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stellalisy

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[ "A 70-year-old man comes to the physician for the evaluation of abdominal pain over the past month.", "The patient describes epigastric pain that radiates to the back.", "He also reports a 10-kg (22-lb) weight loss over the past 6 months.", "He has a history of untreated type 2 diabetes mellitus.", "He has not seen a doctor in 15 years.", "He is retired and spends most of his time at home watching TV.", "He rarely cooks and mainly eats fast food.", "He has smoked one pack of cigarettes daily for the past 50 years.", "He drinks 2–3 cans of beer per day.", "He appears pale.", "His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg.", "Physical examination shows jaundice of the conjunctivae and the skin.", "The abdomen is soft, with no rebound or guarding.", "Laboratory studies show a serum glucose concentration of 260 mg/dL.", "Abdominal sonography shows enlargement of the gallbladder." ]

[ "1. Patient is 70 years old.", "2. Patient has abdominal pain for the past month.", "3. Patient describes epigastric pain that radiates to the back.", "4. Patient has lost 10 kg (22 lbs) in the past 6 months.", "5. Patient has a history of untreated type 2 diabetes mellitus.", "6. Patient has not seen a doctor in 15 years.", "7. Patient is retired and spends most of his time at home watching TV.", "8. Patient rarely cooks and mainly eats fast food.", "9. Patient has smoked one pack of cigarettes daily for the past 50 years.", "10. Patient drinks 2-3 cans of beer per day.", "11. Patient appears pale.", "12. Patient's temperature is 37°C (98.6°F).", "13. Patient's pulse is 80/min.", "14. Patient's blood pressure is 150/90 mm Hg.", "15. Physical examination shows jaundice of the conjunctivae and the skin.", "16. Abdomen is soft, with no rebound or guarding.", "17. Laboratory studies show a serum glucose concentration of 260 mg/dL.", "18. Abdominal sonography shows enlargement of the gallbladder." ]

[ "1. The patient describes epigastric pain that radiates to the back.", "2. He also reports a 10-kg (22-lb) weight loss over the past 6 months.", "3. He has a history of untreated type 2 diabetes mellitus.", "4. He has not seen a doctor in 15 years.", "5. He is retired and spends most of his time at home watching TV.", "6. He rarely cooks and mainly eats fast food.", "7. He has smoked one pack of cigarettes daily for the past 50 years.", "8. He drinks 2–3 cans of beer per day.", "9. He appears pale.", "10. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg.", "11. Physical examination shows jaundice of the conjunctivae and the skin.", "12. The abdomen is soft, with no rebound or guarding.", "13. Laboratory studies show a serum glucose concentration of 260 mg/dL.", "14. Abdominal sonography shows enlargement of the gallbladder." ]

[ "A 63-year-old African American man with a history of hypertension and dyslipidemia presents to the emergency department with facial swelling and difficulty breathing.", "Symptoms began suddenly that morning and continued to worsen.", "He started taking lisinopril several weeks ago.", "His blood pressure is 110/74 mm Hg, heart rate is 94/min, and respiratory rate is 20/min.", "Physical examination is notable for swelling of his lips and inspiratory stridor.", "Clinical lab results suggest a normal C1 esterase inhibitor level." ]

[ "1. A 63-year-old African American man presented to the emergency department.", "2. He has a history of hypertension and dyslipidemia.", "3. Symptoms began suddenly that morning and continued to worsen.", "4. He started taking lisinopril several weeks ago.", "5. His blood pressure is 110/74 mm Hg.", "6. His heart rate is 94/min.", "7. His respiratory rate is 20/min.", "8. Physical examination is notable for swelling of his lips and inspiratory stridor.", "9. Clinical lab results suggest a normal C1 esterase inhibitor level." ]

[ "1. Symptoms began suddenly that morning.", "2. Symptoms continued to worsen.", "3. He started taking lisinopril several weeks ago.", "4. His blood pressure is 110/74 mm Hg.", "5. His heart rate is 94/min.", "6. His respiratory rate is 20/min.", "7. Physical examination is notable for swelling of his lips.", "8. Physical examination is notable for inspiratory stridor.", "9. Clinical lab results suggest a normal C1 esterase inhibitor level." ]

