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stellalisy

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[ "A 60-year-old man presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck.", "The symptoms started 45 minutes ago while he was washing the dishes.", "He also complains of nausea.", "He has been a regular smoker for 45 years, averaging a pack of cigarettes each day.", "He also drinks heavily on weekends.", "His medical history is significant for a stroke 3 months ago, but the patient admits he has not been taking his medications.", "Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F).", "Physical examination reveals a visibly distressed man who is sweating profusely.", "The chest is clear to auscultation and a 4th heart sound can be heard.", "Aspirin was administered upon arrival.", "His ECG is shown in the picture." ]

[ "1. Patient is a 60-year-old man.", "2. Patient presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck.", "3. Symptoms started 45 minutes ago while he was washing the dishes.", "4. Patient also complains of nausea.", "5. Patient has been a regular smoker for 45 years, averaging a pack of cigarettes each day.", "6. Patient also drinks heavily on weekends.", "7. Patient's medical history is significant for a stroke 3 months ago.", "8. Patient admits he has not been taking his medications.", "9. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F).", "10. Physical examination reveals a visibly distressed man who is sweating profusely.", "11. Chest is clear to auscultation and a 4th heart sound can be heard.", "12. Aspirin was administered upon arrival.", "13. Patient's ECG is shown in the picture." ]

[ "1. The symptoms started 45 minutes ago while he was washing the dishes.", "2. He complains of nausea.", "3. He has been a regular smoker for 45 years, averaging a pack of cigarettes each day.", "4. He also drinks heavily on weekends.", "5. His medical history is significant for a stroke 3 months ago, but the patient admits he has not been taking his medications.", "6. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F).", "7. Physical examination reveals a visibly distressed man who is sweating profusely.", "8. The chest is clear to auscultation and a 4th heart sound can be heard.", "9. Aspirin was administered upon arrival.", "10. His ECG is shown in the picture." ]

[ "A 3-year-old girl is brought by her parents to the office for bloody diarrhea and a seizure.", "The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago, but the bloody diarrhea started 12 hours ago.", "The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness.", "Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.", "Her vital signs include: blood pressure is 130/85 mm Hg, her respiratory rate is 25/min, her heart rate is 120/min, and her temperature is 39.2°C (102.6°F).", "On physical examination, she looks pale and sleepy, the cardiopulmonary auscultation is normal, the abdomen is painful on palpation, and the skin assessment reveals the presence of disseminated pinpoint petechiae.", "The urinalysis show hematuria.", "The Coombs test is negative.", "The complete blood count results are as follows: | Hemoglobin 7 g/dL | Hematocrit 25 % | Leukocyte count 17,000/mm3 | Neutrophils 70% | Bands 2% | Eosinophils 1% | Basophils 0% | Lymphocytes 22% | Monocytes 5% | Platelet count 7,000/mm3 | Her coagulation tests are as follows: | Partial thromboplastin time (activated) 30 seconds | Prothrombin time 12 seconds | Reticulocyte count 1 % | Thrombin time < 2 seconds deviation from control | ." ]

[ "1. A 3-year-old girl is brought by her parents to the office.", "2. The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago.", "3. The bloody diarrhea started 12 hours ago.", "4. The seizure was the last symptom to appear 3 hours ago.", "5. The seizure consisted of repetitive movement of arms and legs with loss of consciousness.", "6. Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.", "7. Her blood pressure is 130/85 mm Hg.", "8. Her respiratory rate is 25/min.", "9. Her heart rate is 120/min.", "10. Her temperature is 39.2°C (102.6°F).", "11. On physical examination, she looks pale and sleepy.", "12. The cardiopulmonary auscultation is normal.", "13. The abdomen is painful on palpation.", "14. The skin assessment reveals the presence of disseminated pinpoint petechiae.", "15. The urinalysis show hematuria.", "16. The Coombs test is negative.", "17. The Hemoglobin is 7 g/dL.", "18. The Hematocrit is 25 %.", "19. The Leukocyte count is 17,000/mm3.", "20. The Neutrophils are 70%.", "21. The Bands are 2%.", "22. The Eosinophils are 1%.", "23. The Basophils are 0%.", "24. The Lymphocytes are 22%.", "25. The Monocytes are 5%.", "26. The Platelet count is 7,000/mm3.", "27. The Partial thromboplastin time (activated) is 30 seconds.", "28. The Prothrombin time is 12 seconds.", "29. The Reticulocyte count is 1 %.", "30. The Thrombin time is < 2 seconds deviation from control." ]

[ "1. The patient started having fever, abdominal pain, and diarrhea about 3 days ago.", "2. The bloody diarrhea started 12 hours ago.", "3. The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness.", "4. The patient's 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.", "5. The patient's blood pressure is 130/85 mm Hg.", "6. The patient's respiratory rate is 25/min.", "7. The patient's heart rate is 120/min.", "8. The patient's temperature is 39.2°C (102.6°F).", "9. On physical examination, the patient looks pale and sleepy.", "10. The cardiopulmonary auscultation is normal.", "11. The abdomen is painful on palpation.", "12. The skin assessment reveals the presence of disseminated pinpoint petechiae.", "13. The urinalysis shows hematuria.", "14. The Coombs test is negative.", "15. The complete blood count results are as follows: Hemoglobin 7 g/dL, Hematocrit 25%, Leukocyte count 17,000/mm3, Neutrophils 70%, Bands 2%, Eosinophils 1%, Basophils 0%, Lymphocytes 22%, Monocytes 5%, Platelet count 7,000/mm3.", "16. The patient's coagulation tests are as follows: Partial thromboplastin time (activated) 30 seconds, Prothrombin time 12 seconds, Reticulocyte count 1%, Thrombin time < 2 seconds deviation from control." ]

[ "A 68-year-old woman presents to the emergency room with productive cough and fever.", "She has a chronic cough that has been getting progressively worse over the last 2 weeks.", "Last night she developed a fever and vomited.", "She smoked one pack of cigarettes per day for 40 years and recently quit.", "Her past medical history includes COPD and her medications include ipratropium and fluticasone.", "On physical exam her temperature is 102.2°F (39°C), blood pressure is 131/78 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 95% on room air.", "She has decreased breath sounds bilaterally with diffuse crackles.", "You obtain a sputum sample and identify an organism that grows selectively on medium containing factors V and X." ]

[ "1. A 68-year-old woman presents to the emergency room.", "2. She has a productive cough and fever.", "3. She has a chronic cough that has been getting progressively worse over the last 2 weeks.", "4. Last night she developed a fever and vomited.", "5. She smoked one pack of cigarettes per day for 40 years and recently quit.", "6. Her past medical history includes COPD.", "7. Her medications include ipratropium and fluticasone.", "8. On physical exam her temperature is 102.2°F (39°C).", "9. Her blood pressure is 131/78 mmHg.", "10. Her pulse is 110/min.", "11. Her respirations are 22/min.", "12. Her oxygen saturation is 95% on room air.", "13. She has decreased breath sounds bilaterally with diffuse crackles.", "14. You obtain a sputum sample.", "15. An organism is identified that grows selectively on medium containing factors V and X." ]

[ "1. She has a chronic cough.", "2. The chronic cough has been getting progressively worse over the last 2 weeks.", "3. Last night she developed a fever.", "4. Last night she vomited.", "5. She smoked one pack of cigarettes per day for 40 years.", "6. She recently quit smoking.", "7. Her past medical history includes COPD.", "8. Her medications include ipratropium and fluticasone.", "9. On physical exam her temperature is 102.2°F (39°C).", "10. Her blood pressure is 131/78 mmHg.", "11. Her pulse is 110/min.", "12. Her respirations are 22/min.", "13. Her oxygen saturation is 95% on room air.", "14. She has decreased breath sounds bilaterally.", "15. She has diffuse crackles.", "16. An organism was identified in a sputum sample.", "17. The organism grows selectively on medium containing factors V and X." ]

[ "A 36-year-old man comes to the physician because of progressive fatigue and night sweats for 2 months.", "During this time, he has also had a 10-kg (22-lb) weight loss.", "Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes.", "Examination of the abdomen shows hepatosplenomegaly.", "Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells.", "A diagnosis of Hodgkin lymphoma is made.", "The patient is started on a chemotherapeutic regimen that includes bleomycin." ]

[ "1. A 36-year-old man comes to the physician.", "2. He has progressive fatigue and night sweats for 2 months.", "3. He has had a 10-kg (22-lb) weight loss.", "4. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes.", "5. Examination of the abdomen shows hepatosplenomegaly.", "6. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells.", "7. A diagnosis of Hodgkin lymphoma is made.", "8. The patient is started on a chemotherapeutic regimen that includes bleomycin." ]

[ "1. The patient has had a 10-kg (22-lb) weight loss.", "2. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes.", "3. Examination of the abdomen shows hepatosplenomegaly.", "4. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells.", "5. A diagnosis of Hodgkin lymphoma is made.", "6. The patient is started on a chemotherapeutic regimen that includes bleomycin." ]

[ "An 7-year-old girl is brought to the pediatrician by her concerned mother, because she is \"more physically matured\" than the rest of the girls in her class.", "On physical exam, she is noted to have breast development and pubic hair.", "On gonadotropin reseasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels.", "Thyroid function tests and an MRI of the head are both within normal limits." ]

[ "1. An 7-year-old girl is brought to the pediatrician by her concerned mother.", "2. The girl is \"more physically matured\" than the rest of the girls in her class.", "3. On physical exam, she is noted to have breast development and pubic hair.", "4. On gonadotropin reseasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels.", "5. Thyroid function tests are within normal limits.", "6. An MRI of the head is within normal limits." ]

[ "1. On physical exam, she is noted to have breast development.", "2. On physical exam, she is noted to have pubic hair.", "3. On gonadotropin releasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels.", "4. Thyroid function tests are within normal limits.", "5. An MRI of the head is within normal limits." ]

[ "A 45-year-old woman presents to the emergency department with hematemesis.", "Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.", "She frequently travels for work and is often stressed.", "She drinks alcohol socially and does not smoke tobacco or marijuana.", "She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up \"several cup of\" frank red blood before arrival.", "Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.", "Gastric ultrasound reveals high gastric residual volume.", "The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.", "The patient's initial laboratory data return in the meantime: | | Hemoglobin: 5 g/dL | Hematocrit: 18 % | Leukocyte count: 8,000/mm^3 with normal differential | Platelet count: 400,000/mm^3 | | Serum: | Na+: 140 mEq/L | Cl-: 115 mEq/L | K+: 3.2 mEq/L | HCO3-: 26 mEq/L | BUN: 60 mg/dL | Glucose: 104 mg/dL | Creatinine: 1.1 mg/dL | | Blood type: AB | Rhesus status: negative | | After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.", "The patient now complains of feeling hot with intermittent shivering.", "She denies any other symptoms.", "Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.", "Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed.", "No rash is seen." ]

[ "1. A 45-year-old woman presents to the emergency department with hematemesis.", "2. Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.", "3. She frequently travels for work and is often stressed.", "4. She drinks alcohol socially and does not smoke tobacco or marijuana.", "5. She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up \"several cup of\" frank red blood before arrival.", "6. Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.", "7. Gastric ultrasound reveals high gastric residual volume.", "8. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.", "9. The patient's initial laboratory data return: Hemoglobin: 5 g/dL, Hematocrit: 18 %, Leukocyte count: 8,000/mm^3 with normal differential, Platelet count: 400,000/mm^3, Serum: Na+: 140 mEq/L, Cl-: 115 mEq/L, K+: 3.2 mEq/L, HCO3-: 26 mEq/L, BUN: 60 mg/dL, Glucose: 104 mg/dL, Creatinine: 1.1 mg/dL, Blood type: AB, Rhesus status: negative.", "10. After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.", "11. The patient now complains of feeling hot with intermittent shivering.", "12. She denies any other symptoms.", "13. Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.", "14. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed.", "15. No rash is seen." ]

[ "1. The patient complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.", "2. The patient frequently travels for work and is often stressed.", "3. The patient drinks alcohol socially and does not smoke tobacco or marijuana.", "4. The patient has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up \"several cup of\" frank red blood before arrival.", "5. The patient's temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.", "6. Gastric ultrasound reveals high gastric residual volume.", "7. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.", "8. The patient's initial laboratory data return: Hemoglobin: 5 g/dL, Hematocrit: 18 %, Leukocyte count: 8,000/mm^3 with normal differential, Platelet count: 400,000/mm^3, Serum: Na+: 140 mEq/L, Cl-: 115 mEq/L, K+: 3.2 mEq/L, HCO3-: 26 mEq/L, BUN: 60 mg/dL, Glucose: 104 mg/dL, Creatinine: 1.1 mg/dL, Blood type: AB, Rhesus status: negative.", "9. After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.", "10. The patient now complains of feeling hot with intermittent shivering.", "11. The patient's temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.", "12. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed. No rash is seen." ]

[ "A 66-year-old man comes to the physician because of a 3-week history of shortness of breath with exertion.", "He has hypertension, hyperlipidemia, and type 2 diabetes mellitus.", "Current medications include aspirin, losartan, simvastatin, and insulin.", "His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 96%.", "Cardiac examination is shown." ]

[ "1. A 66-year-old man comes to the physician.", "2. He has a 3-week history of shortness of breath with exertion.", "3. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus.", "4. His current medications include aspirin, losartan, simvastatin, and insulin.", "5. His temperature is 37.1°C (98.8°F).", "6. His pulse is 74/min.", "7. His blood pressure is 150/84 mm Hg.", "8. Pulse oximetry on room air shows an oxygen saturation of 96%.", "9. Cardiac examination is shown." ]

[ "1. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus.", "2. Current medications include aspirin, losartan, simvastatin, and insulin.", "3. His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg.", "4. Pulse oximetry on room air shows an oxygen saturation of 96%.", "5. Cardiac examination is shown." ]

[ "A 27-year-old gravida 2, para 2 woman presents to her OB/GYN’s office concerned that she may be pregnant.", "She and her husband use condoms for contraception.", "The night before, the condom broke during intercourse.", "She has 2 children under the age of 3 and does not want another child at this time.", "She says she cannot take “the pill” because she had a blood clot in her leg after her last cesarean section successfully treated with 6 months of anticoagulation.", "She smokes cigarettes and drinks alcohol regularly." ]

[ "1. A 27-year-old woman presents to her OB/GYN's office.", "2. She is gravida 2, para 2.", "3. She and her husband use condoms for contraception.", "4. The night before, the condom broke during intercourse.", "5. She has 2 children under the age of 3.", "6. She does not want another child at this time.", "7. She cannot take \"the pill\" because she had a blood clot in her leg after her last cesarean section.", "8. The blood clot was successfully treated with 6 months of anticoagulation.", "9. She smokes cigarettes regularly.", "10. She drinks alcohol regularly." ]

[ "1. She and her husband use condoms for contraception.", "2. The condom broke during intercourse the night before.", "3. She has 2 children under the age of 3.", "4. She does not want another child at this time.", "5. She cannot take \"the pill\" because she had a blood clot in her leg after her last cesarean section.", "6. The blood clot was successfully treated with 6 months of anticoagulation.", "7. She smokes cigarettes regularly.", "8. She drinks alcohol regularly." ]

[ "A 25-year-old Ashkenazi Jewish man presents to his primary care physician for a follow-up visit.", "One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners.", "During that visit, it was determined that his blood pressure was 175/100 mmHg.", "He returns this week to have his vitals rechecked.", "His temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 182/100 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air." ]

[ "1. A 25-year-old Ashkenazi Jewish man presented to his primary care physician for a follow-up visit.", "2. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners.", "3. During that visit, it was determined that his blood pressure was 175/100 mmHg.", "4. He returns this week to have his vitals rechecked.", "5. His temperature is 99.5°F (37.5°C).", "6. His pulse is 80/min.", "7. His blood pressure is 182/100 mmHg.", "8. His respirations are 10/min.", "9. His oxygen saturation is 98% on room air." ]

[ "1. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners.", "2. During that visit, it was determined that his blood pressure was 175/100 mmHg.", "3. He returns this week to have his vitals rechecked.", "4. His temperature is 99.5°F (37.5°C).", "5. His pulse is 80/min.", "6. His blood pressure is 182/100 mmHg.", "7. His respirations are 10/min.", "8. His oxygen saturation is 98% on room air." ]

[ "A 63-year-old man is brought to the emergency department after having 8–9 episodes of red watery stool.", "He has no abdominal pain or fever.", "He underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.", "He has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.", "Current medications include aspirin, metoprolol, and simvastatin.", "He drinks one beer daily.", "He is in distress.", "His temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 86/58 mm Hg.", "Examination shows pale conjunctivae.", "The abdomen is soft and nontender.", "Bowel sounds are increased.", "The lungs are clear to auscultation.", "Cardiac examination shows an S4 gallop.", "Rectal examination shows frank blood.", "Laboratory studies show: | Hemoglobin 9.8 g/dL | Leukocyte count 7,800/mm3 | Platelet count 280,000/mm3 | Prothrombin time 14 seconds (INR=0.9) | Serum | Na+ 135 mEq/L | K+ 4.1 mEq/L | Cl- 101 mEq/L | Urea nitrogen 16 mg/dL | Glucose 96 mg/dL | Creatinine 0.7 mg/dL | Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.", "A nasogastric tube is inserted.", "Aspiration shows clear gastric content containing bile.", "Directly afterwards, his pulse is 133/min and blood pressure is 80/54 mm Hg." ]

[ "1. Patient is 63 years old.", "2. Patient has had 8-9 episodes of red watery stool.", "3. Patient has no abdominal pain or fever.", "4. Patient underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.", "5. Patient has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.", "6. Patient's current medications include aspirin, metoprolol, and simvastatin.", "7. Patient drinks one beer daily.", "8. Patient is in distress.", "9. Patient's temperature is 37.3°C (99.1°F).", "10. Patient's pulse is 110/min.", "11. Patient's respirations are 14/min.", "12. Patient's blood pressure is 86/58 mm Hg.", "13. Patient's conjunctivae are pale.", "14. Patient's abdomen is soft and nontender.", "15. Patient's bowel sounds are increased.", "16. Patient's lungs are clear to auscultation.", "17. Patient's cardiac examination shows an S4 gallop.", "18. Patient's rectal examination shows frank blood.", "19. Patient's hemoglobin is 9.8 g/dL.", "20. Patient's leukocyte count is 7,800/mm3.", "21. Patient's platelet count is 280,000/mm3.", "22. Patient's prothrombin time is 14 seconds (INR=0.9).", "23. Patient's serum Na+ is 135 mEq/L.", "24. Patient's serum K+ is 4.1 mEq/L.", "25. Patient's serum Cl- is 101 mEq/L.", "26. Patient's urea nitrogen is 16 mg/dL.", "27. Patient's glucose is 96 mg/dL.", "28. Patient's creatinine is 0.7 mg/dL.", "29. Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.", "30. A nasogastric tube is inserted.", "31. Aspiration shows clear gastric content containing bile.", "32. Patient's pulse is 133/min directly afterwards.", "33. Patient's blood pressure is 80/54 mm Hg directly afterwards." ]

[ "1. He has no abdominal pain or fever.", "2. He underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.", "3. He has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.", "4. Current medications include aspirin, metoprolol, and simvastatin.", "5. He drinks one beer daily.", "6. He is in distress.", "7. His temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 86/58 mm Hg.", "8. Examination shows pale conjunctivae.", "9. The abdomen is soft and nontender.", "10. Bowel sounds are increased.", "11. The lungs are clear to auscultation.", "12. Cardiac examination shows an S4 gallop.", "13. Rectal examination shows frank blood.", "14. Laboratory studies show: Hemoglobin 9.8 g/dL, Leukocyte count 7,800/mm3, Platelet count 280,000/mm3, Prothrombin time 14 seconds (INR=0.9), Serum Na+ 135 mEq/L, K+ 4.1 mEq/L, Cl- 101 mEq/L, Urea nitrogen 16 mg/dL, Glucose 96 mg/dL, Creatinine 0.7 mg/dL.", "15. Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.", "16. A nasogastric tube is inserted.", "17. Aspiration shows clear gastric content containing bile.", "18. Directly afterwards, his pulse is 133/min and blood pressure is 80/54 mm Hg." ]

[ "A 15-month-old boy with Down syndrome is brought to the physician for a well-child examination.", "The mother is concerned about giving the child any more vaccinations, as she reports he had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age.", "He has had a runny nose for 2 days.", "He has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications.", "He was treated for intussusception at 6 months of age.", "His father was diagnosed with HIV 2 years ago.", "His medications include phenytoin, levetiracetam, and vitamin supplements.", "He is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs.", "His immunizations are up-to-date.", "Vital signs are within normal limits.", "Examination shows low-set ears, hypertelorism, and a flat head.", "The remainder of the examination shows no abnormalities." ]

