then suddenly stopped breathing.", "4. His father reports that his lips turned slightly blue, and the patient’s entire body became limp.", "5. The episode lasted a few seconds, and the patient seemed to act normally afterwards.", "6. The patient’s father notes that the patient’s older brother had similar episodes as a child.", "7. He denies any family history of neurological disease.", "8. The patient’s temperature is 98.5°F (36.9°C).", "9. The patient's blood pressure is 86/64 mmHg.", "10. The patient's pulse is 98/min.", "11. The patient's respirations are 26/min.", "12. On physical exam, the patient is in no acute distress playing on his father’s lap.", "13. The patient's neurological exam is unremarkable." ]

[ "1. The patient started crying after his older brother took a toy away from him.", "2. The patient was difficult to soothe.", "3. The patient suddenly stopped breathing.", "4. The patient's lips turned slightly blue.", "5. The patient's entire body became limp.", "6. The episode lasted a few seconds.", "7. The patient seemed to act normally afterwards.", "8. The patient's older brother had similar episodes as a child.", "9. There is no family history of neurological disease.", "10. The patient's temperature is 98.5°F (36.9°C).", "11. The patient's blood pressure is 86/64 mmHg.", "12. The patient's pulse is 98/min.", "13. The patient's respirations are 26/min.", "14. On physical exam, the patient is in no acute distress playing on his father’s lap.", "15. The patient's neurological exam is unremarkable." ]

[ "A 27-year-old woman presents to the emergency department for pain in multiple joints.", "She states that she has had symmetric joint pain that started yesterday and has been worsening.", "It is affecting her wrists, elbows, and shoulders.", "She also endorses a subjective fever and some fatigue but denies any other symptoms.", "The patient works as a schoolteacher and is generally healthy.", "She is currently sexually active with 2 male partners and uses condoms occasionally.", "Her temperature is 100°F (37.8°C), blood pressure is 122/85 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Her laboratory values are within normal limits.", "Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.", "The patient is discharged with ibuprofen.", "Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control." ]

[ "1. A 27-year-old woman presents to the emergency department for pain in multiple joints.", "2. She states that she has had symmetric joint pain that started yesterday and has been worsening.", "3. It is affecting her wrists, elbows, and shoulders.", "4. She also endorses a subjective fever and some fatigue but denies any other symptoms.", "5. The patient works as a schoolteacher and is generally healthy.", "6. She is currently sexually active with 2 male partners and uses condoms occasionally.", "7. Her temperature is 100°F (37.8°C), blood pressure is 122/85 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "8. Her laboratory values are within normal limits.", "9. Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.", "10. The patient is discharged with ibuprofen.", "11. Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control." ]

[ "1. The patient has symmetric joint pain affecting her wrists, elbows, and shoulders.", "2. The joint pain started yesterday and has been worsening.", "3. She endorses a subjective fever and some fatigue.", "4. The patient denies any other symptoms.", "5. She works as a schoolteacher and is generally healthy.", "6. The patient is currently sexually active with 2 male partners and uses condoms occasionally.", "7. Her temperature is 100°F (37.8°C).", "8. Her blood pressure is 122/85 mmHg.", "9. Her pulse is 88/min.", "10. Her respirations are 14/min.", "11. Her oxygen saturation is 99% on room air.", "12. Her laboratory values are within normal limits.", "13. Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.", "14. The patient is discharged with ibuprofen.", "15. Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control." ]

[ "A 57-year-old man with HIV and GERD comes to the emergency department because of productive cough with malodorous phlegm and night sweats for the past week.", "He has smoked 1 pack of cigarettes daily for 30 years and he drinks 8–10 beers daily.", "His temperature is 38.9°C (102.0°F).", "Physical examination shows coarse crackles and dullness to percussion at the right lung base.", "Scattered expiratory wheezing is heard throughout both lung fields.", "The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).", "An x-ray of the chest is shown." ]

[ "1. A 57-year-old man with HIV and GERD comes to the emergency department.", "2. He has had productive cough with malodorous phlegm and night sweats for the past week.", "3. He has smoked 1 pack of cigarettes daily for 30 years.", "4. He drinks 8–10 beers daily.", "5. His temperature is 38.9°C (102.0°F).", "6. Physical examination shows coarse crackles and dullness to percussion at the right lung base.", "7. Scattered expiratory wheezing is heard throughout both lung fields.", "8. The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).", "9. An x-ray of the chest is shown." ]

[ "1. He has smoked 1 pack of cigarettes daily for 30 years.", "2. He drinks 8–10 beers daily.", "3. His temperature is 38.9°C (102.0°F).", "4. Physical examination shows coarse crackles and dullness to percussion at the right lung base.", "5. Scattered expiratory wheezing is heard throughout both lung fields.", "6. The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).", "7. An x-ray of the chest is shown." ]

[ "A 20-year-old woman is brought to the emergency department by her boyfriend for right arm and leg weakness, numbness, and tingling that has been resolving gradually.", "The symptoms started 4 hours ago after she had an argument with her boyfriend during which she slapped and kicked him.", "She says she has been limping and cannot use her right arm anymore.", "She has never had similar symptoms in the past.", "She has a history of genital herpes and trichotillomania.", "She is alert and oriented.", "Physical examination shows upper and lower face symmetry and normal speech.", "She has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.", "She has 4/5 strength in the right arm and leg when ambulating.", "She cannot stand on her toes when asked.", "Her deep tendon reflexes are 2+ bilaterally.", "She has normal proprioception, light touch sensation, and two-point discrimination in all extremities.", "She has a negative Spurling test.", "CT of the head without contrast shows no abnormalities." ]