[ "A 21-year-old female college student comes to the physician because of a two-week history of vaginal itching and burning.", "She also noticed white vaginal discharge despite cleaning her genital area daily using a \"\"soap-free, natural\"\" vaginal douche.", "She is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.", "She has type 1 diabetes mellitus.", "The patient swims for the college swimming team.", "She had an intrauterine device implanted 3 months ago and does not use barrier protection.", "She smokes one pack of cigarettes per day and does not drink alcohol.", "Speculum examination shows an erythematous vagina covered in copious white discharge.", "Her vaginal pH is 4.4 and the microscopic image of a KOH preparation shows multiple pseudohyphae." ]

[ "1. Patient is a 21-year-old female college student.", "2. Patient has a two-week history of vaginal itching and burning.", "3. Patient has noticed white vaginal discharge despite cleaning her genital area daily using a \"soap-free, natural\" vaginal douche.", "4. Patient is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.", "5. Patient has type 1 diabetes mellitus.", "6. Patient swims for the college swimming team.", "7. Patient had an intrauterine device implanted 3 months ago and does not use barrier protection.", "8. Patient smokes one pack of cigarettes per day and does not drink alcohol.", "9. Speculum examination shows an erythematous vagina covered in copious white discharge.", "10. Patient's vaginal pH is 4.4.", "11. Microscopic image of a KOH preparation shows multiple pseudohyphae." ]

[ "1. The patient noticed white vaginal discharge despite cleaning her genital area daily using a \"soap-free, natural\" vaginal douche.", "2. She is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.", "3. She has type 1 diabetes mellitus.", "4. The patient swims for the college swimming team.", "5. She had an intrauterine device implanted 3 months ago and does not use barrier protection.", "6. She smokes one pack of cigarettes per day and does not drink alcohol.", "7. Speculum examination shows an erythematous vagina covered in copious white discharge.", "8. Her vaginal pH is 4.4.", "9. The microscopic image of a KOH preparation shows multiple pseudohyphae." ]

[ "A 72-year-old female recently fractured her hip in a fall.", "She suffers from regular joint pain in her fingers, and hip X-rays reveal low bone mineral density.", "She has a history of diabetes mellitus and was diagnosed 2 years ago with end-stage renal disease.", "Serum phosphate levels are markedly elevated." ]

[ "1. A 72-year-old female recently fractured her hip in a fall.", "2. She suffers from regular joint pain in her fingers.", "3. Hip X-rays reveal low bone mineral density.", "4. She has a history of diabetes mellitus.", "5. She was diagnosed 2 years ago with end-stage renal disease.", "6. Serum phosphate levels are markedly elevated." ]

[ "1. She suffers from regular joint pain in her fingers.", "2. Hip X-rays reveal low bone mineral density.", "3. She has a history of diabetes mellitus.", "4. She was diagnosed 2 years ago with end-stage renal disease.", "5. Serum phosphate levels are markedly elevated." ]

[ "A 52-year-old man presents to his primary care physician for his annual check-up.", "He says that he has no health concerns; however, his wife is concerned that he has become increasingly forgetful.", "For example, he has become forgetful during his daily activities and recently has been getting lost during errands like shopping.", "She says that these symptoms have been occurring for about a year.", "She says that she became alarmed when he started forgetting the names of their children.", "Finally, over the last month he has become more irritable, which has led to several confrontations at work.", "Based on the age of onset for his disease, the patient is referred for genetic testing." ]

[ "1. A 52-year-old man presents to his primary care physician for his annual check-up.", "2. He says that he has no health concerns.", "3. His wife is concerned that he has become increasingly forgetful.", "4. He has become forgetful during his daily activities.", "5. He has been getting lost during errands like shopping.", "6. His wife says that these symptoms have been occurring for about a year.", "7. He has started forgetting the names of their children.", "8. Over the last month he has become more irritable.", "9. This has led to several confrontations at work.", "10. Based on the age of onset for his disease, the patient is referred for genetic testing." ]

[ "1. The patient says he has no health concerns.", "2. The patient's wife is concerned about his increasing forgetfulness.", "3. The patient has been forgetful during daily activities.", "4. The patient has been getting lost during errands like shopping.", "5. The symptoms have been occurring for about a year.", "6. The wife became alarmed when the patient started forgetting the names of their children.", "7. Over the last month, the patient has become more irritable.", "8. The patient has had several confrontations at work due to irritability.", "9. The patient is referred for genetic testing based on the age of onset for his disease." ]