[ "1. Patient is a 15-month-old boy with Down syndrome.", "2. Mother is concerned about giving the child any more vaccinations.", "3. Patient had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age.", "4. Patient has had a runny nose for 2 days.", "5. Patient has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications.", "6. Patient was treated for intussusception at 6 months of age.", "7. Patient's father was diagnosed with HIV 2 years ago.", "8. Patient's medications include phenytoin, levetiracetam, and vitamin supplements.", "9. Patient is allergic to amoxicillin.", "10. Patient has previously developed localized urticaria after consumption of eggs.", "11. Patient's immunizations are up-to-date.", "12. Patient's vital signs are within normal limits.", "13. Examination shows low-set ears, hypertelorism, and a flat head.", "14. The remainder of the examination shows no abnormalities." ]

[ "1. The child had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12 months of age.", "2. The child has had a runny nose for 2 days.", "3. The child has a seizure disorder with seizures lasting 1–2 minutes a few times a week that has not been controlled by medications.", "4. The child was treated for intussusception at 6 months of age.", "5. The child's father was diagnosed with HIV 2 years ago.", "6. The child's medications include phenytoin, levetiracetam, and vitamin supplements.", "7. The child is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs.", "8. The child's immunizations are up-to-date.", "9. Examination shows low-set ears, hypertelorism, and a flat head.", "10. The remainder of the examination shows no abnormalities." ]

[ "A 1-year-old boy is brought to his pediatrician’s office due to regression of development.", "She has observed that he is not progressing as he did during the 1st year of his life.", "There seems to be a regression in some behavioral and other milestones.", "She is also concerned about his facial development.", "On examination, the vital signs are normal.", "He has coarse facial features with a bulging frontal bone.", "Additionally, his lips are enlarged and corneal clouding is observed.", "Urine studies show an increase in dermatan sulfate." ]

[ "1. A 1-year-old boy is brought to his pediatrician's office.", "2. The pediatrician has observed regression in some behavioral and other milestones.", "3. The pediatrician is also concerned about his facial development.", "4. On examination, the vital signs are normal.", "5. He has coarse facial features with a bulging frontal bone.", "6. His lips are enlarged.", "7. Corneal clouding is observed.", "8. Urine studies show an increase in dermatan sulfate." ]

[ "1. She has observed that he is not progressing as he did during the 1st year of his life.", "2. There seems to be a regression in some behavioral and other milestones.", "3. She is also concerned about his facial development.", "4. On examination, the vital signs are normal.", "5. He has coarse facial features with a bulging frontal bone.", "6. Additionally, his lips are enlarged and corneal clouding is observed.", "7. Urine studies show an increase in dermatan sulfate." ]

[ "A 6-year-old African American girl is brought to the physician by her mother because she has recently developed axillary and pubic hair.", "She also has multiple pustules on her forehead and has had oily skin for 3 months.", "Her mother reports that she recently bought some deodorant for the girl because of her body odor.", "Her mother has hypothyroidism.", "She is at the 95th percentile for height and the 99th percentile for weight and BMI.", "Her vital signs are within normal limits.", "She has no palpable glandular breast tissue.", "There is coarse hair under both axilla and sparse dark hair on the mons pubis and along the labia majora." ]

[ "1. Patient is a 6-year-old African American girl.", "2. Patient was brought to the physician by her mother.", "3. Patient has recently developed axillary and pubic hair.", "4. Patient has multiple pustules on her forehead.", "5. Patient has had oily skin for 3 months.", "6. Patient's mother recently bought deodorant for her due to body odor.", "7. Patient's mother has hypothyroidism.", "8. Patient is at the 95th percentile for height.", "9. Patient is at the 99th percentile for weight and BMI.", "10. Patient's vital signs are within normal limits.", "11. Patient has no palpable glandular breast tissue.", "12. Patient has coarse hair under both axilla.", "13. Patient has sparse dark hair on the mons pubis and along the labia majora." ]

[ "1. She has multiple pustules on her forehead.", "2. She has had oily skin for 3 months.", "3. Her mother recently bought deodorant for her because of her body odor.", "4. Her mother has hypothyroidism.", "5. She is at the 95th percentile for height.", "6. She is at the 99th percentile for weight and BMI.", "7. Her vital signs are within normal limits.", "8. She has no palpable glandular breast tissue.", "9. There is coarse hair under both axilla.", "10. There is sparse dark hair on the mons pubis and along the labia majora." ]

[ "A 45-year-old woman comes to the physician for a health maintenance examination.", "Her father has a history of type 2 diabetes mellitus.", "She has gained 18-kg (40-lb) since the birth of her son 6 years ago.", "Her BMI is 31 kg/m2.", "Physical examination shows hyperpigmented plaques in the axillae and posterior neck.", "Laboratory studies show a hemoglobin A1c of 6.4% and an elevated serum insulin level." ]

[ "1. A 45-year-old woman comes to the physician for a health maintenance examination.", "2. Her father has a history of type 2 diabetes mellitus.", "3. She has gained 18-kg (40-lb) since the birth of her son 6 years ago.", "4. Her BMI is 31 kg/m2.", "5. Physical examination shows hyperpigmented plaques in the axillae and posterior neck.", "6. Laboratory studies show a hemoglobin A1c of 6.4%.", "7. Laboratory studies show an elevated serum insulin level." ]

[ "1. Her father has a history of type 2 diabetes mellitus.", "2. She has gained 18-kg (40-lb) since the birth of her son 6 years ago.", "3. Her BMI is 31 kg/m2.", "4. Physical examination shows hyperpigmented plaques in the axillae and posterior neck.", "5. Laboratory studies show a hemoglobin A1c of 6.4%.", "6. Laboratory studies show an elevated serum insulin level." ]

[ "An 89-year-old woman presents with worsening dyspnea on exertion and generalized fatigue.", "She has fainted once.", "Exam reveals a crescendo-decrescendo systolic ejection murmur that radiates to the carotids." ]

[ "1. Patient is 89 years old.", "2. Patient presents with worsening dyspnea on exertion and generalized fatigue.", "3. Patient has fainted once.", "4. Exam reveals a crescendo-decrescendo systolic ejection murmur.", "5. Murmur radiates to the carotids." ]

[ "1. She has fainted once.", "2. Exam reveals a crescendo-decrescendo systolic ejection murmur.", "3. The murmur radiates to the carotids." ]

[ "A 22-year-old man presents to the emergency department for chest pain.", "He says that the chest pain began a few hours prior to presentation and is associated with nausea, abdominal discomfort, and sweating.", "He has experienced similar symptoms multiple times in the past, which brings him great concern because he believes he may be having a heart attack.", "This concern has persisted for 2 months.", "This has caused him to avoid taking long train rides or driving on divided highways.", "Approximately 7 months ago his parents divorced.", "Medical history is significant for obesity.", "He denies any medications or illicit drug use.", "Physical examination is unremarkable.", "An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min." ]

[ "1. A 22-year-old man presents to the emergency department for chest pain.", "2. The chest pain began a few hours prior to presentation.", "3. The chest pain is associated with nausea, abdominal discomfort, and sweating.", "4. He has experienced similar symptoms multiple times in the past.", "5. He believes he may be having a heart attack.", "6. His concern has persisted for 2 months.", "7. He has avoided taking long train rides or driving on divided highways.", "8. Approximately 7 months ago his parents divorced.", "9. Medical history is significant for obesity.", "10. He denies any medications or illicit drug use.", "11. Physical examination is unremarkable.", "12. An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min." ]

[ "1. The patient reports that the chest pain started a few hours before seeking medical attention.", "2. The chest pain is accompanied by nausea, abdominal discomfort, and sweating.", "3. The patient has had similar symptoms on multiple occasions in the past.", "4. The patient is concerned that he may be having a heart attack due to the recurring symptoms.", "5. The patient has been worried about this for 2 months.", "6. His concern has led him to avoid long train rides and driving on divided highways.", "7. The patient's parents divorced approximately 7 months ago.", "8. The patient has a significant medical history of obesity.", "9. The patient denies using any medications or illicit drugs.", "10. The physical examination did not reveal any remarkable findings.", "11. An electrocardiogram shows sinus tachycardia with a pulse of 110/min." ]

[ "An investigator is developing a new vaccine.", "Eukaryote ribosomes are utilized to create a novel protein." ]

[ "1. An investigator is developing a new vaccine.", "2. Eukaryote ribosomes are utilized.", "3. A novel protein is being created." ]

[ "1. Eukaryote ribosomes are present in eukaryotic cells.", "2. Ribosomes are used to synthesize proteins.", "3. The process of using ribosomes to create a new protein is called translation." ]

[ "A 70-year-old Caucasian woman presents with a 2-week history of blood-tinged sputum.", "Her past medical history is significant for peptic ulcer disease for which she underwent triple-drug therapy.", "She is a lifetime non-smoker and worked as a teacher before retiring at the age of 60 years.", "A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months.", "Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min.", "Physical examination is unremarkable.", "A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung.", "A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus." ]

[ "1. Patient is a 70-year-old Caucasian woman.", "2. Patient has a 2-week history of blood-tinged sputum.", "3. Patient has a past medical history of peptic ulcer disease.", "4. Patient underwent triple-drug therapy for peptic ulcer disease.", "5. Patient is a lifetime non-smoker.", "6. Patient worked as a teacher before retiring at the age of 60 years.", "7. Patient has had a weight loss of 6.8 kg (15 lb) over the last 5 months.", "8. Patient's blood pressure is 135/85 mm Hg.", "9. Patient's temperature is 37.7°C (99.9°F).", "10. Patient's pulse is 95/min.", "11. Patient's respiratory rate is 18/min.", "12. Physical examination is unremarkable.", "13. Contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung.", "14. CT-guided biopsy reveals malignant tissue architecture and gland formation with a significant amount of mucus." ]

[ "1. Past medical history includes peptic ulcer disease", "2. Underwent triple-drug therapy for peptic ulcer disease", "3. Lifetime non-smoker", "4. Worked as a teacher before retiring at age 60", "5. Review of systems shows weight loss of 6.8 kg (15 lb) over last 5 months", "6. Vitals: blood pressure 135/85 mm Hg", "7. Vitals: temperature 37.7°C (99.9°F)", "8. Vitals: pulse 95/min", "9. Vitals: respiratory rate 18/min", "10. Physical examination is unremarkable", "11. Contrast CT scan of the chest shows irregular mass in peripheral region of inferior lobe of right lung", "12. CT-guided biopsy reveals malignant tissue architecture and gland formation with significant amount of mucus" ]

[ "Four days after admission to the hospital for community-acquired pneumonia, a 68-year-old woman has abdominal pain and multiple episodes of loose stools.", "They are watery, foul-smelling, and occasionally streaked with blood.", "She has approximately 6 episodes daily.", "She feels tired.", "She is currently being treated with intravenous ceftriaxone and oral azithromycin.", "She underwent a laparoscopic cholecystectomy 5 years ago.", "She returned from a trip to Bolivia 4 weeks ago.", "Her temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg.", "Bronchial breath sounds are heard over her right lung.", "Abdominal examination shows mild diffuse tenderness throughout the lower quadrants.", "The abdomen is not distended.", "The remainder of her examination shows no abnormalities.", "Her hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h." ]

[ "1. Patient is 68-year-old woman.", "2. Patient was admitted to the hospital four days ago for community-acquired pneumonia.", "3. Patient has abdominal pain and multiple episodes of loose stools.", "4. Loose stools are watery, foul-smelling, and occasionally streaked with blood.", "5. Patient has approximately 6 episodes of loose stools daily.", "6. Patient feels tired.", "7. Patient is currently being treated with intravenous ceftriaxone and oral azithromycin.", "8. Patient underwent a laparoscopic cholecystectomy 5 years ago.", "9. Patient returned from a trip to Bolivia 4 weeks ago.", "10. Patient's temperature is 37.5°C (99.5°F).", "11. Patient's pulse is 98/min.", "12. Patient's blood pressure is 138/80 mm Hg.", "13. Bronchial breath sounds are heard over patient's right lung.", "14. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants.", "15. Abdomen is not distended.", "16. Remainder of patient's examination shows no abnormalities.", "17. Patient's hemoglobin concentration is 12 g/dL.", "18. Patient's leukocyte count is 14,100/mm3.", "19. Patient's erythrocyte sedimentation rate is 37 mm/h." ]

[ "1. The patient's stool is watery, foul-smelling, and occasionally streaked with blood.", "2. The patient has approximately 6 episodes of stool daily.", "3. The patient feels tired.", "4. The patient is currently being treated with intravenous ceftriaxone and oral azithromycin.", "5. The patient underwent a laparoscopic cholecystectomy 5 years ago.", "6. The patient returned from a trip to Bolivia 4 weeks ago.", "7. The patient's temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg.", "8. Bronchial breath sounds are heard over the patient's right lung.", "9. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants.", "10. The patient's abdomen is not distended.", "11. The remainder of the patient's examination shows no abnormalities.", "12. The patient's hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h." ]

[ "An otherwise healthy 52-year-old man comes to the physician because of a 2-month history of palpitations.", "He says that he can feel his heart beat in his chest all the time.", "For the past 3 weeks, he has shortness of breath on exertion.", "He has not had chest pain, orthopnea, or nocturnal dyspnea.", "He emigrated from Nepal at the age of 25 years.", "He does not take any medications.", "His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg.", "The lungs are clear to auscultation.", "Cardiac examination is shown." ]

[ "1. Patient is a 52-year-old man.", "2. Patient has a 2-month history of palpitations.", "3. Patient feels his heart beat in his chest all the time.", "4. Patient has shortness of breath on exertion for the past 3 weeks.", "5. Patient has no chest pain, orthopnea, or nocturnal dyspnea.", "6. Patient emigrated from Nepal at the age of 25 years.", "7. Patient does not take any medications.", "8. Patient's temperature is 36.5°C (97.7°F).", "9. Patient's pulse is 103/min.", "10. Patient's blood pressure is 138/56 mm Hg.", "11. Lungs are clear to auscultation.", "12. Cardiac examination is shown." ]

[ "1. He can feel his heart beat in his chest all the time.", "2. For the past 3 weeks, he has shortness of breath on exertion.", "3. He has not had chest pain, orthopnea, or nocturnal dyspnea.", "4. He emigrated from Nepal at the age of 25 years.", "5. He does not take any medications.", "6. His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg.", "7. The lungs are clear to auscultation.", "8. Cardiac examination is shown." ]

[ "A 55-year-old male presents to the emergency department after he was seen having a seizure.", "On presentation he is comatose and very jaundiced despite having no previous medical history and dies shortly thereafter.", "Over the next several hours 5 more patients present to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities.", "They all recently returned from a several day camping trip where they slept in the woods and cooked with ingredients they were able to find in the wild.", "The original patient was also part of this camping trip.", "Postmortem analysis reveals massive hepatic necrosis." ]

[ "1. A 55-year-old male presents to the emergency department after he was seen having a seizure.", "2. On presentation he is comatose and very jaundiced.", "3. He had no previous medical history.", "4. He dies shortly thereafter.", "5. Over the next several hours 5 more patients present to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities.", "6. They all recently returned from a several day camping trip.", "7. They slept in the woods and cooked with ingredients they were able to find in the wild.", "8. The original patient was also part of this camping trip.", "9. Postmortem analysis reveals massive hepatic necrosis." ]

[ "1. A patient presented comatose and jaundiced.", "2. The patient had no previous medical history.", "3. The patient died shortly after presentation.", "4. Five more patients presented to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities.", "5. The patients had recently returned from a camping trip.", "6. During the camping trip, they slept in the woods and cooked with wild ingredients.", "7. The original patient was part of the camping trip.", "8. Postmortem analysis revealed massive hepatic necrosis." ]

[ "A 46-year-old woman is brought to the emergency department for respiratory depression.", "Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.", "Blood glucose is 80 mg/dL.", "Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.", "Two hours later, the woman has a tonic-clonic seizure lasting for one minute.", "Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min.", "Pulse oximetry on room air shows an oxygen saturation of 98%.", "The patient appears drowsy and diaphoretic.", "She is not oriented to place or time but responds to her name.", "Examination shows a hematoma on her left temple.", "Neurological examination shows stiff extremities and a tremor in both hands.", "The remainder of the examination shows no abnormalities." ]

[ "1. A 46-year-old woman is brought to the emergency department for respiratory depression.", "2. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.", "3. Blood glucose is 80 mg/dL.", "4. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.", "5. Two hours later, the woman has a tonic-clonic seizure lasting for one minute.", "6. Her pulse is 100/min.", "7. Blood pressure is 145/90 mm Hg.", "8. Respiratory rate is 24/min.", "9. Pulse oximetry on room air shows an oxygen saturation of 98%.", "10. The patient appears drowsy and diaphoretic.", "11. She is not oriented to place or time but responds to her name.", "12. Examination shows a hematoma on her left temple.", "13. Neurological examination shows stiff extremities and a tremor in both hands.", "14. The remainder of the examination shows no abnormalities." ]

[ "1. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.", "2. Blood glucose is 80 mg/dL.", "3. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.", "4. Two hours later, the woman has a tonic-clonic seizure lasting for one minute.", "5. Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min.", "6. Pulse oximetry on room air shows an oxygen saturation of 98%.", "7. The patient appears drowsy and diaphoretic.", "8. She is not oriented to place or time but responds to her name.", "9. Examination shows a hematoma on her left temple.", "10. Neurological examination shows stiff extremities and a tremor in both hands.", "11. The remainder of the examination shows no abnormalities." ]

[ "A 22-year-old man comes to the emergency department because of sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix.", "He does not have shortness of breath or hoarseness.", "He has never had a similar episode before.", "He has asthma treated with an albuterol inhaler, which he uses less than once a month.", "His pulse is 90/min, respirations are 25/min, and blood pressure is 125/80 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 99%.", "Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand.", "There is no swelling of the oropharynx and no audible stridor.", "The lungs are clear to auscultation bilaterally.", "Treatment with intravenous diphenhydramine is begun.", "Shortly after, the abdominal pain and nausea have resolved, the swelling has improved, and the rash has started to fade." ]

[ "1. A 22-year-old man comes to the emergency department.", "2. He has sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix.", "3. He does not have shortness of breath or hoarseness.", "4. He has never had a similar episode before.", "5. He has asthma treated with an albuterol inhaler, which he uses less than once a month.", "6. His pulse is 90/min.", "7. His respirations are 25/min.", "8. His blood pressure is 125/80 mm Hg.", "9. Pulse oximetry on room air shows an oxygen saturation of 99%.", "10. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand.", "11. There is no swelling of the oropharynx and no audible stridor.", "12. The lungs are clear to auscultation bilaterally.", "13. Treatment with intravenous diphenhydramine is begun.", "14. Shortly after, the abdominal pain and nausea have resolved.", "15. The swelling has improved.", "16. The rash has started to fade." ]

[ "1. He does not have shortness of breath or hoarseness.", "2. He has never had a similar episode before.", "3. He has asthma treated with an albuterol inhaler, which he uses less than once a month.", "4. His pulse is 90/min, respirations are 25/min, and blood pressure is 125/80 mm Hg.", "5. Pulse oximetry on room air shows an oxygen saturation of 99%.", "6. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand.", "7. There is no swelling of the oropharynx and no audible stridor.", "8. The lungs are clear to auscultation bilaterally.", "9. Treatment with intravenous diphenhydramine is begun.", "10. Shortly after, the abdominal pain and nausea have resolved, the swelling has improved, and the rash has started to fade." ]

[ "A 2-year-old boy is referred by his primary care physician to a geneticist because of prolonged and recurrent infections.", "Specifically, he has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year.", "He was born with a defect in the cardiac septum that was repaired right after birth and has remained asymptomatic since then.", "On evaluation, the patient appears to have hyperactive reflexes and his arm twitches upon blood pressure measurement." ]

[ "1. A 2-year-old boy is referred by his primary care physician to a geneticist.", "2. The referral is due to prolonged and recurrent infections.", "3. The patient has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year.", "4. The patient was born with a defect in the cardiac septum.", "5. The defect was repaired right after birth.", "6. The defect has remained asymptomatic since then.", "7. On evaluation, the patient appears to have hyperactive reflexes.", "8. The patient's arm twitches upon blood pressure measurement." ]

[ "1. The patient has had an abnormally large number of upper respiratory infections over the last year.", "2. The patient has had an abnormally large number of gastrointestinal infections over the last year.", "3. The patient was born with a defect in the cardiac septum.", "4. The defect in the cardiac septum was repaired right after birth.", "5. The patient has remained asymptomatic since the repair of the cardiac septum.", "6. On evaluation, the patient appears to have hyperactive reflexes.", "7. The patient's arm twitches upon blood pressure measurement." ]