[ "1. Patient is a 20-year-old woman.", "2. Patient was brought to the emergency department by her boyfriend.", "3. Patient has right arm and leg weakness, numbness, and tingling.", "4. Symptoms have been resolving gradually.", "5. Symptoms started 4 hours ago after an argument with her boyfriend during which she slapped and kicked him.", "6. Patient has been limping and cannot use her right arm.", "7. Patient has never had similar symptoms in the past.", "8. Patient has a history of genital herpes and trichotillomania.", "9. Patient is alert and oriented.", "10. Physical examination shows upper and lower face symmetry and normal speech.", "11. Patient has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.", "12. Patient has 4/5 strength in the right arm and leg when ambulating.", "13. Patient cannot stand on her toes when asked.", "14. Patient has 2+ deep tendon reflexes bilaterally.", "15. Patient has normal proprioception, light touch sensation, and two-point discrimination in all extremities.", "16. Patient has a negative Spurling test.", "17. CT of the head without contrast shows no abnormalities." ]

[ "1. The symptoms started 4 hours ago after an argument with her boyfriend.", "2. During the argument, she slapped and kicked him.", "3. She says she has been limping and cannot use her right arm anymore.", "4. She has never had similar symptoms in the past.", "5. She has a history of genital herpes and trichotillomania.", "6. She is alert and oriented.", "7. Physical examination shows upper and lower face symmetry and normal speech.", "8. She has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.", "9. She has 4/5 strength in the right arm and leg when ambulating.", "10. She cannot stand on her toes when asked.", "11. Her deep tendon reflexes are 2+ bilaterally.", "12. She has normal proprioception, light touch sensation, and two-point discrimination in all extremities.", "13. She has a negative Spurling test.", "14. CT of the head without contrast shows no abnormalities." ]

[ "A 14-year-old female presents to her psychiatrist in hopes that she can find help in dealing with the sexual abuse that occurred in her childhood.", "While retelling her story of the numerous encounters the patient had with her abuser, the psychiatrist begins to feel protective and parental towards the client, wishing that he could have somehow helped the young girl." ]

[ "1. A 14-year-old female presents to her psychiatrist.", "2. The patient is seeking help in dealing with sexual abuse that occurred in her childhood.", "3. The patient is retelling her story of numerous encounters with her abuser.", "4. The psychiatrist begins to feel protective and parental towards the client.", "5. The psychiatrist wishes he could have somehow helped the young girl." ]

[ "1. The patient had numerous encounters with her abuser.", "2. The psychiatrist feels protective and parental towards the client.", "3. The psychiatrist wishes he could have somehow helped the young girl." ]

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[ "A 47-year-old woman visits the emergency department due to painful, swollen fingers in both of her hands.", "She has worked as a bus driver for the county school system for the last 20 years.", "Her past medical history is significant for a transient ischemic attack 5 years ago.", "She reports that she has lost weight in the last 2 months although there have been no changes in her diet.", "She also says that she generally feels fatigued all day.", "On examination, nodules are seen over her Achilles tendon and both wrists are erythematous, swollen, and tender to touch.", "Laboratory tests are presented below: | Hemoglobin: 11.0 g/dL | Hematocrit: 40.5% | Leukocyte count: 7400/mm3 | Mean corpuscular volume: 80.1 μm3 | Platelet count: 210,000/mm3 | Erythrocyte sedimentation rate: 55 mm/h | Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20) | ." ]

[ "1. A 47-year-old woman visits the emergency department.", "2. She has painful, swollen fingers in both of her hands.", "3. She has worked as a bus driver for the county school system for the last 20 years.", "4. Her past medical history is significant for a transient ischemic attack 5 years ago.", "5. She reports that she has lost weight in the last 2 months.", "6. There have been no changes in her diet.", "7. She generally feels fatigued all day.", "8. On examination, nodules are seen over her Achilles tendon.", "9. Both wrists are erythematous, swollen, and tender to touch.", "10. Hemoglobin: 11.0 g/dL", "11. Hematocrit: 40.5%", "12. Leukocyte count: 7400/mm3", "13. Mean corpuscular volume: 80.1 μm3", "14. Platelet count: 210,000/mm3", "15. Erythrocyte sedimentation rate: 55 mm/h", "16. Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20)" ]

[ "1. She has worked as a bus driver for the county school system for the last 20 years.", "2. Her past medical history is significant for a transient ischemic attack 5 years ago.", "3. She reports that she has lost weight in the last 2 months although there have been no changes in her diet.", "4. She also says that she generally feels fatigued all day.", "5. On examination, nodules are seen over her Achilles tendon.", "6. Both wrists are erythematous, swollen, and tender to touch.", "7. Laboratory tests: Hemoglobin: 11.0 g/dL.", "8. Hematocrit: 40.5%.", "9. Leukocyte count: 7400/mm3.", "10. Mean corpuscular volume: 80.1 μm3.", "11. Platelet count: 210,000/mm3.", "12. Erythrocyte sedimentation rate: 55 mm/h.", "13. Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20)." ]