[ "A 23-year-old woman, gravida 2, para 1, at 13 weeks gestation, comes to the physician because of a 2-day history of burning pain during urination.", "She has been sexually active with different male partners during the pregnancy and did not use condoms.", "She has not had any fever, chills, or pelvic pain.", "Physical examination shows thick, purulent discharge from the urethra.", "Urine dipstick shows leukocyte esterase, urinalysis shows 10 WBCs/hpf, and Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.", "Pelvic ultrasound shows a viable intrauterine pregnancy." ]

[ "1. Patient is a 23-year-old woman.", "2. Patient is gravida 2, para 1.", "3. Patient is 13 weeks gestation.", "4. Patient has a 2-day history of burning pain during urination.", "5. Patient has been sexually active with different male partners during the pregnancy.", "6. Patient did not use condoms.", "7. Patient has not had any fever, chills, or pelvic pain.", "8. Physical examination shows thick, purulent discharge from the urethra.", "9. Urine dipstick shows leukocyte esterase.", "10. Urinalysis shows 10 WBCs/hpf.", "11. Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.", "12. Pelvic ultrasound shows a viable intrauterine pregnancy." ]

[ "1. She has been sexually active with different male partners during the pregnancy and did not use condoms.", "2. She has not had any fever, chills, or pelvic pain.", "3. Physical examination shows thick, purulent discharge from the urethra.", "4. Urine dipstick shows leukocyte esterase.", "5. Urinalysis shows 10 WBCs/hpf.", "6. Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.", "7. Pelvic ultrasound shows a viable intrauterine pregnancy." ]

[ "A 20-year-old college student is brought to his primary care physician by his parents over the New Years holiday because they are concerned about his behavior since right after high school graduation in May the spring before.", "Prior to this year, he was generally an outgoing and social young man, who now reportedly has been spending the majority of his time alone in his dorm room and room at home, where his mother and father have overheard him talking to other people when he has no guests.", "When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see.", "On exam, his appears to be otherwise healthy and his urine toxicology screen is negative." ]

[ "1. A 20-year-old college student is brought to his primary care physician by his parents. ", "2. The visit is over the New Years holiday. ", "3. The parents are concerned about his behavior since right after high school graduation in May the spring before. ", "4. Prior to this year, he was generally an outgoing and social young man. ", "5. He has been spending the majority of his time alone in his dorm room and room at home. ", "6. His mother and father have overheard him talking to other people when he has no guests. ", "7. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove. ", "8. The oak grove will soon takeover the student union building. ", "9. The voice encourages him to set the trees on fire for all to see. ", "10. On exam, his appears to be otherwise healthy. ", "11. His urine toxicology screen is negative." ]

[ "1. Prior to this year, he was generally an outgoing and social young man.", "2. He has reportedly been spending the majority of his time alone in his dorm room and room at home.", "3. His mother and father have overheard him talking to other people when he has no guests.", "4. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see.", "5. On exam, he appears to be otherwise healthy.", "6. His urine toxicology screen is negative." ]

[ "A 58-year-old man comes to the physician for evaluation of an increasing left-sided cheek swelling and recurrent oral ulcers for 1 year.", "He has smoked a pack of cigarettes daily for 25 years.", "Examination shows a mild, nontender swelling above the angle of the left jaw.", "An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma.", "A left-sided total parotidectomy is performed." ]

[ "1. A 58-year-old man comes to the physician for evaluation of an increasing left-sided cheek swelling and recurrent oral ulcers for 1 year.", "2. He has smoked a pack of cigarettes daily for 25 years.", "3. Examination shows a mild, nontender swelling above the angle of the left jaw.", "4. An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma.", "5. A left-sided total parotidectomy is performed." ]

[ "1. He has smoked a pack of cigarettes daily for 25 years.", "2. Examination shows a mild, nontender swelling above the angle of the left jaw.", "3. An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma.", "4. A left-sided total parotidectomy is performed." ]

[ "A 34-year-old man comes to the physician for a routine health maintenance examination required for his occupation as a school bus driver.", "He feels well and healthy.", "Upon questioning, he reports that he has smoked 2 joints of marijuana every night after work for the past year for recreational purposes.", "He typically smokes 5 joints or more on weekends." ]