[ "A 45-year-old woman presents with a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.", "She says she experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.", "She also has the bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.", "Past medical history is unremarkable.", "The patient denies smoking, alcohol consumption, illicit drug use.", "Her vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).", "Laboratory findings are significant for the following: | Hgb 7.2 gm/dL | MCV 110 fL | RBC 3.6 X109/L | Platelets 10,000/mm3 | Total count 4,200/mm3 | Reticulocyte 0.8% | A peripheral blood smear demonstrates hypersegmented neutrophils.", "Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.", "An upper GI series with small bowel follow-through is performed which shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string." ]

[ "1. Patient is a 45-year-old woman.", "2. Patient has a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.", "3. Patient experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.", "4. Patient has bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.", "5. Patient's past medical history is unremarkable.", "6. Patient denies smoking, alcohol consumption, and illicit drug use.", "7. Patient's vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).", "8. Laboratory findings are significant for Hgb 7.2 gm/dL, MCV 110 fL, RBC 3.6 X109/L, Platelets 10,000/mm3, Total count 4,200/mm3, Reticulocyte 0.8%.", "9. Peripheral blood smear demonstrates hypersegmented neutrophils.", "10. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.", "11. Upper GI series with small bowel follow-through shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string." ]

[ "1. The patient experiences 2–3 episodes of non-bloody diarrhea per month.", "2. The diarrhea is associated with crampy abdominal pain.", "3. The patient has bilateral tingling sensation in a glove and stocking pattern in her upper and lower limbs.", "4. The tingling sensation is sometimes associated with a burning sensation in her hands and legs.", "5. The patient has an unremarkable past medical history.", "6. The patient denies smoking, alcohol consumption, and illicit drug use.", "7. The patient's blood pressure is 100/60 mm Hg without postural changes.", "8. The patient's heart rate is 92/min.", "9. The patient's respiratory rate is 16/min.", "10. The patient's temperature is 37.0℃ (98.6℉).", "11. Laboratory findings show: Hgb 7.2 gm/dL, MCV 110 fL, RBC 3.6 X109/L, Platelets 10,000/mm3, Total count 4,200/mm3, Reticulocyte 0.8%.", "12. A peripheral blood smear demonstrates hypersegmented neutrophils.", "13. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.", "14. An upper GI series with small bowel follow-through shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string." ]

[ "A 15-month-old boy is brought to his pediatrician by his mother with a swollen and painful right elbow.", "She reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.", "The mother reports that he did not appear to be in a great deal of pain after the fall, and that she noted the swelling of the joint a few hours after the fall.", "He recently started walking approximately 2 weeks ago.", "He does not have any known medical issues, and he is not currently on medication.", "The mother's pregnancy was without complications and the boy was delivered vaginally without complications at 40 weeks.", "Aspiration of the right elbow joint reveals frank blood." ]

[ "1. A 15-month-old boy is brought to his pediatrician by his mother.", "2. The boy has a swollen and painful right elbow.", "3. The mother reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.", "4. The mother reports that he did not appear to be in a great deal of pain after the fall.", "5. The mother noted the swelling of the joint a few hours after the fall.", "6. He recently started walking approximately 2 weeks ago.", "7. He does not have any known medical issues.", "8. He is not currently on medication.", "9. The mother's pregnancy was without complications.", "10. The boy was delivered vaginally without complications at 40 weeks.", "11. Aspiration of the right elbow joint reveals frank blood." ]

[ "1. The boy stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.", "2. The mother reports that he did not appear to be in a great deal of pain after the fall.", "3. The mother noted the swelling of the joint a few hours after the fall.", "4. He recently started walking approximately 2 weeks ago.", "5. He does not have any known medical issues.", "6. He is not currently on medication.", "7. The mother's pregnancy was without complications.", "8. The boy was delivered vaginally without complications at 40 weeks.", "9. Aspiration of the right elbow joint reveals frank blood." ]

[ "A 45-year-old male comes into your office one week after he was tackled playing football with his friends.", "The patient states that the medial aspect of his knee collided with another player's knee.", "Since then, he has been taking ibuprofen for knee pain.", "On exam, the patient's right knee appears larger than his left knee with a small effusion.", "The patient has intact sensation and strength in both lower extremities.", "The patient's right knee has no laxity on valgus stress test, but is very lax on varus stress test.", "Lachman's test and posterior drawer test both have firm endpoints without laxity.", "McMurray's test is positive and the patient states he feels catching and locking during the test." ]

[ "1. Patient is 45 years old.", "2. Patient was tackled playing football one week prior.", "3. Patient's medial knee collided with another player's knee.", "4. Patient has been taking ibuprofen for knee pain.", "5. Patient's right knee appears larger than left knee with a small effusion.", "6. Patient has intact sensation and strength in both lower extremities.", "7. Patient's right knee has no laxity on valgus stress test.", "8. Patient's right knee is very lax on varus stress test.", "9. Lachman's test and posterior drawer test have firm endpoints without laxity.", "10. McMurray's test is positive.", "11. Patient states he feels catching and locking during McMurray's test." ]

[ "1. The patient reports a collision between the medial aspect of his knee and another player's knee.", "2. The patient has been taking ibuprofen for knee pain since the collision.", "3. On exam, the patient's right knee appears larger than his left knee with a small effusion.", "4. The patient has intact sensation and strength in both lower extremities.", "5. The patient's right knee has no laxity on valgus stress test, but is very lax on varus stress test.", "6. Lachman's test and posterior drawer test both have firm endpoints without laxity.", "7. McMurray's test is positive and the patient experiences catching and locking during the test." ]

[ "A 19-month-old girl is brought for a well-child examination.", "She was born at term and has been healthy.", "On physical examination, the child is alert and active.", "Her temperature is 37.3 °C (99.1 °F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/54 mm Hg.", "She is at the 75th percentile for height and 80th percentile for weight.", "Cardiac examination shows a normal S1 and a split S2 during inspiration.", "A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border.", "A contrast echocardiogram is performed and reveals a mild transient right-to-left interatrial shunt that becomes apparent when the child coughs." ]

[ "1. A 19-month-old girl is brought for a well-child examination.", "2. She was born at term.", "3. She has been healthy.", "4. On physical examination, the child is alert and active.", "5. Her temperature is 37.3 °C (99.1 °F).", "6. Her pulse is 102/min.", "7. Her respirations are 24/min.", "8. Her blood pressure is 102/54 mm Hg.", "9. She is at the 75th percentile for height.", "10. She is at the 80th percentile for weight.", "11. Cardiac examination shows a normal S1.", "12. Cardiac examination shows a split S2 during inspiration.", "13. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border.", "14. A contrast echocardiogram is performed.", "15. The contrast echocardiogram reveals a mild transient right-to-left interatrial shunt.", "16. The shunt becomes apparent when the child coughs." ]

[ "1. She was born at term", "2. She has been healthy", "3. The child is alert and active", "4. Her temperature is 37.3 °C (99.1 °F)", "5. Her pulse is 102/min", "6. Her respirations are 24/min", "7. Her blood pressure is 102/54 mm Hg", "8. She is at the 75th percentile for height", "9. She is at the 80th percentile for weight", "10. Cardiac examination shows a normal S1", "11. Cardiac examination shows a split S2 during inspiration", "12. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border", "13. A contrast echocardiogram is performed", "14. The echocardiogram reveals a mild transient right-to-left interatrial shunt", "15. The shunt becomes apparent when the child coughs" ]

[ "A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days.", "During this period, the girl has refused to walk.", "Her mother reports that her symptoms began after she fell down while playing.", "Three weeks ago, the patient had a sore throat and was treated with penicillin V.", "Her father has hemophilia A and has had repeated episodes of joint pain and swelling following minor injury.", "The patient's immunizations are up-to-date.", "Her temperature is 38.1°C (100.6°F), pulse is 120/min, and respirations are 21/min.", "The right knee joint is warm and erythematous.", "The girl starts to cry as soon as the physician tries to flex the knee joint." ]

[ "1. A 6-year-old girl is brought to the emergency department.", "2. The girl has right knee pain for the past 3 days.", "3. The girl has refused to walk.", "4. Her symptoms began after she fell down while playing.", "5. Three weeks ago, the patient had a sore throat and was treated with penicillin V.", "6. Her father has hemophilia A.", "7. Her father has had repeated episodes of joint pain and swelling following minor injury.", "8. The patient's immunizations are up-to-date.", "9. Her temperature is 38.1°C (100.6°F).", "10. Her pulse is 120/min.", "11. Her respirations are 21/min.", "12. The right knee joint is warm and erythematous.", "13. The girl starts to cry as soon as the physician tries to flex the knee joint." ]

[ "1. The girl has refused to walk.", "2. Her symptoms began after she fell down while playing.", "3. Three weeks ago, the patient had a sore throat and was treated with penicillin V.", "4. Her father has hemophilia A and has had repeated episodes of joint pain and swelling following minor injury.", "5. The patient's immunizations are up-to-date.", "6. Her temperature is 38.1°C (100.6°F), pulse is 120/min, and respirations are 21/min.", "7. The right knee joint is warm and erythematous.", "8. The girl starts to cry as soon as the physician tries to flex the knee joint." ]

[ "A 35-year-old man attempted to climb Mount Everest.", "At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips.", "A physician in the climbing party performs a rudimentary physical exam which reveals a respiratory rate of 30/min, blood pressure of 130/90 mm Hg, heart rate of 108/min, and temperature of 36.4°C (97.5°F), with few basal crackles on the right side of chest.", "No jugular venous distension or dependent edema is noted.", "With this information, the mountain climber is sent down the mountain for further evaluation.", "Investigation reveals a normal chest X-ray with a normal heart size." ]

[ "1. A 35-year-old man attempted to climb Mount Everest.", "2. At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips.", "3. A physician in the climbing party performed a rudimentary physical exam.", "4. The physical exam revealed a respiratory rate of 30/min.", "5. The physical exam revealed a blood pressure of 130/90 mm Hg.", "6. The physical exam revealed a heart rate of 108/min.", "7. The physical exam revealed a temperature of 36.4°C (97.5°F).", "8. The physical exam revealed few basal crackles on the right side of chest.", "9. The physical exam revealed no jugular venous distension.", "10. The physical exam revealed no dependent edema.", "11. The mountain climber was sent down the mountain for further evaluation.", "12. Investigation revealed a normal chest X-ray.", "13. Investigation revealed a normal heart size." ]

[ "1. Altitude of 7,000 meters", "2. Shortness of breath", "3. Dusky blue tinge around face and lips", "4. Respiratory rate of 30/min", "5. Blood pressure of 130/90 mm Hg", "6. Heart rate of 108/min", "7. Temperature of 36.4°C (97.5°F)", "8. Few basal crackles on the right side of chest", "9. No jugular venous distension", "10. No dependent edema", "11. Mountain climber sent down the mountain for further evaluation", "12. Normal chest X-ray", "13. Normal heart size" ]

[ "A 28-year-old man who was involved in a motorcycle accident presents to the nearest trauma center to get his wounds treated.", "After the initial evaluation and resuscitation by the emergency trauma team, a CT scan shows a skull base fracture." ]

[ "1. A 28-year-old man was involved in a motorcycle accident.", "2. He presents to the nearest trauma center to get his wounds treated.", "3. The emergency trauma team performs an initial evaluation and resuscitation.", "4. A CT scan shows a skull base fracture." ]

[ "1. Initial evaluation and resuscitation performed by emergency trauma team", "2. CT scan conducted", "3. CT scan shows a skull base fracture" ]

[ "A 19-year-old woman comes to the physician for a follow-up examination.", "She has a history of type 1 diabetes mellitus and is compliant with her medications.", "After reviewing the patient's recent blood sugar levels, the physician changes the patient's antidiabetic regimen by changing the dosage of an insulin that does not produce an observable peak in serum insulin concentration." ]

[ "1. A 19-year-old woman comes to the physician for a follow-up examination.", "2. She has a history of type 1 diabetes mellitus.", "3. She is compliant with her medications.", "4. The physician reviews the patient's recent blood sugar levels.", "5. The physician changes the patient's antidiabetic regimen.", "6. The dosage of an insulin is changed.", "7. The insulin does not produce an observable peak in serum insulin concentration." ]

[ "1. The patient has a history of type 1 diabetes mellitus.", "2. The patient is compliant with her medications.", "3. The physician reviewed the patient's recent blood sugar levels.", "4. The physician changed the patient's antidiabetic regimen.", "5. The change involved adjusting the dosage of an insulin.", "6. The insulin does not produce an observable peak in serum insulin concentration." ]

[ "A 31-year-old woman visits her local walk-in clinic for 2 days of dysuria, increased voiding frequency, urgency, and intense suprapubic pain.", "She just came back a day ago from a short honeymoon trip to Prague.", "On physical examination, the patient is found with exquisite suprapubic pain.", "Costovertebral tenderness is absent and pelvic examination is normal.", "Her vital signs are: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min." ]

[ "1. A 31-year-old woman visited her local walk-in clinic.", "2. She had dysuria, increased voiding frequency, urgency, and intense suprapubic pain.", "3. She had recently returned from a honeymoon trip to Prague.", "4. On physical examination, the patient had exquisite suprapubic pain.", "5. Costovertebral tenderness was absent.", "6. Pelvic examination was normal.", "7. Her temperature was 36.5°C (97.7°F).", "8. Her heart rate was 78/min.", "9. Her respiratory rate was 15/min." ]

[ "1. The patient just came back from a short honeymoon trip to Prague a day ago.", "2. On physical examination, the patient has exquisite suprapubic pain.", "3. Costovertebral tenderness is absent.", "4. Pelvic examination is normal.", "5. Vital signs: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min." ]

[ "A 14-year-old boy is brought to the physician by his mother because of a 1-week history of fever, fatigue, and throat pain.", "He appears lethargic.", "His temperature is 38.5°C (101.3°F).", "Physical examination shows bilateral cervical lymphadenopathy.", "Oral examination shows the findings in the photograph.", "A peripheral blood smear shows lymphocytosis with atypical lymphocytes.", "A heterophile antibody test is positive." ]

[ "1. A 14-year-old boy is brought to the physician by his mother.", "2. He has a 1-week history of fever, fatigue, and throat pain.", "3. He appears lethargic.", "4. His temperature is 38.5°C (101.3°F).", "5. Physical examination shows bilateral cervical lymphadenopathy.", "6. Oral examination shows the findings in the photograph.", "7. A peripheral blood smear shows lymphocytosis with atypical lymphocytes.", "8. A heterophile antibody test is positive." ]

[ "1. He appears lethargic.", "2. His temperature is 38.5°C (101.3°F).", "3. Physical examination shows bilateral cervical lymphadenopathy.", "4. Oral examination shows the findings in the photograph.", "5. A peripheral blood smear shows lymphocytosis with atypical lymphocytes.", "6. A heterophile antibody test is positive." ]

[ "A 62-year-old carpenter presents to your clinic complaining of worsening joint pain in her hands.", "She states that the pain is present in all of her fingers, but is worse in the right hand and that it gets better when she has a few days off from work.", "She notes no paresthesias, fever, or fatigue.", "On examination, the patient is afebrile and all vital signs are stable.", "She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand and all 5 digits on this hand have a decreased range of motion.", "An X-ray of her hands is shown." ]

[ "1. A 62-year-old carpenter presents to your clinic.", "2. She is complaining of worsening joint pain in her hands.", "3. The pain is present in all of her fingers.", "4. The pain is worse in the right hand.", "5. The pain gets better when she has a few days off from work.", "6. She notes no paresthesias, fever, or fatigue.", "7. On examination, the patient is afebrile.", "8. All vital signs are stable.", "9. She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand.", "10. All 5 digits on the right hand have a decreased range of motion.", "11. An X-ray of her hands is shown." ]

[ "1. The patient reports pain in all fingers, worse in the right hand, and improved with time off work.", "2. The patient denies experiencing paresthesias, fever, or fatigue.", "3. On examination, the patient is afebrile and has stable vital signs.", "4. The patient has hard, non-tender lesions over the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand.", "5. All 5 digits on the right hand have a decreased range of motion.", "6. An X-ray of the patient's hands is available." ]

[ "A 7-year-old girl presents to the emergency department with a bloody nose that spontaneously started bleeding 20 minutes ago.", "On physical examination, she appears well and has no lymphadenopathy.", "Her heart has a regular rate and rhythm, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly, but she does have petechiae over her lower extremities.", "A complete blood count is obtained and reveals a leukocyte count of 11,300 cells/mcL, hemoglobin 12.1 g/dL, hematocrit 36%, and platelets 15,000/mcL.", "A peripheral smear shows a few morphologically normal platelets.", "Her mother reports that she had a viral infection 2 weeks ago but has been otherwise healthy." ]

[ "1. A 7-year-old girl presents to the emergency department with a bloody nose.", "2. The nose spontaneously started bleeding 20 minutes ago.", "3. On physical examination, she appears well and has no lymphadenopathy.", "4. Her heart has a regular rate and rhythm.", "5. Her lungs are clear to auscultation bilaterally.", "6. Her abdomen is soft without hepatosplenomegaly.", "7. She has petechiae over her lower extremities.", "8. A complete blood count is obtained.", "9. Leukocyte count is 11,300 cells/mcL.", "10. Hemoglobin is 12.1 g/dL.", "11. Hematocrit is 36%.", "12. Platelets are 15,000/mcL.", "13. A peripheral smear shows a few morphologically normal platelets.", "14. Her mother reports she had a viral infection 2 weeks ago.", "15. She has been otherwise healthy." ]

[ "1. On physical examination, she appears well", "2. She has no lymphadenopathy", "3. Her heart has a regular rate and rhythm", "4. Her lungs are clear to auscultation bilaterally", "5. Her abdomen is soft without hepatosplenomegaly", "6. She has petechiae over her lower extremities", "7. A complete blood count reveals a leukocyte count of 11,300 cells/mcL", "8. Hemoglobin is 12.1 g/dL", "9. Hematocrit is 36%", "10. Platelets are 15,000/mcL", "11. A peripheral smear shows a few morphologically normal platelets", "12. Her mother reports that she had a viral infection 2 weeks ago" ]

[ "A 2-year-old boy is brought to the physician by his parents because their son frequently avoids eye contact and has no friends in daycare.", "He was born at term and has been healthy except for an episode of otitis media 6 months ago.", "His immunizations are up-to-date.", "He is at the 95th percentile for height, 20th percentile for weight, and 95th percentile for head circumference.", "Vital signs are within normal limits.", "Examination shows elongated facial features and large ears.", "The patient is shy and does not speak or follow instructions.", "He continually opens and closes his mother's purse and does not maintain eye contact." ]

[ "1. A 2-year-old boy is brought to the physician by his parents.", "2. The boy frequently avoids eye contact and has no friends in daycare.", "3. He was born at term.", "4. He has been healthy except for an episode of otitis media 6 months ago.", "5. His immunizations are up-to-date.", "6. He is at the 95th percentile for height.", "7. He is at the 20th percentile for weight.", "8. He is at the 95th percentile for head circumference.", "9. Vital signs are within normal limits.", "10. Examination shows elongated facial features and large ears.", "11. The patient is shy and does not speak or follow instructions.", "12. He continually opens and closes his mother's purse.", "13. He does not maintain eye contact." ]

[ "1. He was born at term.", "2. He has been healthy except for an episode of otitis media 6 months ago.", "3. His immunizations are up-to-date.", "4. He is at the 95th percentile for height.", "5. He is at the 20th percentile for weight.", "6. He is at the 95th percentile for head circumference.", "7. Vital signs are within normal limits.", "8. Examination shows elongated facial features and large ears.", "9. The patient is shy.", "10. The patient does not speak or follow instructions.", "11. He continually opens and closes his mother's purse.", "12. He does not maintain eye contact." ]

[ "A 78-year-old man is admitted to hospital for treatment of a severe attack of pneumonia he has been experiencing for the past three days.", "A week earlier, he had been feeling well until he developed what he describes as a mild cold.", "Over the next few days, he began to have difficulty breathing and developed a productive cough and fever.", "As his condition worsened despite antibiotic therapy at home, he was admitted for intravenous antibiotics and observation.", "He has a 50-pack-year history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD).", "Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home.", "He has been drinking 3 alcoholic drinks daily for the last 60 years and smoked marijuana during his 20s.", "His lab results from 1 week ago and from his day of admission to hospital are as follows: | 7 days ago | On admission to hospital | Serum glucose (random) 130 mg/dL | Serum electrolytes | Sodium 142 mEq/L | Potassium 3.9 mEq/L | Chloride 101 mEq/L | Serum creatinine 0.8 mg/dL | Blood urea nitrogen 9 mg/dL | Cholesterol, total 170 mg/dL | HDL-cholesterol 42 mg/dL | LDL-cholesterol 110 mg/dL | Triglycerides 130 mg/dL | Serum glucose (random) 100 mg/dL | Serum electrolytes | Sodium 140 mEq/L | Potassium 4.0 mEq/L | Chloride 100 mEq/L | Serum creatinine 0.9 mg/dL | Blood urea nitrogen 11 mg/dL | Cholesterol, total 130 mg/dL | HDL-cholesterol 30 mg/dL | LDL-cholesterol 80 mg/dL | Triglycerides 180 mg/dL | ." ]

[ "1. A 78-year-old man is admitted to hospital for treatment of a severe attack of pneumonia he has been experiencing for the past three days.", "2. A week earlier, he had been feeling well until he developed what he describes as a mild cold.", "3. Over the next few days, he began to have difficulty breathing and developed a productive cough and fever.", "4. As his condition worsened despite antibiotic therapy at home, he was admitted for intravenous antibiotics and observation.", "5. He has a 50-pack-year history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD).", "6. Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home.", "7. He has been drinking 3 alcoholic drinks daily for the last 60 years and smoked marijuana during his 20s.", "8. His lab results from 1 week ago show a serum glucose (random) of 130 mg/dL, sodium of 142 mEq/L, potassium of 3.9 mEq/L, chloride of 101 mEq/L, serum creatinine of 0.8 mg/dL, and blood urea nitrogen of 9 mg/dL.", "9. His lab results from his day of admission to hospital show a serum glucose (random) of 100 mg/dL, sodium of 140 mEq/L, potassium of 4.0 mEq/L, chloride of 100 mEq/L, serum creatinine of 0.9 mg/dL, and blood urea nitrogen of 11 mg/dL.", "10. His lab results from 1 week ago show a cholesterol, total of 170 mg/dL, HDL-cholesterol of 42 mg/dL, LDL-cholesterol of 110 mg/dL, and triglycerides of 130 mg/dL.", "11. His lab results from his day of admission to hospital show a cholesterol, total of 130 mg/dL, HDL-cholesterol of 30 mg/dL, LDL-cholesterol of 80 mg/dL, and triglycerides of 180 mg/dL." ]

[ "1. The patient had been feeling well a week earlier.", "2. He developed what he describes as a mild cold.", "3. He began to have difficulty breathing over the next few days.", "4. He developed a productive cough and fever.", "5. His condition worsened despite antibiotic therapy at home.", "6. He was admitted for intravenous antibiotics and observation.", "7. The patient has a 50-pack-year history of smoking.", "8. He has been diagnosed with chronic obstructive pulmonary disease (COPD).", "9. Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home.", "10. He has been drinking 3 alcoholic drinks daily for the last 60 years.", "11. He smoked marijuana during his 20s.", "12. His lab results from 1 week ago and from his day of admission to hospital are as follows:", "13. Serum glucose (random) 130 mg/dL 7 days ago.", "14. Serum electrolytes: Sodium 142 mEq/L, Potassium 3.9 mEq/L, Chloride 101 mEq/L, Serum creatinine 0.8 mg/dL, Blood urea nitrogen 9 mg/dL, Cholesterol, total 170 mg/dL, HDL-cholesterol 42 mg/dL, LDL-cholesterol 110 mg/dL, Triglycerides 130 mg/dL 7 days ago.", "15. Serum glucose (random) 100 mg/dL on admission to hospital.", "16. Serum electrolytes: Sodium 140 mEq/L, Potassium 4.0 mEq/L, Chloride 100 mEq/L, Serum creatinine 0.9 mg/dL, Blood urea nitrogen 11 mg/dL, Cholesterol, total 130 mg/dL, HDL-cholesterol 30 mg/dL, LDL-cholesterol 80 mg/dL, Triglycerides 180 mg/dL on admission to hospital." ]

[ "A 42-year-old woman comes to the physician because of a 4-week history of progressive difficulty swallowing solid foods.", "The patient reports feeling like food gets stuck in her throat, and that she has to drink a lot of water to swallow her meals.", "Over the past 3 months, she has had progressive fatigue and occasional dyspnea while performing her daily activities.", "Her pulse is 104/min, respirations are 19/min, and blood pressure is 110/70 mm Hg.", "Physical examination shows conjunctival pallor, erythema around the corners of the mouth, and dry, scaly lips.", "Her fingernails appear spoon-shaped and brittle.", "Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space.", "Esophagogastroduodenoscopy shows thin membranes that are protruding into the upper third of the esophagus." ]

[ "1. Patient is 42 years old.", "2. Patient has had difficulty swallowing solid foods for 4 weeks.", "3. Patient feels like food gets stuck in her throat.", "4. Patient has to drink a lot of water to swallow meals.", "5. Patient has had progressive fatigue for 3 months.", "6. Patient has occasional dyspnea while performing daily activities.", "7. Patient's pulse is 104/min.", "8. Patient's respirations are 19/min.", "9. Patient's blood pressure is 110/70 mm Hg.", "10. Physical examination shows conjunctival pallor.", "11. Physical examination shows erythema around the corners of the mouth.", "12. Physical examination shows dry, scaly lips.", "13. Patient's fingernails appear spoon-shaped and brittle.", "14. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space.", "15. Esophagogastroduodenoscopy shows thin membranes that are protruding into the upper third of the esophagus." ]

[ "1. The patient reports feeling like food gets stuck in her throat.", "2. The patient reports having to drink a lot of water to swallow her meals.", "3. Over the past 3 months, the patient has had progressive fatigue.", "4. Over the past 3 months, the patient has had occasional dyspnea while performing her daily activities.", "5. The patient's pulse is 104/min.", "6. The patient's respirations are 19/min.", "7. The patient's blood pressure is 110/70 mm Hg.", "8. Physical examination shows conjunctival pallor.", "9. Physical examination shows erythema around the corners of the mouth.", "10. Physical examination shows dry, scaly lips.", "11. The patient's fingernails appear spoon-shaped.", "12. The patient's fingernails appear brittle.", "13. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space.", "14. Esophagogastroduodenoscopy shows thin membranes protruding into the upper third of the esophagus." ]

[ "A 27-year-old nullipara makes an appointment with her gynecologist to discuss the results of her cervical cancer screening.", "She is not vaccinated against HPV and has a single sexual partner.", "She and her partner are planning pregnancy, so she recently discontinued oral contraception and began to take folate and iron supplements.", "She has no history of gynecologic diseases.", "Her first Pap smear showed atypical squamous cells of undetermined significance, but 2 subsequent Pap smears had normal results.", "The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion.", "Colposcopy was performed at the next visit and a biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.", "The pathologic assessment shows CIN 3." ]

[ "1. A 27-year-old nullipara makes an appointment with her gynecologist.", "2. She is not vaccinated against HPV.", "3. She has a single sexual partner.", "4. She and her partner are planning pregnancy.", "5. She recently discontinued oral contraception.", "6. She began to take folate and iron supplements.", "7. She has no history of gynecologic diseases.", "8. Her first Pap smear showed atypical squamous cells of undetermined significance.", "9. Two subsequent Pap smears had normal results.", "10. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion.", "11. Colposcopy was performed at the next visit.", "12. A biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.", "13. The pathologic assessment shows CIN 3." ]

[ "1. She is not vaccinated against HPV.", "2. She has a single sexual partner.", "3. She recently discontinued oral contraception.", "4. She began to take folate and iron supplements.", "5. She has no history of gynecologic diseases.", "6. Her first Pap smear showed atypical squamous cells of undetermined significance.", "7. 2 subsequent Pap smears had normal results.", "8. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion.", "9. Colposcopy was performed at the next visit.", "10. A biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.", "11. The pathologic assessment shows CIN 3." ]

[ "A 47-year-old woman comes to the physician because of a 3-month history of recurrent episodes of nausea and feeling like the room is spinning.", "Each episode lasts less than a minute and usually occurs when she gets out of bed in the morning or suddenly turns her head.", "She has not vomited and does not have headaches.", "She is asymptomatic between episodes." ]

[ "1. A 47-year-old woman comes to the physician.", "2. She has a 3-month history of recurrent episodes of nausea.", "3. She also has a feeling like the room is spinning.", "4. Each episode lasts less than a minute.", "5. The episodes usually occur when she gets out of bed in the morning or suddenly turns her head.", "6. She has not vomited.", "7. She does not have headaches.", "8. She is asymptomatic between episodes." ]

[ "1. Each episode lasts less than a minute.", "2. Episodes usually occur when she gets out of bed in the morning.", "3. Episodes also occur when she suddenly turns her head.", "4. She has not vomited.", "5. She does not have headaches.", "6. She is asymptomatic between episodes." ]

[ "A 56-year-old man is brought to the emergency department by his wife because of increasing confusion and lethargy for the past 12 hours.", "He is oriented only to person.", "His temperature is 37.3°C (99.1°F), pulse is 109/min, respirations are 18/min, and blood pressure is 108/67 mm Hg.", "Examination shows abdominal distention and several erythematous, lacy lesions on the chest that blanch with pressure.", "His hands make a flapping motion when they are dorsiflexed." ]

[ "1. A 56-year-old man is brought to the emergency department by his wife.", "2. He has been experiencing increasing confusion and lethargy for the past 12 hours.", "3. He is oriented only to person.", "4. His temperature is 37.3°C (99.1°F).", "5. His pulse is 109/min.", "6. His respirations are 18/min.", "7. His blood pressure is 108/67 mm Hg.", "8. Examination shows abdominal distention.", "9. Examination shows several erythematous, lacy lesions on the chest.", "10. The lesions on the chest blanch with pressure.", "11. His hands make a flapping motion when they are dorsiflexed." ]

[ "1. He is oriented only to person.", "2. His temperature is 37.3°C (99.1°F).", "3. His pulse is 109/min.", "4. His respirations are 18/min.", "5. His blood pressure is 108/67 mm Hg.", "6. Examination shows abdominal distention.", "7. Examination shows several erythematous, lacy lesions on the chest that blanch with pressure.", "8. His hands make a flapping motion when they are dorsiflexed." ]

[ "A 63-year-old man comes to the physician because of a 4-hour history of severe pain in the right knee.", "His temperature is 38.0°C (100.1°F).", "Examination shows erythema, edema, and warmth of the right knee; range of motion is limited by pain.", "Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 24,000/mm3 (74% segmented neutrophils).", "Polarized light microscopy shows needle-shaped, negatively birefringent crystals.", "Five hours after treatment with a drug is begun, he develops abdominal cramp, diarrhea, and vomiting." ]

[ "1. A 63-year-old man comes to the physician.", "2. He has a 4-hour history of severe pain in the right knee.", "3. His temperature is 38.0°C (100.1°F).", "4. Examination shows erythema, edema, and warmth of the right knee.", "5. Range of motion is limited by pain.", "6. Arthrocentesis of the knee joint yields cloudy fluid.", "7. Leukocyte count of the fluid is 24,000/mm3 (74% segmented neutrophils).", "8. Polarized light microscopy shows needle-shaped, negatively birefringent crystals.", "9. Five hours after treatment with a drug is begun, he develops abdominal cramp.", "10. He develops diarrhea.", "11. He develops vomiting." ]

[ "1. His temperature is 38.0°C (100.1°F).", "2. Examination shows erythema, edema, and warmth of the right knee.", "3. Range of motion is limited by pain.", "4. Arthrocentesis of the knee joint yields cloudy fluid.", "5. The leukocyte count of the fluid is 24,000/mm3.", "6. 74% of the leukocytes are segmented neutrophils.", "7. Polarized light microscopy shows needle-shaped, negatively birefringent crystals.", "8. Five hours after treatment with a drug is begun, he develops abdominal cramp, diarrhea, and vomiting." ]

[ "A 1-year-old boy presents to the emergency department for several days of irritability and poor feeding.", "His parents are very concerned that he has been acting differently.", "The patient has an unremarkable past medical history and has been followed by a pediatrician.", "His temperature is 102°F (38.9°C), blood pressure is 57/38 mmHg, pulse is 170/min, respirations are 35/min, and oxygen saturation is 99% on room air.", "During the exam the infant is irritable and is crying.", "Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation.", "Fundoscopy is within normal limits.", "Abdominal, cardiac, and pulmonary exam are within normal limits." ]

[ "1. A 1-year-old boy presents to the emergency department.", "2. The parents are concerned that he has been acting differently.", "3. The patient has an unremarkable past medical history.", "4. The patient has been followed by a pediatrician.", "5. The patient's temperature is 102°F (38.9°C).", "6. The patient's blood pressure is 57/38 mmHg.", "7. The patient's pulse is 170/min.", "8. The patient's respirations are 35/min.", "9. The patient's oxygen saturation is 99% on room air.", "10. During the exam the infant is irritable and is crying.", "11. Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation.", "12. Fundoscopy is within normal limits.", "13. Abdominal, cardiac, and pulmonary exam are within normal limits." ]

[ "1. The patient's parents are very concerned about his change in behavior.", "2. The patient has an unremarkable past medical history.", "3. The patient has been followed by a pediatrician.", "4. The patient's temperature is 102°F (38.9°C).", "5. The patient's blood pressure is 57/38 mmHg.", "6. The patient's pulse is 170/min.", "7. The patient's respirations are 35/min.", "8. The patient's oxygen saturation is 99% on room air.", "9. During the exam, the infant is irritable and crying.", "10. The patient's knee cannot be extended while the hip is in a flexed position without significant irritation.", "11. Fundoscopy is within normal limits.", "12. Abdominal exam is within normal limits.", "13. Cardiac exam is within normal limits.", "14. Pulmonary exam is within normal limits." ]

[ "A 74-year-old man comes to the physician because of a 2-month history of shortness of breath and leg swelling.", "He has trouble climbing one flight of stairs due to dyspnea.", "He has hypertension and was diagnosed with multiple myeloma 6 months ago.", "Current medications include hydrochlorothiazide.", "Cardiopulmonary examination shows jugular venous distention, bibasilar crackles, and pitting edema in the lower extremities.", "Transthoracic echocardiography shows a thickened myocardium with elevated diastolic filling pressures." ]

[ "1. A 74-year-old man comes to the physician.", "2. He has a 2-month history of shortness of breath and leg swelling.", "3. He has trouble climbing one flight of stairs due to dyspnea.", "4. He has hypertension.", "5. He was diagnosed with multiple myeloma 6 months ago.", "6. His current medications include hydrochlorothiazide.", "7. Cardiopulmonary examination shows jugular venous distention.", "8. Cardiopulmonary examination shows bibasilar crackles.", "9. Cardiopulmonary examination shows pitting edema in the lower extremities.", "10. Transthoracic echocardiography shows a thickened myocardium.", "11. Transthoracic echocardiography shows elevated diastolic filling pressures." ]

[ "1. He has trouble climbing one flight of stairs due to dyspnea.", "2. He has hypertension.", "3. He was diagnosed with multiple myeloma 6 months ago.", "4. Current medications include hydrochlorothiazide.", "5. Cardiopulmonary examination shows jugular venous distention.", "6. Cardiopulmonary examination shows bibasilar crackles.", "7. Cardiopulmonary examination shows pitting edema in the lower extremities.", "8. Transthoracic echocardiography shows a thickened myocardium.", "9. Transthoracic echocardiography shows elevated diastolic filling pressures." ]

[ "A 47-year-old man is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision.", "On arrival, he is unconscious and unresponsive to painful stimuli.", "His pulse is 120/min, respirations are 10/min, and his blood pressure is 88/60 mm Hg.", "Infusion of 0.9% saline is begun, and intubation is attempted without success.", "Pulse oximetry on 20 L/min of oxygen via bag mask shows an oxygen saturation of 78%." ]

[ "1. A 47-year-old man was brought to the emergency department 30 minutes after a motor vehicle collision.", "2. On arrival, he was unconscious and unresponsive to painful stimuli.", "3. His pulse was 120/min.", "4. His respirations were 10/min.", "5. His blood pressure was 88/60 mm Hg.", "6. 0.9% saline was infused.", "7. Intubation was attempted without success.", "8. Pulse oximetry on 20 L/min of oxygen via bag mask showed an oxygen saturation of 78%." ]

[ "1. On arrival, the patient is unconscious.", "2. On arrival, the patient is unresponsive to painful stimuli.", "3. The patient's pulse is 120/min.", "4. The patient's respirations are 10/min.", "5. The patient's blood pressure is 88/60 mm Hg.", "6. Infusion of 0.9% saline is begun.", "7. Intubation is attempted without success.", "8. Pulse oximetry on 20 L/min of oxygen via bag mask shows an oxygen saturation of 78%." ]

[ "Parents bring an 11-month-old baby to the clinic because the baby has a fever of 39.0°C (102.2°F).", "The baby is irritated and crying constantly.", "She is up to date on immunizations.", "A complete physical examination reveals no significant findings, and all laboratory tests are negative.", "Five days after resolution of her fever, she develops a transient maculopapular rash." ]

[ "1. Parents bring an 11-month-old baby to the clinic.", "2. The baby has a fever of 39.0°C (102.2°F).", "3. The baby is irritated and crying constantly.", "4. The baby is up to date on immunizations.", "5. A complete physical examination reveals no significant findings.", "6. All laboratory tests are negative.", "7. Five days after resolution of her fever, she develops a transient maculopapular rash." ]

[ "1. The baby is irritated.", "2. The baby is crying constantly.", "3. She is up to date on immunizations.", "4. A complete physical examination reveals no significant findings.", "5. All laboratory tests are negative.", "6. Five days after resolution of her fever, she develops a transient maculopapular rash." ]

[ "A 67-year-old man is brought to his primary care practitioner by his daughter who has noticed a ‘pill-rolling’ tremor in his right hand, along with a progressively slow, shuffling gait.", "The patient’s daughter says that these symptoms gradually started 2 weeks ago and have progressively worsened.", "His past medical history is significant for hypertension, which is well-controlled with losartan.", "He does not take any other medications.", "Physical examination reveals a slow shuffling gait, difficulty initiating movements, a resting tremor in his right hand that decreases in intensity with voluntary movement, and cogwheel-like rigidity in the right arm.", "The primary care practitioner decides to prescribe levodopa and carbidopa." ]

[ "1. Patient is 67 years old.", "2. Patient's daughter noticed a \"pill-rolling\" tremor in his right hand.", "3. Patient's daughter noticed a progressively slow, shuffling gait.", "4. Symptoms gradually started 2 weeks ago and have progressively worsened.", "5. Patient has a past medical history of hypertension.", "6. Hypertension is well-controlled with losartan.", "7. Patient does not take any other medications.", "8. Physical examination reveals a slow shuffling gait.", "9. Physical examination reveals difficulty initiating movements.", "10. Physical examination reveals a resting tremor in his right hand that decreases in intensity with voluntary movement.", "11. Physical examination reveals cogwheel-like rigidity in the right arm.", "12. Primary care practitioner decides to prescribe levodopa and carbidopa." ]

[ "1. The patient's daughter reports that symptoms started 2 weeks ago and have worsened.", "2. The patient has a past medical history of hypertension.", "3. The hypertension is well-controlled with losartan.", "4. The patient does not take any other medications.", "5. Physical examination reveals a slow shuffling gait.", "6. Physical examination reveals difficulty initiating movements.", "7. Physical examination reveals a resting tremor in the right hand.", "8. The tremor decreases in intensity with voluntary movement.", "9. Physical examination reveals cogwheel-like rigidity in the right arm.", "10. The primary care practitioner decides to prescribe levodopa and carbidopa." ]

[ "A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body.", "Neurologic exam shows normal sensation throughout the body.", "MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel." ]

[ "1. Patient is 79 years old.", "2. Patient has a long-standing history of hypertension and diabetes.", "3. Patient presents to the emergency department with sudden-onset of loss of motor function on the left side of his body.", "4. Neurologic exam shows normal sensation throughout the body.", "5. MRI of the brain is obtained.", "6. MRI of the brain shows a small sub-cortical infarct involving a perforating vessel." ]

[ "1. Neurologic exam shows normal sensation throughout the body.", "2. MRI of the brain is obtained.", "3. MRI shows a small sub-cortical infarct.", "4. The infarct involves a perforating vessel." ]

[ "A cardiology specialist working in the university hospital center noticed that a large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history.", "In order to determine whether a relationship existed between myocardial infarction and malignant processes, he decided to pursue a case-control study.", "His selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction, while control cases were patients on the same ward without a history of a myocardial infarction.", "Their charts and medical documentation were then reviewed for a history of any type of malignancy.", "The results of the study led the cardiologist to conclude that, for patients with malignancy, the odds of having a myocardial infarction were 3.2 times higher when compared to patients without malignancy." ]

[ "1. A cardiology specialist was working in the university hospital center.", "2. A large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history.", "3. He decided to pursue a case-control study to determine whether a relationship existed between myocardial infarction and malignant processes.", "4. The selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction.", "5. The control cases were patients on the same ward without a history of a myocardial infarction.", "6. Their charts and medical documentation were then reviewed for a history of any type of malignancy.", "7. The results of the study led the cardiologist to conclude that, for patients with malignancy, the odds of having a myocardial infarction were 3.2 times higher when compared to patients without malignancy." ]