[ "1. A 34-year-old man comes to the physician for a routine health maintenance examination.", "2. The man's occupation is a school bus driver.", "3. The man feels well and healthy.", "4. The man has smoked 2 joints of marijuana every night after work for the past year.", "5. The man smokes marijuana for recreational purposes.", "6. The man typically smokes 5 joints or more on weekends." ]

[ "1. The patient feels well and healthy.", "2. The patient has smoked 2 joints of marijuana every night after work for the past year for recreational purposes.", "3. The patient typically smokes 5 joints or more on weekends." ]

[ "A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father who is concerned about the child developing a body odor.", "He reports that she has started to smell “like a teenage boy” especially after physical activity.", "The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age.", "Her temperature is 99°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 85/min, and respirations are 18/min.", "On exam, she has hair in her axillary and pubic regions.", "Genital examination demonstrates clitoral enlargement and labioscrotal fusion." ]

[ "1. A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father. ", "2. The father is concerned about the child developing a body odor. ", "3. He reports that she has started to smell “like a teenage boy” especially after physical activity. ", "4. The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age. ", "5. Her temperature is 99°F (37.2°C). ", "6. Her blood pressure is 150/90 mmHg. ", "7. Her pulse is 85/min. ", "8. Her respirations are 18/min. ", "9. On exam, she has hair in her axillary and pubic regions. ", "10. Genital examination demonstrates clitoral enlargement and labioscrotal fusion." ]

[ "1. The patient reports that she has started to smell \"like a teenage boy\" especially after physical activity.", "2. The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age.", "3. Her temperature is 99°F (37.2°C).", "4. Her blood pressure is 150/90 mmHg.", "5. Her pulse is 85/min.", "6. Her respirations are 18/min.", "7. On exam, she has hair in her axillary and pubic regions.", "8. Genital examination demonstrates clitoral enlargement and labioscrotal fusion." ]

[ "A 25-year-old woman presents to the clinic for burning with urination.", "She is a newlywed and reports 3 similar episodes within the past 4 months.", "She claims that since yesterday she has noticed a burning sensation whenever she urinates, an increase in urinary frequency, and some clear vaginal discharge.", "She denies fever, chills, back pain, or chest pain.", "Her past medical history is significant for chlamydia that was adequately treated 3 years ago.", "She is currently sexually active with her husband and has an IUD.", "She is subsequently prescribed a course of nitrofurantoin for her symptoms." ]

[ "1. A 25-year-old woman presents to the clinic for burning with urination.", "2. She reports 3 similar episodes within the past 4 months.", "3. She claims that since yesterday she has noticed a burning sensation whenever she urinates, an increase in urinary frequency, and some clear vaginal discharge.", "4. She denies fever, chills, back pain, or chest pain.", "5. Her past medical history is significant for chlamydia that was adequately treated 3 years ago.", "6. She is a newlywed.", "7. She is currently sexually active with her husband.", "8. She has an IUD.", "9. She is subsequently prescribed a course of nitrofurantoin for her symptoms." ]

[ "1. She is a newlywed.", "2. She reports 3 similar episodes within the past 4 months.", "3. Since yesterday, she has noticed a burning sensation whenever she urinates.", "4. She has noticed an increase in urinary frequency since yesterday.", "5. She has noticed some clear vaginal discharge since yesterday.", "6. She denies fever.", "7. She denies chills.", "8. She denies back pain.", "9. She denies chest pain.", "10. Her past medical history is significant for chlamydia.", "11. The chlamydia was adequately treated 3 years ago.", "12. She is currently sexually active with her husband.", "13. She has an IUD.", "14. She is subsequently prescribed a course of nitrofurantoin for her symptoms." ]

[ "A 17-year-old boy comes to the physician 1 week after noticing a lesion on his penis.", "There is no history of itching or pain associated with the lesion.", "He is sexually active with two female partners and uses condoms inconsistently.", "Five weeks ago, he returned from a trip to the Caribbean with some of his football teammates.", "He takes no medications.", "He has recently started an intense exercise program.", "His vital signs are within normal limits.", "Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally.", "A photograph of the lesion is shown." ]