[ "1. The cardiologist pursued a case-control study to determine the relationship between myocardial infarction and malignant processes.", "2. The selected cases for the study were patients hospitalized in an internal ward with a history of myocardial infarction.", "3. The control cases for the study were patients on the same ward without a history of myocardial infarction.", "4. Charts and medical documentation of the patients were reviewed for a history of any type of malignancy.", "5. The study results showed that the odds of having a myocardial infarction were 3.2 times higher for patients with malignancy compared to patients without malignancy." ]

[ "A 27-year-old woman presents to her primary care physician’s office with fatigue, headaches, and concentration difficulties.", "Her symptoms began approximately 7 months prior to presentation.", "Throughout this time, she reports problems with initiating and remaining asleep, has noticed periods of muscle soreness, and has feelings of restlessness.", "She states that she is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices.", "She is also worried about how her colleagues and supervisor think of her performance at work.", "She denies any significant past medical history besides occasional palpitations.", "She takes a daily multivitamin.", "Family history is significant for panic disorder in her mother.", "She currently lives alone and at times socializes with friends.", "She occasionally drinks alcohol during social gatherings, does not smoke, and denies any illicit drug use.", "Her temperature is 99°F (37.2 °C), blood pressure is 110/75, pulse is 101/min, and respirations are 18/min.", "Physical examination is unremarkable." ]

[ "1. A 27-year-old woman presents to her primary care physician's office.", "2. She has fatigue, headaches, and concentration difficulties.", "3. Her symptoms began approximately 7 months prior to presentation.", "4. She reports problems with initiating and remaining asleep.", "5. She has noticed periods of muscle soreness and has feelings of restlessness.", "6. She is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices.", "7. She is also worried about how her colleagues and supervisor think of her performance at work.", "8. She denies any significant past medical history besides occasional palpitations.", "9. She takes a daily multivitamin.", "10. Family history is significant for panic disorder in her mother.", "11. She currently lives alone and at times socializes with friends.", "12. She occasionally drinks alcohol during social gatherings.", "13. She does not smoke and denies any illicit drug use.", "14. Her temperature is 99°F (37.2 °C).", "15. Her blood pressure is 110/75.", "16. Her pulse is 101/min.", "17. Her respirations are 18/min.", "18. Physical examination is unremarkable." ]

[ "1. Her symptoms began approximately 7 months prior to presentation.", "2. She reports problems with initiating and remaining asleep.", "3. She has noticed periods of muscle soreness.", "4. She has feelings of restlessness.", "5. She is very concerned about whether she will be able to pay her monthly expenses.", "6. She is concerned about if her parents are satisfied with her career choices.", "7. She is worried about how her colleagues and supervisor think of her performance at work.", "8. She denies any significant past medical history besides occasional palpitations.", "9. She takes a daily multivitamin.", "10. Family history is significant for panic disorder in her mother.", "11. She currently lives alone and at times socializes with friends.", "12. She occasionally drinks alcohol during social gatherings.", "13. She does not smoke.", "14. She denies any illicit drug use.", "15. Her temperature is 99°F (37.2 °C).", "16. Her blood pressure is 110/75.", "17. Her pulse is 101/min.", "18. Her respirations are 18/min.", "19. Physical examination is unremarkable." ]

[ "A 73-year-old man comes in to the emergency department because of nausea and severe pain in his upper abdomen and right shoulder blade for the past day.", "He was able to eat a little for breakfast but vomited up the meal a couple of hours later.", "He has type 2 diabetes mellitus treated with metformin.", "He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week.", "He appears acutely distressed.", "His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 95%.", "The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus.", "The remainder of the examination shows no abnormalities.", "Laboratory studies show: | Hemoglobin 14.3 g/dL | Leukocyte count 18,100/mm3 | Platelet count 216,000/mm3 | Serum | Aspartate aminotransferase (AST, SGOT) 41 U/L | Alanine aminotransferase (ALT, SGPT) 19 U/L | Alkaline phosphatase 110 U/L | Total bilirubin 0.9 mg/dL | Direct bilirubin 0.2 mg/dL | Albumin 4.1 g/dL | Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen." ]

[ "1. A 73-year-old man comes in to the emergency department.", "2. He has nausea and severe pain in his upper abdomen and right shoulder blade for the past day.", "3. He was able to eat a little for breakfast but vomited up the meal a couple of hours later.", "4. He has type 2 diabetes mellitus treated with metformin.", "5. He has smoked half a pack of cigarettes daily for 40 years.", "6. He drinks 4 beers every week.", "7. He appears acutely distressed.", "8. His temperature is 38.8°C (102°F).", "9. His pulse is 124/min.", "10. His blood pressure is 92/68 mm Hg.", "11. Pulse oximetry on room air shows an oxygen saturation of 95%.", "12. The abdomen is soft.", "13. There is tenderness to palpation of the right upper quadrant with soft crepitus.", "14. The remainder of the examination shows no abnormalities.", "15. Laboratory studies show a hemoglobin of 14.3 g/dL.", "16. Laboratory studies show a leukocyte count of 18,100/mm3.", "17. Laboratory studies show a platelet count of 216,000/mm3.", "18. Laboratory studies show an aspartate aminotransferase (AST, SGOT) of 41 U/L.", "19. Laboratory studies show an alanine aminotransferase (ALT, SGPT) of 19 U/L.", "20. Laboratory studies show an alkaline phosphatase of 110 U/L.", "21. Laboratory studies show a total bilirubin of 0.9 mg/dL.", "22. Laboratory studies show a direct bilirubin of 0.2 mg/dL.", "23. Laboratory studies show an albumin of 4.1 g/dL.", "24. Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen." ]

[ "1. He was able to eat a little for breakfast but vomited up the meal a couple of hours later.", "2. He has type 2 diabetes mellitus treated with metformin.", "3. He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week.", "4. He appears acutely distressed.", "5. His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg.", "6. Pulse oximetry on room air shows an oxygen saturation of 95%.", "7. The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus.", "8. The remainder of the examination shows no abnormalities.", "9. Laboratory studies show: Hemoglobin 14.3 g/dL, Leukocyte count 18,100/mm3, Platelet count 216,000/mm3, Serum Aspartate aminotransferase (AST, SGOT) 41 U/L, Alanine aminotransferase (ALT, SGPT) 19 U/L, Alkaline phosphatase 110 U/L, Total bilirubin 0.9 mg/dL, Direct bilirubin 0.2 mg/dL, Albumin 4.1 g/dL.", "10. Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen." ]

[ "A 26-year-old man presented with a headache and fatigue for the past few months.", "On presentation to the clinic, the blood pressure is 190/110 mm Hg; the femoral pulse is reduced compared to the radial pulse, and an ejection click is heard.", "There was no murmur." ]

[ "1. A 26-year-old man presented with a headache and fatigue for the past few months.", "2. On presentation to the clinic, the blood pressure is 190/110 mm Hg.", "3. The femoral pulse is reduced compared to the radial pulse.", "4. An ejection click is heard.", "5. There was no murmur." ]

[ "1. Blood pressure on presentation to the clinic is 190/110 mm Hg.", "2. The femoral pulse is reduced compared to the radial pulse.", "3. An ejection click is heard.", "4. There was no murmur." ]

[ "A 57-year-old man with a history of diabetes and stage 3 chronic kidney disease is admitted to the hospital for elective coronary angiography.", "The senior resident admitting the patient to the ward is concerned about his chronic renal impairment and the scheduled angiography, which will require the use of intravenous contrast." ]

[ "1. A 57-year-old man has a history of diabetes.", "2. The man has stage 3 chronic kidney disease.", "3. The man is admitted to the hospital for elective coronary angiography.", "4. The senior resident admitting the patient is concerned about the man's chronic renal impairment.", "5. The scheduled angiography will require the use of intravenous contrast." ]

[ "1. The senior resident is admitting the patient to the ward.", "2. The patient has chronic renal impairment.", "3. The patient is scheduled for an angiography.", "4. The angiography will require the use of intravenous contrast." ]

[ "A 17-year-old girl is brought in a wheelchair because of gradually progressive difficulty in walking, incoordination, and frequent falls.", "Her symptoms started at 9 years old with clumsiness while walking.", "She later experienced difficulties with coordination, which later involved her arms and trunk.", "She was born at term with normal developmental milestones.", "The physical examination reveals severely ataxic gait, nystagmus, absent deep tendon reflexes, and loss of vibration and proprioception." ]

[ "1. A 17-year-old girl is brought in a wheelchair.", "2. She has gradually progressive difficulty in walking, incoordination, and frequent falls.", "3. Her symptoms started at 9 years old with clumsiness while walking.", "4. Her difficulties with coordination later involved her arms and trunk.", "5. She was born at term with normal developmental milestones.", "6. The physical examination reveals severely ataxic gait.", "7. The physical examination reveals nystagmus.", "8. The physical examination reveals absent deep tendon reflexes.", "9. The physical examination reveals loss of vibration and proprioception." ]

[ "1. Her symptoms started at 9 years old with clumsiness while walking.", "2. She later experienced difficulties with coordination.", "3. The difficulties with coordination later involved her arms and trunk.", "4. She was born at term.", "5. She had normal developmental milestones.", "6. The physical examination reveals severely ataxic gait.", "7. The physical examination reveals nystagmus.", "8. The physical examination reveals absent deep tendon reflexes.", "9. The physical examination reveals loss of vibration and proprioception." ]

[ "A previously healthy 51-year-old man is brought to the emergency department because of confusion for 2 hours.", "His wife reports that he fell and hit his head while changing a ceiling light the previous evening.", "On arrival, he is unconscious.", "His temperature is 37.1°C (98.8°F), pulse is 54/min, respirations are 8/min and irregular, and blood pressure is 198/106 mm Hg.", "The right pupil is dilated and fixed; the left pupil is round and reactive to light.", "There is extension of the extremities to painful stimuli.", "He is intubated and mechanically ventilated.", "A mannitol infusion is begun.", "A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe." ]

[ "1. A 51-year-old man is brought to the emergency department because of confusion for 2 hours.", "2. His wife reports that he fell and hit his head while changing a ceiling light the previous evening.", "3. On arrival, he is unconscious.", "4. His temperature is 37.1°C (98.8°F).", "5. His pulse is 54/min.", "6. His respirations are 8/min and irregular.", "7. His blood pressure is 198/106 mm Hg.", "8. The right pupil is dilated and fixed.", "9. The left pupil is round and reactive to light.", "10. There is extension of the extremities to painful stimuli.", "11. He is intubated and mechanically ventilated.", "12. A mannitol infusion is begun.", "13. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe." ]

[ "1. His wife reports that he fell and hit his head while changing a ceiling light the previous evening.", "2. On arrival, he is unconscious.", "3. His temperature is 37.1°C (98.8°F).", "4. His pulse is 54/min.", "5. His respirations are 8/min and irregular.", "6. His blood pressure is 198/106 mm Hg.", "7. The right pupil is dilated and fixed.", "8. The left pupil is round and reactive to light.", "9. There is extension of the extremities to painful stimuli.", "10. He is intubated and mechanically ventilated.", "11. A mannitol infusion is begun.", "12. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe." ]

[ "A 1-year-old female presents to the emergency department with 2 days of fever up to 103ºF.", "During the course of her work-up, a urine culture reveals gram negative rods and a urinary tract infection (UTI) is diagnosed.", "She is placed on ceftriaxone and quickly defervesces.", "Follow-up of the urine culture reveals the causal bacteria was E.", "coli, without any concerning resistance patterns and was susceptible to ceftriaxone.", "This is her first UTI and there is no family history of renal abnormalities or vesicourethral reflux." ]

[ "1. A 1-year-old female presents to the emergency department.", "2. She has 2 days of fever up to 103ºF.", "3. A urine culture reveals gram negative rods.", "4. A UTI is diagnosed.", "5. She is placed on ceftriaxone.", "6. She quickly defervesces.", "7. Follow-up of the urine culture reveals the causal bacteria was E. coli.", "8. There are no concerning resistance patterns.", "9. The bacteria is susceptible to ceftriaxone.", "10. This is her first UTI.", "11. There is no family history of renal abnormalities.", "12. There is no family history of vesicourethral reflux." ]

[ "1. Urine culture reveals gram negative rods", "2. Urinary tract infection (UTI) is diagnosed", "3. Patient is placed on ceftriaxone", "4. Patient quickly defervesces", "5. Causal bacteria in urine culture was E. coli", "6. No concerning resistance patterns found in bacteria", "7. Bacteria was susceptible to ceftriaxone", "8. Patient's first UTI", "9. No family history of renal abnormalities", "10. No family history of vesicourethral reflux" ]

[ "A 22-year-old woman presents to her primary care physician because she has been having severe pruritus on her left leg.", "She says the symptoms started 1 week ago after she went on a hiking trip with her friends.", "She wore shorts during the hike and felt as if something brushed her skin on the front of her leg just below the knee.", "She has no past medical history and no family history of autoimmune diseases.", "On physical exam, she has red pruritic papules and vesicles on her left leg." ]

[ "1. A 22-year-old woman presents to her primary care physician.", "2. She has been having severe pruritus on her left leg.", "3. The symptoms started 1 week ago.", "4. She went on a hiking trip with her friends.", "5. She wore shorts during the hike.", "6. She felt as if something brushed her skin on the front of her leg just below the knee.", "7. She has no past medical history.", "8. She has no family history of autoimmune diseases.", "9. On physical exam, she has red pruritic papules and vesicles on her left leg." ]

[ "1. The symptoms started 1 week ago.", "2. The symptoms started after a hiking trip with friends.", "3. She wore shorts during the hike.", "4. She felt something brush her skin on the front of her leg just below the knee.", "5. She has no past medical history.", "6. She has no family history of autoimmune diseases.", "7. On physical exam, she has red pruritic papules and vesicles on her left leg." ]

[ "An adopted 7-year-old boy is brought to a pediatrician with a history of progressive muscular weakness, intellectual impairment, and speech problems.", "The adoptive parents say that the patient was normal at birth, but as he grew older, his muscular weakness increased.", "Physical examination reveals the wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs.", "Thenar and hypothenar eminences are also flattened.", "However, deep tendon reflexes are 2+ bilaterally.", "His face has an atypical appearance with thin cheeks and temporal wasting.", "When he was asked to make a tight fist and open his hands quickly, he could not open them immediately, and relaxation of the contracted muscles was very slow.", "The pediatrician suspects genetic muscular dystrophy." ]

[ "1. An adopted 7-year-old boy is brought to a pediatrician.", "2. The patient has a history of progressive muscular weakness, intellectual impairment, and speech problems.", "3. The adoptive parents say the patient was normal at birth.", "4. As the patient grew older, his muscular weakness increased.", "5. Physical examination reveals wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs.", "6. Thenar and hypothenar eminences are flattened.", "7. Deep tendon reflexes are 2+ bilaterally.", "8. The patient's face has an atypical appearance with thin cheeks and temporal wasting.", "9. When asked to make a tight fist and open his hands quickly, the patient could not open them immediately.", "10. Relaxation of the contracted muscles was very slow.", "11. The pediatrician suspects genetic muscular dystrophy." ]

[ "1. The adoptive parents say the patient was normal at birth.", "2. The patient's muscular weakness increased as he grew older.", "3. Physical examination reveals wasting of muscles in the dorsal forearm and anterior compartment of the lower legs.", "4. The thenar and hypothenar eminences are flattened.", "5. Deep tendon reflexes are 2+ bilaterally.", "6. The patient's face has an atypical appearance with thin cheeks and temporal wasting.", "7. When asked to make a tight fist and open his hands quickly, the patient could not open them immediately, and relaxation of the contracted muscles was very slow.", "8. The pediatrician suspects genetic muscular dystrophy." ]

[ "A 36-year-old woman presents to her primary care physician for her yearly physical exam.", "She says that she has been experiencing some mild shortness of breath, but otherwise has no medical complaints.", "Her past medical history is significant for allergies and asthma as a child, but she is not currently taking any medications or supplements.", "She does not smoke and drinks about 2 glasses of wine per week as a social activity.", "On physical exam she is asked to take deep breaths during cardiac auscultation.", "The physician notices that the splitting of S2 decreases during inspiration." ]

[ "1. A 36-year-old woman presents to her primary care physician for her yearly physical exam.", "2. She says that she has been experiencing some mild shortness of breath.", "3. She has no other medical complaints.", "4. Her past medical history is significant for allergies and asthma as a child.", "5. She is not currently taking any medications or supplements.", "6. She does not smoke.", "7. She drinks about 2 glasses of wine per week as a social activity.", "8. On physical exam she is asked to take deep breaths during cardiac auscultation.", "9. The physician notices that the splitting of S2 decreases during inspiration." ]

[ "1. The patient has been experiencing mild shortness of breath.", "2. The patient has no other medical complaints.", "3. The patient had allergies and asthma as a child.", "4. The patient is not currently taking any medications or supplements.", "5. The patient does not smoke.", "6. The patient drinks about 2 glasses of wine per week as a social activity.", "7. During the physical exam, the patient is asked to take deep breaths during cardiac auscultation.", "8. The physician notices that the splitting of S2 decreases during inspiration." ]

[ "A 47-year-old woman presents to the emergency department with calf pain and swelling that has persisted for the past 24 hours.", "She recently had an elective cholecystectomy performed 3 days ago that was complicated intraoperatively by bleeding requiring a transfusion of 1 unit of packed red blood cells.", "The patient is otherwise healthy, and her vitals are within normal limits.", "Physical exam is notable for an enlarged and tender right calf.", "Ultrasound with doppler reveals non-compressible veins of the affected leg." ]

[ "1. A 47-year-old woman presents to the emergency department.", "2. She has calf pain and swelling that has persisted for the past 24 hours.", "3. She recently had an elective cholecystectomy performed 3 days ago.", "4. The cholecystectomy was complicated intraoperatively by bleeding.", "5. The bleeding required a transfusion of 1 unit of packed red blood cells.", "6. The patient is otherwise healthy.", "7. Her vitals are within normal limits.", "8. Physical exam is notable for an enlarged and tender right calf.", "9. Ultrasound with doppler reveals non-compressible veins of the affected leg." ]

[ "1. Elective cholecystectomy performed 3 days ago", "2. Complicated intraoperatively by bleeding", "3. Required transfusion of 1 unit of packed red blood cells", "4. Patient is otherwise healthy", "5. Vitals are within normal limits", "6. Physical exam notable for an enlarged and tender right calf", "7. Ultrasound with doppler reveals non-compressible veins of the affected leg" ]

[ "A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation with a headache and blurred vision.", "The vital signs are as follows: blood pressure, 170/95 mm Hg; heart rate, 88/min; respiratory rate, 15/min; and temperature, 36.6℃ (97.9℉).", "The physical examination is significant for pitting edema of the lower extremity.", "Meningeal signs are negative.", "The ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate.", "The dipstick test shows 1+ proteinuria.", "While the blood is being drawn, the patient has a generalized tonic-clonic seizure." ]

[ "1. A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation.", "2. The patient has a headache and blurred vision.", "3. The patient's blood pressure is 170/95 mm Hg.", "4. The patient's heart rate is 88/min.", "5. The patient's respiratory rate is 15/min.", "6. The patient's temperature is 36.6℃ (97.9℉).", "7. The physical examination is significant for pitting edema of the lower extremity.", "8. Meningeal signs are negative.", "9. The ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate.", "10. The dipstick test shows 1+ proteinuria.", "11. The patient has a generalized tonic-clonic seizure while the blood is being drawn." ]

[ "1. Blood pressure: 170/95 mm Hg", "2. Heart rate: 88/min", "3. Respiratory rate: 15/min", "4. Temperature: 36.6℃ (97.9℉)", "5. Physical examination significant for pitting edema of the lower extremity", "6. Meningeal signs are negative", "7. Ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate", "8. Dipstick test shows 1+ proteinuria", "9. Patient has a generalized tonic-clonic seizure while blood is being drawn" ]

[ "A 12-month-old girl is brought in by her mother to the pediatrician for the first time since her 6-month checkup.", "The mother states that her daughter had been doing fine, but the parents are now concerned that their daughter is still not able to stand up or speak.", "On exam, the patient has a temperature of 98.5°F (36.9°C), pulse is 96/min, respirations are 20/min, and blood pressure is 100/80 mmHg.", "The child appears to have difficulty supporting herself while sitting.", "The patient has no other abnormal physical findings.", "She plays by herself and is making babbling noises but does not respond to her own name.", "She appears to have some purposeless motions.", "A previous clinic note documents typical development at her 6-month visit and mentioned that the patient was sitting unsupported at that time." ]

[ "1. A 12-month-old girl is brought in by her mother to the pediatrician.", "2. The mother states that her daughter had been doing fine.", "3. The parents are now concerned that their daughter is still not able to stand up or speak.", "4. The patient has a temperature of 98.5°F (36.9°C).", "5. The patient's pulse is 96/min.", "6. The patient's respirations are 20/min.", "7. The patient's blood pressure is 100/80 mmHg.", "8. The child appears to have difficulty supporting herself while sitting.", "9. The patient has no other abnormal physical findings.", "10. She plays by herself and is making babbling noises.", "11. The patient does not respond to her own name.", "12. She appears to have some purposeless motions.", "13. A previous clinic note documents typical development at her 6-month visit.", "14. The patient was sitting unsupported at her 6-month visit." ]

[ "1. The mother states that her daughter had been doing fine.", "2. The parents are concerned that their daughter is still not able to stand up or speak.", "3. On exam, the patient has a temperature of 98.5°F (36.9°C).", "4. The patient's pulse is 96/min.", "5. The patient's respirations are 20/min.", "6. The patient's blood pressure is 100/80 mmHg.", "7. The child appears to have difficulty supporting herself while sitting.", "8. The patient has no other abnormal physical findings.", "9. She plays by herself and is making babbling noises but does not respond to her own name.", "10. She appears to have some purposeless motions.", "11. A previous clinic note documents typical development at her 6-month visit.", "12. The patient was sitting unsupported at that time." ]

[ "A 55-year-old man comes to the emergency department because of cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours.", "He has no history of serious illness and takes no medications.", "He drinks 2–3 alcoholic beverages daily.", "His temperature is 37.2°C (99.0°F), pulse is 107/min, and blood pressure is 145/80 mm Hg.", "Examination of the back shows left costovertebral angle tenderness.", "An x-ray of the abdomen shows no abnormalities.", "Abdominal ultrasound shows a 4-mm stone in the distal left ureter and a scatter of small stones in the left renal pelvis.", "Urinalysis shows RBCs and needle-shaped crystals, but no WBCs.", "Pain medication and intravenous fluids are administered." ]

[ "1. A 55-year-old man comes to the emergency department.", "2. He has cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours.", "3. He has no history of serious illness and takes no medications.", "4. He drinks 2–3 alcoholic beverages daily.", "5. His temperature is 37.2°C (99.0°F).", "6. His pulse is 107/min.", "7. His blood pressure is 145/80 mm Hg.", "8. Examination of the back shows left costovertebral angle tenderness.", "9. An x-ray of the abdomen shows no abnormalities.", "10. Abdominal ultrasound shows a 4-mm stone in the distal left ureter.", "11. Abdominal ultrasound shows a scatter of small stones in the left renal pelvis.", "12. Urinalysis shows RBCs and needle-shaped crystals, but no WBCs.", "13. Pain medication and intravenous fluids are administered." ]

[ "1. He has no history of serious illness and takes no medications.", "2. He drinks 2–3 alcoholic beverages daily.", "3. His temperature is 37.2°C (99.0°F).", "4. His pulse is 107/min.", "5. His blood pressure is 145/80 mm Hg.", "6. Examination of the back shows left costovertebral angle tenderness.", "7. An x-ray of the abdomen shows no abnormalities.", "8. Abdominal ultrasound shows a 4-mm stone in the distal left ureter and a scatter of small stones in the left renal pelvis.", "9. Urinalysis shows RBCs and needle-shaped crystals, but no WBCs.", "10. Pain medication and intravenous fluids are administered." ]

[ "A 4-year-old boy is brought to the physician because of a 1-month history of generalized fatigue.", "During the past week, he has also had fever and severe leg pain that keeps him awake at night.", "Examination shows cervical and axillary lymphadenopathy.", "His liver is palpated 4 cm below the right costal margin and the spleen is palpated 3 cm below the left costal margin.", "His hemoglobin concentration is 10.2 g/dL, leukocyte count is 64,500/mm3, and platelet count is 29,000/mm3.", "A bone marrow aspirate predominantly shows immature cells that stain positive for CD10, CD19, and TdT." ]

[ "1. A 4-year-old boy is brought to the physician.", "2. He has a 1-month history of generalized fatigue.", "3. During the past week, he has had fever and severe leg pain.", "4. The leg pain keeps him awake at night.", "5. Examination shows cervical and axillary lymphadenopathy.", "6. His liver is palpated 4 cm below the right costal margin.", "7. His spleen is palpated 3 cm below the left costal margin.", "8. His hemoglobin concentration is 10.2 g/dL.", "9. His leukocyte count is 64,500/mm3.", "10. His platelet count is 29,000/mm3.", "11. A bone marrow aspirate predominantly shows immature cells.", "12. The immature cells stain positive for CD10.", "13. The immature cells stain positive for CD19.", "14. The immature cells stain positive for TdT." ]

[ "1. He has had fever during the past week.", "2. He has had severe leg pain that keeps him awake at night.", "3. Examination shows cervical lymphadenopathy.", "4. Examination shows axillary lymphadenopathy.", "5. His liver is palpated 4 cm below the right costal margin.", "6. His spleen is palpated 3 cm below the left costal margin.", "7. His hemoglobin concentration is 10.2 g/dL.", "8. His leukocyte count is 64,500/mm3.", "9. His platelet count is 29,000/mm3.", "10. A bone marrow aspirate predominantly shows immature cells.", "11. The immature cells stain positive for CD10.", "12. The immature cells stain positive for CD19.", "13. The immature cells stain positive for TdT." ]

[ "A 41-year-old man comes to the physician because of a 10-day history of generalized weakness.", "He has also had headaches and night sweats and is a known user of illicit intravenous drugs.", "His temperature is 39.1°C (102.4°F), pulse is 110/min, respirations are 17/min, and blood pressure is 127/78 mm Hg.", "There are several track marks on his forearms.", "A holosystolic murmur that increases on inspiration is heard along the left sternal border.", "Laboratory studies show a leukocyte count of 13,900/mm3 and an erythrocyte sedimentation rate of 58 mm/h." ]

[ "1. A 41-year-old man comes to the physician.", "2. He has a 10-day history of generalized weakness.", "3. He has also had headaches and night sweats.", "4. He is a known user of illicit intravenous drugs.", "5. His temperature is 39.1°C (102.4°F).", "6. His pulse is 110/min.", "7. His respirations are 17/min.", "8. His blood pressure is 127/78 mm Hg.", "9. There are several track marks on his forearms.", "10. A holosystolic murmur that increases on inspiration is heard along the left sternal border.", "11. Laboratory studies show a leukocyte count of 13,900/mm3.", "12. Laboratory studies show an erythrocyte sedimentation rate of 58 mm/h." ]

[ "1. He has had headaches.", "2. He has had night sweats.", "3. He is a known user of illicit intravenous drugs.", "4. His temperature is 39.1°C (102.4°F).", "5. His pulse is 110/min.", "6. His respirations are 17/min.", "7. His blood pressure is 127/78 mm Hg.", "8. There are several track marks on his forearms.", "9. A holosystolic murmur is heard along the left sternal border.", "10. The murmur increases on inspiration.", "11. Laboratory studies show a leukocyte count of 13,900/mm3.", "12. Laboratory studies show an erythrocyte sedimentation rate of 58 mm/h." ]

[ "A 17-year-old girl presents to the emergency department with a painful rash on her head.", "She says that she started noticing a rash 2 weeks ago that has gotten worse over time.", "In addition, she says that she has been very thirsty over the same time period and often needs to urgently use the restroom during the day, which has been disrupting her ability to pay attention in school.", "Otherwise she says that she has some headaches, but attributes this to migraines that run in her family.", "She does not take any medications, doesn't smoke, and drinks socially with her friends.", "On physical exam, a disfiguring red scalp rash is observed and radiographs reveal lytic appearing skull lesions." ]

[ "1. Patient is a 17-year-old female.", "2. Patient presents to the emergency department with a painful rash on her head.", "3. Patient started noticing the rash 2 weeks ago.", "4. Rash has gotten worse over time.", "5. Patient has been very thirsty over the same time period.", "6. Patient often needs to urgently use the restroom during the day.", "7. Patient's need to use the restroom has been disrupting her ability to pay attention in school.", "8. Patient has some headaches, which she attributes to migraines that run in her family.", "9. Patient does not take any medications.", "10. Patient does not smoke.", "11. Patient drinks socially with her friends.", "12. On physical exam, a disfiguring red scalp rash is observed.", "13. Radiographs reveal lytic appearing skull lesions." ]

[ "1. The patient started noticing a rash 2 weeks ago.", "2. The rash has gotten worse over time.", "3. The patient has been very thirsty over the same time period.", "4. The patient often needs to urgently use the restroom during the day.", "5. The restroom urgency has been disrupting her ability to pay attention in school.", "6. The patient has some headaches.", "7. The patient attributes the headaches to migraines that run in her family.", "8. The patient does not take any medications.", "9. The patient doesn't smoke.", "10. The patient drinks socially with her friends.", "11. On physical exam, a disfiguring red scalp rash is observed.", "12. Radiographs reveal lytic appearing skull lesions." ]

[ "A 57-year-old man presents to the emergency department with a change in his mental status.", "His wife noticed he was particularly somnolent this evening which prompted her to bring him in.", "The patient has a past medical history of congestive heart failure, diabetes, and hypertension.", "His temperature is 99.5°F (37.5°C), blood pressure is 97/58 mmHg, pulse is 40/min, respirations are 17/min, and oxygen saturation is 95% on room air.", "A fingerstick blood glucose is notable for a value of 47 mg/dL." ]

[ "1. A 57-year-old man presents to the emergency department.", "2. His wife noticed he was particularly somnolent this evening.", "3. His past medical history includes congestive heart failure, diabetes, and hypertension.", "4. His temperature is 99.5°F (37.5°C).", "5. His blood pressure is 97/58 mmHg.", "6. His pulse is 40/min.", "7. His respirations are 17/min.", "8. His oxygen saturation is 95% on room air.", "9. A fingerstick blood glucose is notable for a value of 47 mg/dL." ]

[ "1. The patient's wife noticed he was particularly somnolent this evening.", "2. The patient has a past medical history of congestive heart failure, diabetes, and hypertension.", "3. The patient's temperature is 99.5°F (37.5°C).", "4. The patient's blood pressure is 97/58 mmHg.", "5. The patient's pulse is 40/min.", "6. The patient's respirations are 17/min.", "7. The patient's oxygen saturation is 95% on room air.", "8. A fingerstick blood glucose is notable for a value of 47 mg/dL." ]

[ "A 16-year-old boy comes to his primary care clinic for a sports physical.", "He states that he wants to try out for his high school’s football team this year.", "He's \"trying to get in better shape.” The patient has no complaints except for occasional headaches when he is stressed about exams.", "The patient also mentions that he is embarrassed of his “small penis” and asks if there is something he can take for that.", "The patient’s temperature is 98°F (36.7°C), blood pressure is 118/76 mmHg, and pulse is 79/min.", "On physical examination, the patient is obese and has no visible facial hair.", "His testes are less than 20 mL in volume, and his phallus measures less than 8 cm.", "Initial labs show testosterone levels of 95 ng/dL and a low follicle stimulating hormone/luteinizing hormone ratio." ]

[ "1. A 16-year-old boy comes to his primary care clinic for a sports physical.", "2. He states that he wants to try out for his high school’s football team this year.", "3. He's \"trying to get in better shape.”", "4. The patient has no complaints except for occasional headaches when he is stressed about exams.", "5. The patient also mentions that he is embarrassed of his “small penis” and asks if there is something he can take for that.", "6. The patient’s temperature is 98°F (36.7°C).", "7. The patient’s blood pressure is 118/76 mmHg.", "8. The patient’s pulse is 79/min.", "9. On physical examination, the patient is obese and has no visible facial hair.", "10. His testes are less than 20 mL in volume.", "11. His phallus measures less than 8 cm.", "12. Initial labs show testosterone levels of 95 ng/dL.", "13. Initial labs show a low follicle stimulating hormone/luteinizing hormone ratio." ]

[ "1. The patient wants to try out for his high school’s football team this year.", "2. He is \"trying to get in better shape.”", "3. The patient has occasional headaches when stressed about exams.", "4. The patient is embarrassed about his “small penis” and asks if there is something he can take for that.", "5. The patient’s temperature is 98°F (36.7°C), blood pressure is 118/76 mmHg, and pulse is 79/min.", "6. On physical examination, the patient is obese and has no visible facial hair.", "7. His testes are less than 20 mL in volume.", "8. His phallus measures less than 8 cm.", "9. Initial labs show testosterone levels of 95 ng/dL.", "10. The patient has a low follicle stimulating hormone/luteinizing hormone ratio." ]

[ "A 72-year-old man presents to the hospital with retrosternal chest pain and shortness of breath.", "The pain started 5 hours prior to arrival and has not changed after sublingual nitroglycerin intake.", "The patient has a history of long-standing persistent atrial fibrillation but had not been taking anticoagulants at the time of presentation.", "He had also been diagnosed with iron-deficiency anemia 3 months before admission and is taking 120 mg of elemental iron daily.", "He has no history of ischemic heart disease.", "Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery.", "The patient is managed with percutaneous coronary intervention (PCI).", "Six hours after the PCI, the patient develops cardiogenic shock; 8 hours after presentation, he dies, despite intensive care management.", "The autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.", "The microscopic image depicts a macroscopically intact myocardium." ]

[ "1. Patient is 72 years old.", "2. Patient presents with retrosternal chest pain and shortness of breath.", "3. Pain started 5 hours prior to arrival.", "4. Pain has not changed after sublingual nitroglycerin intake.", "5. Patient has a history of long-standing persistent atrial fibrillation.", "6. Patient was not taking anticoagulants at the time of presentation.", "7. Patient had been diagnosed with iron-deficiency anemia 3 months before admission.", "8. Patient is taking 120 mg of elemental iron daily.", "9. Patient has no history of ischemic heart disease.", "10. Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery.", "11. Patient is managed with percutaneous coronary intervention (PCI).", "12. Six hours after the PCI, the patient develops cardiogenic shock.", "13. 8 hours after presentation, patient dies despite intensive care management.", "14. Autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.", "15. Microscopic image depicts macroscopically intact myocardium." ]

[ "1. The pain started 5 hours prior to arrival and has not changed after sublingual nitroglycerin intake.", "2. The patient has a history of long-standing persistent atrial fibrillation but had not been taking anticoagulants at the time of presentation.", "3. He had also been diagnosed with iron-deficiency anemia 3 months before admission and is taking 120 mg of elemental iron daily.", "4. He has no history of ischemic heart disease.", "5. Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery.", "6. The patient is managed with percutaneous coronary intervention (PCI).", "7. Six hours after the PCI, the patient develops cardiogenic shock; 8 hours after presentation, he dies, despite intensive care management.", "8. The autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.", "9. The microscopic image depicts a macroscopically intact myocardium." ]

[ "A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube in order to allow for better ventilator support of his breathing.", "At birth, he was flaccid with a poor sucking reflex.", "Since then, his weakness has progressively worsened such that he is unable to sit, eat, or breathe independently.", "Family history reveals that his grandfather was affected by a degenerative disorder at age 50, and his father had the same degenerative disorder at age 30.", "Examination is significant for tongue fasciculations and absent deep tendon reflexes." ]

[ "1. A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube.", "2. At birth, he was flaccid with a poor sucking reflex.", "3. His weakness has progressively worsened such that he is unable to sit, eat, or breathe independently.", "4. Family history reveals his grandfather was affected by a degenerative disorder at age 50.", "5. His father had the same degenerative disorder at age 30.", "6. Examination is significant for tongue fasciculations.", "7. Examination is significant for absent deep tendon reflexes." ]

[ "1. At birth, he was flaccid with a poor sucking reflex.", "2. His weakness has progressively worsened.", "3. He is unable to sit, eat, or breathe independently.", "4. Family history reveals that his grandfather was affected by a degenerative disorder at age 50.", "5. His father had the same degenerative disorder at age 30.", "6. Examination is significant for tongue fasciculations.", "7. Examination is significant for absent deep tendon reflexes." ]

[ "A 73-year-old man is brought to the emergency department 30 minutes after the sudden onset of right-sided body weakness.", "His wife reports that he does not seem to understand simple questions.", "He has type 2 diabetes mellitus and has smoked 1 pack of cigarettes daily for 45 years.", "The patient speaks fluently, but he answers questions with nonsensical phrases and cannot repeat single words." ]

[ "1. A 73-year-old man is brought to the emergency department.", "2. The onset of symptoms was sudden.", "3. The symptoms are right-sided body weakness.", "4. His wife reports that he does not seem to understand simple questions.", "5. He has type 2 diabetes mellitus.", "6. He has smoked 1 pack of cigarettes daily for 45 years.", "7. The patient speaks fluently.", "8. He answers questions with nonsensical phrases.", "9. He cannot repeat single words." ]

[ "1. The patient's wife reports that he does not seem to understand simple questions.", "2. He has type 2 diabetes mellitus.", "3. He has smoked 1 pack of cigarettes daily for 45 years.", "4. The patient speaks fluently.", "5. He answers questions with nonsensical phrases.", "6. He cannot repeat single words." ]

[ "A 23-year-old woman comes to physician for an annual health maintenance examination.", "She feels well.", "She is 155 cm (5 ft 1 in) tall and weighs 79 kg (174 lb); BMI is 33 kg/m2.", "Examination shows a skin rash over both axillae.", "A photograph of her left axilla is shown." ]

[ "1. A 23-year-old woman comes to physician for an annual health maintenance examination.", "2. She feels well.", "3. She is 155 cm (5 ft 1 in) tall.", "4. She weighs 79 kg (174 lb).", "5. BMI is 33 kg/m2.", "6. Examination shows a skin rash over both axillae.", "7. A photograph of her left axilla is shown." ]

[ "1. She feels well.", "2. She is 155 cm (5 ft 1 in) tall.", "3. She weighs 79 kg (174 lb).", "4. Her BMI is 33 kg/m2.", "5. Examination shows a skin rash over both axillae.", "6. A photograph of her left axilla is shown." ]

[ "A 72-year-old female is brought in by ambulance after being found down in her home.", "Her daughter discovered her after returning from work and does not know how long she has been down.", "Physical exam reveals right sided paralysis with a positive babinski sign.", "She is also found to produce strained stuttering speech with no perceivable meaning.", "She is unable to follow any instructions and cannot repeat speech.", "An MRI is obtained showing a left MCA infarct." ]

[ "1. A 72-year-old female is brought in by ambulance. ", "2. Her daughter discovered her after returning from work and does not know how long she has been down. ", "3. Physical exam reveals right sided paralysis with a positive babinski sign. ", "4. She is also found to produce strained stuttering speech with no perceivable meaning. ", "5. She is unable to follow any instructions and cannot repeat speech. ", "6. An MRI is obtained showing a left MCA infarct." ]

[ "1. Her daughter discovered her after returning from work.", "2. Her daughter does not know how long she has been down.", "3. Physical exam reveals right sided paralysis.", "4. Physical exam reveals a positive babinski sign.", "5. She is found to produce strained stuttering speech.", "6. The speech has no perceivable meaning.", "7. She is unable to follow any instructions.", "8. She cannot repeat speech.", "9. An MRI is obtained.", "10. The MRI shows a left MCA infarct." ]

[ "A 66-year-old male with a history of diabetes and knee osteoarthritis presents to his primary care provider in July complaining of headaches and blurry vision.", "He reports a 6-month history of occasional dull diffuse headaches and blurry vision.", "He notes that the episodes have increased in severity since the weather got warmer and that he occasionally feels extremely itchy when he spends time outdoors.", "The patient lives in southern Arizona.", "Moreover, he has felt chronically fatigued and has lost 10 pounds without dieting or changing his appetite.", "He currently takes metformin and his most recent hemoglobin A1c was 6.5%.", "Physical examination reveals multiple bruises on the bilateral upper and lower extremities and hepatosplenomegaly.", "Fundoscopic examination demonstrates enlarged retinal veins.", "Multiple laboratory tests are pending." ]

[ "1. A 66-year-old male presents to his primary care provider in July.", "2. He has a history of diabetes and knee osteoarthritis.", "3. He complains of headaches and blurry vision.", "4. He has a 6-month history of occasional dull diffuse headaches and blurry vision.", "5. The episodes have increased in severity since the weather got warmer.", "6. He occasionally feels extremely itchy when he spends time outdoors.", "7. He lives in southern Arizona.", "8. He has felt chronically fatigued.", "9. He has lost 10 pounds without dieting or changing his appetite.", "10. He currently takes metformin.", "11. His most recent hemoglobin A1c was 6.5%.", "12. Physical examination reveals multiple bruises on the bilateral upper and lower extremities and hepatosplenomegaly.", "13. Fundoscopic examination demonstrates enlarged retinal veins.", "14. Multiple laboratory tests are pending." ]

[ "1. The patient reports a 6-month history of occasional dull diffuse headaches and blurry vision.", "2. The episodes have increased in severity since the weather got warmer.", "3. He occasionally feels extremely itchy when he spends time outdoors.", "4. The patient lives in southern Arizona.", "5. He has felt chronically fatigued.", "6. He has lost 10 pounds without dieting or changing his appetite.", "7. He currently takes metformin.", "8. His most recent hemoglobin A1c was 6.5%.", "9. Physical examination reveals multiple bruises on the bilateral upper and lower extremities.", "10. Physical examination reveals hepatosplenomegaly.", "11. Fundoscopic examination demonstrates enlarged retinal veins.", "12. Multiple laboratory tests are pending." ]

[ "A 25-year-old woman is brought to the emergency department for the evaluation of severe abdominal pain for the last hour.", "Abdominal ultrasound shows a non-compressible and enlarged appendix.", "The patient is diagnosed with acute appendicitis.", "While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery because she does not trust doctors.", "She states that all doctors are “bad” and all they think about is money.", "She adds that she thinks that nurses are “angels” and that they should take care of her instead of the “arrogant” doctors." ]

[ "1. A 25-year-old woman is brought to the emergency department for the evaluation of severe abdominal pain for the last hour.", "2. Abdominal ultrasound shows a non-compressible and enlarged appendix.", "3. The patient is diagnosed with acute appendicitis.", "4. While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery.", "5. The patient states that all doctors are “bad”.", "6. The patient states that all doctors think about is money.", "7. The patient states that nurses are “angels”.", "8. The patient states that nurses should take care of her instead of the “arrogant” doctors." ]

[ "1. Abdominal ultrasound shows a non-compressible and enlarged appendix.", "2. The patient is diagnosed with acute appendicitis.", "3. The patient reports that she does not want to undergo surgery because she does not trust doctors.", "4. She states that all doctors are “bad” and all they think about is money.", "5. She adds that she thinks that nurses are “angels” and that they should take care of her instead of the “arrogant” doctors." ]

[ "A 20-year-old woman presents with persistent sadness for the last 2 months.", "She says that she is always feeling tired and nothing seems to cheer her up.", "Although previously a top student at her college, she did not register for classes this term, because she does not feel like going to school anymore.", "She says her friends complain that she does not want to ‘hang out’ with them anymore.", "She is sleeping more than usual and often does not want to leave the bed in the morning.", "The patient denies any suicidal ideation or preoccupation with death.", "Her past medical history is unremarkable.", "She currently takes a daily multivitamin.", "The vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F).", "Her body mass index (BMI) is 17.5 kg/m2.", "On physical examination, the patient is pale.", "Mucous membranes and oral cavity are dry with poor dentition.", "Multiple calluses are present on the knuckles of her left hand." ]

[ "1. Patient is a 20-year-old woman.", "2. Patient has persistent sadness for the last 2 months.", "3. Patient is always feeling tired and nothing seems to cheer her up.", "4. Patient was previously a top student at her college.", "5. Patient did not register for classes this term.", "6. Patient's friends complain that she does not want to 'hang out' with them anymore.", "7. Patient is sleeping more than usual.", "8. Patient often does not want to leave the bed in the morning.", "9. Patient denies any suicidal ideation or preoccupation with death.", "10. Patient's past medical history is unremarkable.", "11. Patient currently takes a daily multivitamin.", "12. Patient's vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F).", "13. Patient's body mass index (BMI) is 17.5 kg/m2.", "14. On physical examination, patient is pale.", "15. Mucous membranes and oral cavity are dry with poor dentition.", "16. Multiple calluses are present on the knuckles of her left hand." ]

[ "1. The patient reports feeling constantly tired and unable to find joy in anything.", "2. She was a top student at her college but did not register for classes this term due to lack of motivation.", "3. Her friends have noticed that she no longer wants to spend time with them.", "4. She is sleeping more than usual and struggles to get out of bed in the morning.", "5. The patient denies having any thoughts of suicide or preoccupation with death.", "6. Her past medical history is unremarkable.", "7. She takes a daily multivitamin.", "8. Vital signs: pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, temperature 36.9°C (98.5°F).", "9. Her BMI is 17.5 kg/m2.", "10. On physical examination, the patient appears pale.", "11. Her mucous membranes and oral cavity are dry with poor dentition.", "12. Multiple calluses are present on the knuckles of her left hand." ]

[ "A 31-year-old man presents to the clinic with complaints of sudden onset of fever, headache, chills, and a painful “bump” in his right groin.", "He recently spent three months working as a park ranger in New Mexico.", "His physical exam is notable for an enlarged lymph node in the inguinal region that is extremely tender to palpation.", "The patient is promptly treated with antibiotics, and his case is reported to the Centers for Disease Control and Prevention." ]

[ "1. A 31-year-old man presents to the clinic.", "2. He has sudden onset of fever, headache, chills, and a painful “bump” in his right groin.", "3. He recently spent three months working as a park ranger in New Mexico.", "4. His physical exam is notable for an enlarged lymph node in the inguinal region.", "5. The lymph node is extremely tender to palpation.", "6. The patient is promptly treated with antibiotics.", "7. His case is reported to the Centers for Disease Control and Prevention." ]

[ "1. He recently spent three months working as a park ranger in New Mexico.", "2. His physical exam is notable for an enlarged lymph node in the inguinal region.", "3. The enlarged lymph node is extremely tender to palpation.", "4. The patient is promptly treated with antibiotics.", "5. His case is reported to the Centers for Disease Control and Prevention." ]

[ "As the only full-time inpatient endocrinologist at your hospital, you have been tasked with deciding which blood glucose measuring device to use on the wards.", "A medical device representative presents you with the data in Image A.", "All readings were performed on the same individual whose blood glucose was known to be 125 mg/dL at the time." ]

[ "1. The speaker is an inpatient endocrinologist.", "2. The speaker works full-time at a hospital.", "3. The speaker has been tasked with deciding which blood glucose measuring device to use on the wards.", "4. A medical device representative presented the speaker with data in Image A.", "5. All readings in Image A were performed on the same individual.", "6. The individual's blood glucose was known to be 125 mg/dL at the time of the readings." ]

[ "1. A medical device representative presents data in Image A.", "2. All readings were performed on the same individual.", "3. The individual's blood glucose was known to be 125 mg/dL at the time." ]

[ "A 21-year-old male comes to the physician’s office with complaints of fatigue.", "The patient is a college intramural athlete and has noticed that during hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest.", "Usually he is able to recover and the cramps subside after rest.", "After strenuous workouts he has also noticed that his urine is dark.", "On exam, the patient has no acute symptoms and appears to be sitting comfortably with a completely normal exam.", "The patient does not have any tenderness to palpation of his muscles." ]

[ "1. A 21-year-old male comes to the physician's office with complaints of fatigue.", "2. The patient is a college intramural athlete.", "3. During hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest.", "4. Usually he is able to recover and the cramps subside after rest.", "5. After strenuous workouts he has also noticed that his urine is dark.", "6. On exam, the patient has no acute symptoms.", "7. The patient appears to be sitting comfortably with a completely normal exam.", "8. The patient does not have any tenderness to palpation of his muscles." ]

[ "1. The patient is a college intramural athlete.", "2. During hard workouts with his team, he gets severe muscle pain and weakness.", "3. He has to stop and rest during hard workouts.", "4. He is able to recover and the cramps subside after rest.", "5. After strenuous workouts, his urine is dark.", "6. On exam, the patient has no acute symptoms.", "7. The patient appears to be sitting comfortably with a completely normal exam.", "8. The patient does not have any tenderness to palpation of his muscles." ]

[ "A 78-year-old man comes to the physician because of a 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and a feeling of fullness in his head.", "The symptoms were initially mild but have progressively worsened.", "He has a history of gastroesophageal reflux disease treated with esomeprazole.", "He does not smoke cigarettes.", "His pulse is 99/min and blood pressure is 95/66 mm Hg.", "Examination shows swelling and redness of the face and neck.", "There is distention of the superficial veins of his neck and upper thorax.", "Plain radiographs of the chest show a widened mediastinum and unremarkable lung fields." ]

[ "1. Patient is 78 years old.", "2. Patient has 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and feeling of fullness in head.", "3. Symptoms initially mild but have progressively worsened.", "4. Patient has history of gastroesophageal reflux disease treated with esomeprazole.", "5. Patient does not smoke cigarettes.", "6. Pulse is 99/min.", "7. Blood pressure is 95/66 mm Hg.", "8. Examination shows swelling and redness of face and neck.", "9. Distention of superficial veins of neck and upper thorax.", "10. Plain radiographs of chest show widened mediastinum and unremarkable lung fields." ]

[ "1. The symptoms were initially mild but have progressively worsened.", "2. He has a history of gastroesophageal reflux disease treated with esomeprazole.", "3. He does not smoke cigarettes.", "4. His pulse is 99/min and blood pressure is 95/66 mm Hg.", "5. Examination shows swelling and redness of the face and neck.", "6. There is distention of the superficial veins of his neck and upper thorax.", "7. Plain radiographs of the chest show a widened mediastinum and unremarkable lung fields." ]

[ "A 52-year-old man is brought to the emergency department 30 minutes after his farmhand found him on the ground sweating profusely.", "On arrival, he is lethargic and unable to provide any history.", "His temperature is 37.5°C (99.5°F), pulse is 42/min, and blood pressure is 95/60 mm Hg.", "Physical examination shows diaphoresis and excessive salivation.", "The pupils are constricted.", "There is scattered expiratory wheezing throughout both lung fields.", "His clothes are soaked with vomit, urine, and feces." ]

[ "1. A 52-year-old man was brought to the emergency department.", "2. His farmhand found him on the ground sweating profusely 30 minutes prior.", "3. He is lethargic and unable to provide any history.", "4. His temperature is 37.5°C (99.5°F).", "5. His pulse is 42/min.", "6. His blood pressure is 95/60 mm Hg.", "7. Physical examination shows diaphoresis and excessive salivation.", "8. His pupils are constricted.", "9. There is scattered expiratory wheezing throughout both lung fields.", "10. His clothes are soaked with vomit, urine, and feces." ]

[ "1. On arrival, the patient is lethargic and unable to provide any history.", "2. The patient's temperature is 37.5°C (99.5°F).", "3. The patient's pulse is 42/min.", "4. The patient's blood pressure is 95/60 mm Hg.", "5. Physical examination shows diaphoresis and excessive salivation.", "6. The patient's pupils are constricted.", "7. There is scattered expiratory wheezing throughout both lung fields.", "8. The patient's clothes are soaked with vomit, urine, and feces." ]

[ "A 40-year-old woman is admitted to the hospital about four hours after her husband discovered that she ingested a bottle of acetaminophen in an attempted suicide.", "The patient denies any symptoms at this time.", "Vital signs include a blood pressure of 115/80 mmHg and pulse of 85/min.", "Physical exam is unremarkable.", "AST and ALT levels are approximately 2500 U/L.", "APAP level is 160 mcg/mL, and INR is 1.7.", "The patient refuses N-acetyl-cysteine (NAC) treatment." ]

[ "1. A 40-year-old woman is admitted to the hospital.", "2. Her husband discovered that she ingested a bottle of acetaminophen four hours prior.", "3. The patient denies any symptoms at this time.", "4. Blood pressure is 115/80 mmHg and pulse is 85/min.", "5. Physical exam is unremarkable.", "6. AST and ALT levels are approximately 2500 U/L.", "7. APAP level is 160 mcg/mL.", "8. INR is 1.7.", "9. The patient refuses N-acetyl-cysteine (NAC) treatment." ]

[ "1. The patient denies any symptoms at this time.", "2. Vital signs include a blood pressure of 115/80 mmHg and pulse of 85/min.", "3. Physical exam is unremarkable.", "4. AST and ALT levels are approximately 2500 U/L.", "5. APAP level is 160 mcg/mL, and INR is 1.7.", "6. The patient refuses N-acetyl-cysteine (NAC) treatment." ]

[ "An 11-month-old baby boy is brought to the emergency room by his parents for vomiting.", "His mom reports that he has had a cold for the past week with a runny nose and low-grade fevers.", "However, his condition worsened today when he began coughing and struggling to breathe.", "During one of his coughing spells he threw up his milk as well.", "The parents deny any sick contacts, changes in diet, or bowel changes but endorse fatigue and decreased appetite.", "A physical examination demonstrates a healthy-looking baby with an intense cough and significant inspiratory stridor." ]

[ "1. An 11-month-old baby boy is brought to the emergency room by his parents.", "2. His mom reports he has had a cold for the past week with a runny nose and low-grade fevers.", "3. His condition worsened today when he began coughing and struggling to breathe.", "4. During one of his coughing spells he threw up his milk.", "5. The parents deny any sick contacts, changes in diet, or bowel changes.", "6. The parents endorse fatigue and decreased appetite.", "7. A physical examination demonstrates a healthy-looking baby with an intense cough.", "8. A physical examination demonstrates a healthy-looking baby with significant inspiratory stridor." ]

[ "1. His mom reports that he has had a cold for the past week with a runny nose and low-grade fevers.", "2. His condition worsened today when he began coughing and struggling to breathe.", "3. During one of his coughing spells he threw up his milk.", "4. The parents deny any sick contacts, changes in diet, or bowel changes but endorse fatigue and decreased appetite.", "5. A physical examination demonstrates a healthy-looking baby with an intense cough and significant inspiratory stridor." ]

[ "A 56-year-old male undergoes a pancreaticoduodenectomy for resection of a tumor of the head of the pancreas.", "His medical history is otherwise insignificant except for a series of minor respiratory and gastrointestinal infections since childhood that were effectively treated with antibiotics.", "Before today, he has not had any prior surgeries or required a blood transfusion.", "In the post anesthesia care unit, his hemoglobin is measured and found to be 5.2 g/dL.", "A transfusion of 2 units of packed red blood cells is ordered.", "Minutes after the transfusion is initiated, the patient reports severe itching, nausea, and shortness of breath.", "His vital signs show a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118.", "The patient's nurse stops the transfusion immediately." ]

[ "1. Patient is 56-years-old.", "2. Patient underwent pancreaticoduodenectomy.", "3. Reason for surgery was resection of a tumor of the head of the pancreas.", "4. Patient's medical history includes minor respiratory and gastrointestinal infections since childhood.", "5. Patient has not had any prior surgeries or required a blood transfusion.", "6. Hemoglobin measured in post anesthesia care unit was 5.2 g/dL.", "7. 2 units of packed red blood cells were ordered for transfusion.", "8. Minutes after transfusion was initiated, patient reported severe itching, nausea, and shortness of breath.", "9. Patient's vital signs showed a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118.", "10. Transfusion was stopped immediately by the patient's nurse." ]

[ "1. His medical history is otherwise insignificant except for a series of minor respiratory and gastrointestinal infections since childhood.", "2. The infections were effectively treated with antibiotics.", "3. Before today, he has not had any prior surgeries.", "4. Before today, he has not required a blood transfusion.", "5. In the post anesthesia care unit, his hemoglobin is measured and found to be 5.2 g/dL.", "6. A transfusion of 2 units of packed red blood cells is ordered.", "7. Minutes after the transfusion is initiated, the patient reports severe itching, nausea, and shortness of breath.", "8. His vital signs show a drop in blood pressure from 138/88 to 92/47.", "9. His vital signs show an increase in heart rate from 94 to 118.", "10. The patient's nurse stops the transfusion immediately." ]

[ "A 5-year-old girl is brought to the emergency department after sustaining an atraumatic tibial fracture while playing with her friends.", "This patient has a history of fractures in her upper and lower extremities.", "Children's services have investigated the family several times in the past and found no abuse.", "She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures.", "She is up to date on all vaccines and is meeting all developmental milestones.", "The mother has a brother with a similar history that is still living.", "Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).", "Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally.", "The sclera of both eyes are blue.", "Additionally, her teeth are brown and distorted.", "Her leg is swollen, erythematous, and tender to palpation.", "An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms.", "The physician suspects this is a genetic condition." ]

[ "1. A 5-year-old girl is brought to the emergency department after sustaining an atraumatic tibial fracture while playing with her friends.", "2. This patient has a history of fractures in her upper and lower extremities.", "3. Children's services have investigated the family several times in the past and found no abuse.", "4. She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures.", "5. She is up to date on all vaccines and is meeting all developmental milestones.", "6. The mother has a brother with a similar history that is still living.", "7. Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).", "8. Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally.", "9. The sclera of both eyes are blue.", "10. Additionally, her teeth are brown and distorted.", "11. Her leg is swollen, erythematous, and tender to palpation.", "12. An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms.", "13. The physician suspects this is a genetic condition." ]

[ "1. The patient has a history of fractures in her upper and lower extremities.", "2. Children's services have investigated the family several times in the past and found no abuse.", "3. She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures.", "4. She is up to date on all vaccines and is meeting all developmental milestones.", "5. The mother has a brother with a similar history that is still living.", "6. Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).", "7. Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally.", "8. The sclera of both eyes are blue.", "9. Additionally, her teeth are brown and distorted.", "10. Her leg is swollen, erythematous, and tender to palpation.", "11. An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms.", "12. The physician suspects this is a genetic condition." ]

[ "A 72-year-old woman presents to her primary care physician because she is coughing pink sputum and has difficulty breathing.", "She says that she was feeling pretty good until she traveled to her grandson's wedding last week.", "Since then she has had increasing difficulty sleeping and walking due to her shortness of breath.", "Physical exam reveals swollen ankles, basilar crackles bilaterally, and a murmur best heard in the left lateral decubitus position.", "She is already taking several medications for this condition; however, given the recent worsening of symptoms she is started on an additional medication." ]

[ "1. A 72-year-old woman presents to her primary care physician.", "2. She is coughing pink sputum and has difficulty breathing.", "3. She was feeling pretty good until she traveled to her grandson's wedding last week.", "4. Since then she has had increasing difficulty sleeping and walking due to her shortness of breath.", "5. Physical exam reveals swollen ankles.", "6. Physical exam reveals basilar crackles bilaterally.", "7. Physical exam reveals a murmur best heard in the left lateral decubitus position.", "8. She is already taking several medications for this condition.", "9. Given the recent worsening of symptoms she is started on an additional medication." ]

[ "1. The patient was feeling pretty good until she traveled to her grandson's wedding last week.", "2. Since then, she has had increasing difficulty sleeping and walking due to her shortness of breath.", "3. Physical exam reveals swollen ankles.", "4. Physical exam reveals basilar crackles bilaterally.", "5. Physical exam reveals a murmur best heard in the left lateral decubitus position.", "6. The patient is already taking several medications for this condition.", "7. Given the recent worsening of symptoms, she is started on an additional medication." ]

[ "A 37-year-old woman is brought to the emergency department for acute abdominal pain for the past 2 hours.", "She reports that the pain is constant, 10/10, and is diffusely spread across her stomach.", "She reports nausea and 1 episode of vomiting 1 hour ago, painless bloody urine, and paresthesias in her hands bilaterally.", "The patient claims similar episodes in the past following the use of alcohol, though with milder pain.", "Her past medical history is significant for pelvic inflammatory disease that was adequately treated 5 years ago.", "She is currently sexually active with her husband without contraceptive use.", "Her temperature is 98.6°F (37°C), blood pressure is 148/98 mmHg, pulse is 103/min, respirations are 18/min, and oxygen saturation is 99% on room air.", "A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness and decreased sensation of the hands bilaterally." ]

[ "1. A 37-year-old woman is brought to the emergency department for acute abdominal pain for the past 2 hours.", "2. The pain is constant, 10/10, and is diffusely spread across her stomach.", "3. She reports nausea and 1 episode of vomiting 1 hour ago.", "4. She reports painless bloody urine and paresthesias in her hands bilaterally.", "5. The patient claims similar episodes in the past following the use of alcohol, though with milder pain.", "6. Her past medical history is significant for pelvic inflammatory disease that was adequately treated 5 years ago.", "7. She is currently sexually active with her husband without contraceptive use.", "8. Her temperature is 98.6°F (37°C).", "9. Her blood pressure is 148/98 mmHg.", "10. Her pulse is 103/min.", "11. Her respirations are 18/min.", "12. Her oxygen saturation is 99% on room air.", "13. A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness.", "14. A physical examination demonstrates decreased sensation of the hands bilaterally." ]

[ "1. The patient reports constant, 10/10 pain diffusely spread across her stomach.", "2. The patient reports nausea and 1 episode of vomiting 1 hour ago.", "3. The patient reports painless bloody urine and paresthesias in her hands bilaterally.", "4. The patient claims similar episodes in the past following the use of alcohol, though with milder pain.", "5. The patient's past medical history includes adequately treated pelvic inflammatory disease 5 years ago.", "6. The patient is currently sexually active with her husband without contraceptive use.", "7. The patient's temperature is 98.6°F (37°C).", "8. The patient's blood pressure is 148/98 mmHg.", "9. The patient's pulse is 103/min.", "10. The patient's respirations are 18/min.", "11. The patient's oxygen saturation is 99% on room air.", "12. A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness and decreased sensation of the hands bilaterally." ]

[ "A medical research study is being conducted to evaluate the specificity of a novel blood test for rheumatoid arthritis.", "Of the 300 patients enrolled, half are diagnosed with RA.", "The remaining patients are age-matched controls.", "In the subgroup of patients with RA, 125 are found positive for the novel blood test.", "In the control group, 45 are found positive." ]

[ "1. A medical research study is being conducted to evaluate the specificity of a novel blood test for rheumatoid arthritis.", "2. 300 patients are enrolled in the study.", "3. Half of the patients enrolled are diagnosed with RA.", "4. The remaining patients are age-matched controls.", "5. 125 patients with RA are found positive for the novel blood test.", "6. 45 patients in the control group are found positive for the novel blood test." ]

[ "1. 300 patients are enrolled in the study.", "2. Half of the patients are diagnosed with RA.", "3. The remaining patients are age-matched controls.", "4. In the subgroup of patients with RA, 125 are found positive for the novel blood test.", "5. In the control group, 45 are found positive." ]

[ "A 58-year-old man comes to the emergency department because of multiple episodes of coughing up blood over the past 2 hours.", "He says that he has coughed up approximately half a cup of bright-red blood each time.", "He has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.", "He has a history of hypertension and chronic obstructive pulmonary disease.", "He has worked in a car manufacturing company for over 20 years.", "He drinks 2 to 3 beers every evening.", "He has smoked 1 pack of cigarettes daily for the past 30 years.", "His medications include amlodipine, tiotropium, and an albuterol inhaler as needed.", "His temperature is 37.2 °C (99.0 °F), blood pressure is 102/68 mm Hg, pulse is 108/min, and respirations are 22/min.", "Pulse oximetry on room air shows an oxygen saturation of 89%.", "He appears anxious and cachectic.", "Examination of the lung shows decreased breath sounds bilaterally.", "There is no cervical or axillary lymphadenopathy.", "His hemoglobin is 11.5 g/dL, leukocyte count is 8,800/mm3, and a platelet count is 160,000/mm3.", "His coagulation parameters are within normal limits.", "Serum studies and urine analysis show no abnormalities.", "He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun.", "An x-ray of the chest shows hyperinflation of the lung fields and a 2-cm nodule in the right lower lobe." ]

[ "1. Patient is 58 years old.", "2. Patient has had multiple episodes of coughing up blood over the past 2 hours.", "3. Patient has coughed up approximately half a cup of bright-red blood each time.", "4. Patient has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.", "5. Patient has a history of hypertension and chronic obstructive pulmonary disease.", "6. Patient has worked in a car manufacturing company for over 20 years.", "7. Patient drinks 2 to 3 beers every evening.", "8. Patient has smoked 1 pack of cigarettes daily for the past 30 years.", "9. Patient's medications include amlodipine, tiotropium, and an albuterol inhaler as needed.", "10. Patient's temperature is 37.2 °C (99.0 °F).", "11. Patient's blood pressure is 102/68 mm Hg.", "12. Patient's pulse is 108/min.", "13. Patient's respirations are 22/min.", "14. Pulse oximetry on room air shows an oxygen saturation of 89%.", "15. Patient appears anxious and cachectic.", "16. Examination of the lung shows decreased breath sounds bilaterally.", "17. There is no cervical or axillary lymphadenopathy.", "18. Patient's hemoglobin is 11.5 g/dL.", "19. Patient's leukocyte count is 8,800/mm3.", "20. Patient's platelet count is 160,000/mm3.", "21. Patient's coagulation parameters are within normal limits.", "22. Serum studies and urine analysis show no abnormalities.", "23. Patient is intubated and mechanically ventilated.", "24. Infusion of 0.9% saline is begun.", "25. X-ray of the chest shows hyperinflation of the lung fields.", "26. X-ray of the chest shows a 2-cm nodule in the right lower lobe." ]

[ "1. The patient has coughed up approximately half a cup of bright-red blood each time.", "2. He has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.", "3. The patient has a history of hypertension and chronic obstructive pulmonary disease.", "4. He has worked in a car manufacturing company for over 20 years.", "5. The patient drinks 2 to 3 beers every evening.", "6. He has smoked 1 pack of cigarettes daily for the past 30 years.", "7. His medications include amlodipine, tiotropium, and an albuterol inhaler as needed.", "8. His temperature is 37.2 °C (99.0 °F), blood pressure is 102/68 mm Hg, pulse is 108/min, and respirations are 22/min.", "9. Pulse oximetry on room air shows an oxygen saturation of 89%.", "10. The patient appears anxious and cachectic.", "11. Examination of the lung shows decreased breath sounds bilaterally.", "12. There is no cervical or axillary lymphadenopathy.", "13. His hemoglobin is 11.5 g/dL, leukocyte count is 8,800/mm3, and a platelet count is 160,000/mm3.", "14. His coagulation parameters are within normal limits.", "15. Serum studies and urine analysis show no abnormalities.", "16. He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun.", "17. An x-ray of the chest shows hyperinflation of the lung fields and a 2-cm nodule in the right lower lobe." ]

[ "A previously healthy 3-year-old girl is brought to the physician because she refuses to use her left arm after “tripping over a stone” that morning on the way to the supermarket while holding her mother's hand.", "She did not hit the ground.", "Development has been normal for her age.", "She appears anxious.", "Her vital signs are within normal limits.", "The left forearm is held close to her body in partial extension and pronation.", "There is no swelling or bruising of the elbow or the forearm.", "Palpation of the proximal radius produces pain.", "The child cries on attempting to passively supinate the forearm." ]

[ "1. A 3-year-old girl was brought to the physician.", "2. She refused to use her left arm.", "3. She tripped over a stone that morning while holding her mother's hand.", "4. She did not hit the ground.", "5. Development has been normal for her age.", "6. She appears anxious.", "7. Her vital signs are within normal limits.", "8. The left forearm is held close to her body in partial extension and pronation.", "9. There is no swelling or bruising of the elbow or the forearm.", "10. Palpation of the proximal radius produces pain.", "11. The child cries on attempting to passively supinate the forearm." ]

[ "1. She did not hit the ground.", "2. Development has been normal for her age.", "3. She appears anxious.", "4. Her vital signs are within normal limits.", "5. The left forearm is held close to her body in partial extension and pronation.", "6. There is no swelling or bruising of the elbow or the forearm.", "7. Palpation of the proximal radius produces pain.", "8. The child cries on attempting to passively supinate the forearm." ]

[ "A previously healthy 29-year-old woman comes to the physician because of a 3-day history of low-grade fever, muscle aches, and a rash.", "She has had 4 male sexual partners over the past year and uses condoms inconsistently.", "Examination shows a diffuse maculopapular rash that includes the palms and soles.", "Testing for nonspecific anticardiolipin antibodies is positive." ]

[ "1. A 29-year-old woman came to the physician.", "2. She had a 3-day history of low-grade fever, muscle aches, and a rash.", "3. She had 4 male sexual partners over the past year.", "4. She uses condoms inconsistently.", "5. Examination showed a diffuse maculopapular rash that included the palms and soles.", "6. Testing for nonspecific anticardiolipin antibodies was positive." ]

[ "1. She has had 4 male sexual partners over the past year.", "2. She uses condoms inconsistently.", "3. Examination shows a diffuse maculopapular rash.", "4. The rash includes the palms and soles.", "5. Testing for nonspecific anticardiolipin antibodies is positive." ]

[ "A 59-year-old man with New York Heart Association Class II heart failure presents to your outpatient clinic for routine follow-up.", "His blood pressure is 134/89 mm Hg and heart rate is 75/min.", "Physical examination reveals clear lung sounds bilaterally with normal S1 and S2 heart sounds.", "He currently takes captopril, bisoprolol, and furosemide.", "You would like to add on spironolactone." ]

[ "1. A 59-year-old man presents to an outpatient clinic for routine follow-up.", "2. The man has New York Heart Association Class II heart failure.", "3. His blood pressure is 134/89 mm Hg.", "4. His heart rate is 75/min.", "5. Physical examination reveals clear lung sounds bilaterally with normal S1 and S2 heart sounds.", "6. He currently takes captopril, bisoprolol, and furosemide.", "7. The doctor would like to add on spironolactone." ]

[ "1. Blood pressure is 134/89 mm Hg.", "2. Heart rate is 75/min.", "3. Physical examination reveals clear lung sounds bilaterally.", "4. Physical examination reveals normal S1 and S2 heart sounds.", "5. Current medications include captopril, bisoprolol, and furosemide.", "6. Considering adding on spironolactone." ]

[ "A 32-year-old man comes to the physician because of a 1-week history of fever, nausea, headache, and confusion.", "Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy.", "He is sexually active with a new partner that he met 2 months ago and they use condoms inconsistently.", "He appears ill.", "Physical examination shows nuchal rigidity.", "Further evaluation shows infection with a single-stranded, positive-sense RNA virus." ]

[ "1. A 32-year-old man comes to the physician.", "2. He has a 1-week history of fever, nausea, headache, and confusion.", "3. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy.", "4. He is sexually active with a new partner he met 2 months ago.", "5. They use condoms inconsistently.", "6. He appears ill.", "7. Physical examination shows nuchal rigidity.", "8. Further evaluation shows infection with a single-stranded, positive-sense RNA virus." ]

[ "1. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy.", "2. He is sexually active with a new partner that he met 2 months ago.", "3. They use condoms inconsistently.", "4. He appears ill.", "5. Physical examination shows nuchal rigidity.", "6. Further evaluation shows infection with a single-stranded, positive-sense RNA virus." ]

[ "A 64-year-old man presents for a routine physical.", "He states that he has felt abnormally weak during this time and has had trouble focusing in the setting of losing 5 pounds.", "The patient states he has a decreased appetite and also has not had a bowel movement in the past 5 days and feels uncomfortable.", "On review of system, he endorses abdominal pain.", "His temperature is 97.5°F (36.4°C), blood pressure is 132/83 mmHg, pulse is 115/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is notable only for the patient being able to recall 1 of 3 objects.", "His cranial nerve exam is unremarkable and his gait is stable.", "Urinalysis is initially notable for a clear and voluminous sample with a low specific gravity." ]

[ "1. A 64-year-old man presents for a routine physical.", "2. He states that he has felt abnormally weak during this time.", "3. He has had trouble focusing in the setting of losing 5 pounds.", "4. The patient states he has a decreased appetite.", "5. He has not had a bowel movement in the past 5 days and feels uncomfortable.", "6. On review of system, he endorses abdominal pain.", "7. His temperature is 97.5°F (36.4°C).", "8. His blood pressure is 132/83 mmHg.", "9. His pulse is 115/min.", "10. His respirations are 15/min.", "11. His oxygen saturation is 98% on room air.", "12. Physical exam is notable only for the patient being able to recall 1 of 3 objects.", "13. His cranial nerve exam is unremarkable.", "14. His gait is stable.", "15. Urinalysis is initially notable for a clear and voluminous sample with a low specific gravity." ]

[ "1. The patient has felt abnormally weak.", "2. The patient has had trouble focusing.", "3. The patient has lost 5 pounds.", "4. The patient has a decreased appetite.", "5. The patient has not had a bowel movement in the past 5 days.", "6. The patient feels uncomfortable.", "7. The patient endorses abdominal pain.", "8. The patient's temperature is 97.5°F (36.4°C).", "9. The patient's blood pressure is 132/83 mmHg.", "10. The patient's pulse is 115/min.", "11. The patient's respirations are 15/min.", "12. The patient's oxygen saturation is 98% on room air.", "13. The patient is able to recall 1 of 3 objects.", "14. The patient's cranial nerve exam is unremarkable.", "15. The patient's gait is stable.", "16. The urinalysis is initially notable for a clear and voluminous sample.", "17. The urinalysis has a low specific gravity." ]

[ "Ten days after a motor vehicle collision, a 28-year-old man develops jaundiced skin.", "Upon initial presentation for his injuries, the patient was taken for an emergency laparotomy, which revealed significant internal hemorrhage from blunt abdominal trauma to the spleen.", "He required rapid transfusion with a total of 7 units of packed red blood cells.", "He has recovered well from the procedure until this morning, when he began to develop jaundiced skin and sclerae.", "He does not have pruritus.", "He has had no prior surgeries and takes no other medications.", "He is sexually active with one female partner.", "Prior to the accident, he drank 4 beers per day.", "His vital signs are within normal limits.", "Abdominal examination is limited due to pain.", "There are no palpable abdominal masses.", "There is a midline surgical scar with no erythema, purulence, or drainage.", "He has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.", "CT scans show a resolving hematoma in the peritoneal cavity.", "Laboratory studies show: | Hemoglobin 9.7 g/dL | Hematocrit 30% | Leukocyte count 7,000/mm3 | Platelet count 135,000/mm3 | Serum | Total bilirubin 3.9 mg/dL | Indirect bilirubin 3.7 mg/dL | Direct bilirubin 0.2 mg/dL | Aspartate aminotransferase (AST) 60 U/L | Alanine aminotransferase (ALT) 92 U/L | ." ]

[ "1. Patient is 28 years old.", "2. Patient presented 10 days after motor vehicle collision.", "3. Patient underwent emergency laparotomy due to blunt abdominal trauma to the spleen.", "4. Patient required rapid transfusion with a total of 7 units of packed red blood cells.", "5. Patient had no prior surgeries and takes no other medications.", "6. Patient is sexually active with one female partner.", "7. Prior to the accident, patient drank 4 beers per day.", "8. Patient's vital signs are within normal limits.", "9. Abdominal examination is limited due to pain.", "10. No palpable abdominal masses.", "11. Midline surgical scar with no erythema, purulence, or drainage.", "12. Patient has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.", "13. CT scans show a resolving hematoma in the peritoneal cavity.", "14. Patient has jaundiced skin and sclerae.", "15. Patient does not have pruritus.", "16. Laboratory studies show: Hemoglobin 9.7 g/dL, Hematocrit 30%, Leukocyte count 7,000/mm3, Platelet count 135,000/mm3, Total bilirubin 3.9 mg/dL, Indirect bilirubin 3.7 mg/dL, Direct bilirubin 0.2 mg/dL, Aspartate aminotransferase (AST) 60 U/L, Alanine aminotransferase (ALT) 92 U/L." ]

[ "1. The patient had emergency laparotomy for significant internal hemorrhage from blunt abdominal trauma to the spleen.", "2. The patient received a total of 7 units of packed red blood cells.", "3. The patient developed jaundiced skin and sclerae.", "4. The patient does not have pruritus.", "5. The patient had no prior surgeries and takes no other medications.", "6. The patient is sexually active with one female partner.", "7. Prior to the accident, the patient drank 4 beers per day.", "8. The patient's vital signs are within normal limits.", "9. Abdominal examination is limited due to pain.", "10. There are no palpable abdominal masses.", "11. The patient has a midline surgical scar with no erythema, purulence, or drainage.", "12. The patient has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.", "13. CT scans show a resolving hematoma in the peritoneal cavity.", "14. Laboratory studies show: Hemoglobin 9.7 g/dL, Hematocrit 30%, Leukocyte count 7,000/mm3, Platelet count 135,000/mm3, Total bilirubin 3.9 mg/dL, Indirect bilirubin 3.7 mg/dL, Direct bilirubin 0.2 mg/dL, Aspartate aminotransferase (AST) 60 U/L, Alanine aminotransferase (ALT) 92 U/L." ]

[ "A 69-year-old man comes to the physician because of a cough for the past 3 months.", "The cough is mostly dry, but the patient recalls a recent episode in which he coughed up mucus with dark red streaks.", "He has felt tired for the past few months.", "Over the past month, he has had poor appetite and a 5-kg (11-lb) weight loss.", "He also has occasional back pain, which has worsened in recent weeks.", "He has no recent travel history.", "He has smoked a pack of cigarettes daily for 30 years.", "He does not drink alcohol.", "His vitals are within normal limits.", "Auscultation of the lungs reveals wheezing in the lower right lung field.", "There is no peripheral lymphadenopathy.", "The liver is of normal size, and the spleen is not palpable.", "Laboratory studies show a hemoglobin concentration of 13.5 g/dL, serum calcium concentration of 12.3 mg/dL, and a total serum protein of 7.0 g/dL.", "X-rays of the chest are shown." ]

[ "1. Patient is 69 years old.", "2. Patient has had a cough for 3 months.", "3. Cough is mostly dry.", "4. Patient recently coughed up mucus with dark red streaks.", "5. Patient has felt tired for the past few months.", "6. Patient has had poor appetite and a 5-kg (11-lb) weight loss over the past month.", "7. Patient has occasional back pain, which has worsened in recent weeks.", "8. Patient has no recent travel history.", "9. Patient has smoked a pack of cigarettes daily for 30 years.", "10. Patient does not drink alcohol.", "11. Patient's vitals are within normal limits.", "12. Auscultation of the lungs reveals wheezing in the lower right lung field.", "13. No peripheral lymphadenopathy.", "14. Liver is of normal size.", "15. Spleen is not palpable.", "16. Laboratory studies show a hemoglobin concentration of 13.5 g/dL.", "17. Laboratory studies show a serum calcium concentration of 12.3 mg/dL.", "18. Laboratory studies show a total serum protein of 7.0 g/dL.", "19. X-rays of the chest are shown." ]

[ "1. The cough is mostly dry.", "2. The patient recalls a recent episode in which he coughed up mucus with dark red streaks.", "3. He has felt tired for the past few months.", "4. Over the past month, he has had poor appetite.", "5. He has experienced a 5-kg (11-lb) weight loss.", "6. He has occasional back pain, which has worsened in recent weeks.", "7. He has no recent travel history.", "8. He has smoked a pack of cigarettes daily for 30 years.", "9. He does not drink alcohol.", "10. His vitals are within normal limits.", "11. Auscultation of the lungs reveals wheezing in the lower right lung field.", "12. There is no peripheral lymphadenopathy.", "13. The liver is of normal size, and the spleen is not palpable.", "14. Laboratory studies show a hemoglobin concentration of 13.5 g/dL.", "15. Laboratory studies show a serum calcium concentration of 12.3 mg/dL.", "16. Laboratory studies show a total serum protein of 7.0 g/dL.", "17. X-rays of the chest are shown." ]

[ "A 37-year-old man comes to the physician because of a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia.", "He has had a 10-kg (22-lb) weight loss during this period.", "He does not smoke or drink alcohol.", "Laryngoscopic examination shows an abnormal mass located on the right true vocal cord.", "Immunohistochemistry of the mass shows expression of HPV-16 DNA." ]

[ "1. A 37-year-old man comes to the physician.", "2. He has a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia.", "3. He has had a 10-kg (22-lb) weight loss during this period.", "4. He does not smoke or drink alcohol.", "5. Laryngoscopic examination shows an abnormal mass located on the right true vocal cord.", "6. Immunohistochemistry of the mass shows expression of HPV-16 DNA." ]

[ "1. He has had a 10-kg (22-lb) weight loss during this period.", "2. He does not smoke or drink alcohol.", "3. Laryngoscopic examination shows an abnormal mass located on the right true vocal cord.", "4. Immunohistochemistry of the mass shows expression of HPV-16 DNA." ]

[ "An investigator is studying patients with an autosomal dominant mutation in the long arm of chromosome 10.", "This mutation alters the structure of CD95 receptors and impairs the binding of a ligand to this receptor." ]

[ "1. An investigator is studying patients.", "2. The patients have an autosomal dominant mutation.", "3. The mutation is in the long arm of chromosome 10.", "4. The mutation alters the structure of CD95 receptors.", "5. The mutation impairs the binding of a ligand to this receptor." ]

[ "1. Mutation alters the structure of CD95 receptors.", "2. Mutation impairs the binding of a ligand to the CD95 receptor." ]

[ "An investigator is studying cardiovascular changes during exercise.", "He is following a 25-year-old female volunteer who is training for a marathon.", "Her training consists of running on a treadmill for increasing amounts of time.", "During her training sessions, laboratory studies show increased concentrations of adenosine and lactate in the active muscles." ]

[ "1. An investigator is studying cardiovascular changes during exercise.", "2. The investigator is following a 25-year-old female volunteer.", "3. The volunteer is training for a marathon.", "4. The training consists of running on a treadmill for increasing amounts of time.", "5. During her training sessions, laboratory studies show increased concentrations of adenosine in the active muscles.", "6. During her training sessions, laboratory studies show increased concentrations of lactate in the active muscles." ]

[ "1. He is following a 25-year-old female volunteer.", "2. The female volunteer is training for a marathon.", "3. Her training consists of running on a treadmill for increasing amounts of time.", "4. Laboratory studies show increased concentrations of adenosine in the active muscles during her training sessions.", "5. Laboratory studies show increased concentrations of lactate in the active muscles during her training sessions." ]