[ "1. A 17-year-old boy comes to the physician.", "2. He noticed a lesion on his penis 1 week ago.", "3. There is no history of itching or pain associated with the lesion.", "4. He is sexually active with two female partners.", "5. He uses condoms inconsistently.", "6. He returned from a trip to the Caribbean with some of his football teammates 5 weeks ago.", "7. He takes no medications.", "8. He has recently started an intense exercise program.", "9. His vital signs are within normal limits.", "10. Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally.", "11. A photograph of the lesion is shown." ]

[ "1. No history of itching or pain associated with the lesion.", "2. He is sexually active with two female partners and uses condoms inconsistently.", "3. Five weeks ago, he returned from a trip to the Caribbean with some of his football teammates.", "4. He takes no medications.", "5. He has recently started an intense exercise program.", "6. His vital signs are within normal limits.", "7. Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally.", "8. A photograph of the lesion is shown." ]

[ "A 36-year-old man presents to a physician for a post-transplant medical evaluation.", "He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant.", "He complains of fever, cough, and anorexia for the last 6-7 days.", "His cough is productive of thick sputum.", "His temperature is 38.5°C (101.5°F).", "The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance.", "A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray.", "A sputum analysis reveals branched, irregular, gram-positive filamentous rods." ]

[ "1. A 36-year-old man presents to a physician for a post-transplant medical evaluation.", "2. He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant.", "3. He complains of fever, cough, and anorexia for the last 6-7 days.", "4. His cough is productive of thick sputum.", "5. His temperature is 38.5°C (101.5°F).", "6. The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance.", "7. A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray.", "8. A sputum analysis reveals branched, irregular, gram-positive filamentous rods." ]

[ "1. He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant.", "2. He complains of fever, cough, and anorexia for the last 6-7 days.", "3. His cough is productive of thick sputum.", "4. His temperature is 38.5°C (101.5°F).", "5. The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance.", "6. A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray.", "7. A sputum analysis reveals branched, irregular, gram-positive filamentous rods." ]

[ "A 54-year-old woman presents to her gynecologist complaining of incontinence.", "She reports leakage of a small amount of urine when she coughs or laughs as well as occasionally when she is exercising.", "She denies any pain with urination.", "She underwent menopause 2 years ago and noted that this problem has increased in frequency since that time.", "Her history is significant only for three uncomplicated pregnancies with vaginal births.", "Urinalysis, post-void residual, and cystometrogram are conducted and all show normal results.", "The patient's vital signs are as follows: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%.", "Physical examination is significant for pelvic organ prolapse on pelvic exam." ]

[ "1. Patient is 54 years old.", "2. Patient is complaining of incontinence.", "3. Patient reports leakage of small amount of urine when coughing, laughing, and exercising.", "4. Patient denies any pain with urination.", "5. Patient underwent menopause 2 years ago.", "6. Problem has increased in frequency since menopause.", "7. Patient has had three uncomplicated pregnancies with vaginal births.", "8. Urinalysis, post-void residual, and cystometrogram show normal results.", "9. Patient's temperature is 37.5 C.", "10. Patient's heart rate is 80.", "11. Patient's blood pressure is 128/67.", "12. Patient's respiratory rate is 12.", "13. Patient's SpO2 is 99%.", "14. Pelvic organ prolapse is present on pelvic exam." ]

[ "1. The patient reports leakage of a small amount of urine when she coughs or laughs.", "2. The patient reports leakage of urine occasionally when she is exercising.", "3. The patient denies any pain with urination.", "4. The patient underwent menopause 2 years ago.", "5. The patient noted that the urinary leakage problem has increased in frequency since menopause.", "6. The patient has a history of three uncomplicated pregnancies with vaginal births.", "7. Urinalysis shows normal results.", "8. Post-void residual test shows normal results.", "9. Cystometrogram shows normal results.", "10. The patient's vital signs are: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%.", "11. Physical examination shows pelvic organ prolapse on pelvic exam." ]

[ "Researchers from a public health institute located in the United States conducted a multicenter cohort study on a large number of elderly individuals in order to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation.", "After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine compared to 20% of diseased study participants in the control group that did not receive the vaccine.", "If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained, regardless of the different baseline risk for shingles development." ]

[ "1. Researchers from a public health institute located in the United States conducted a multicenter cohort study. ", "2. The study was conducted on a large number of elderly individuals. ", "3. The purpose of the study was to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation. ", "4. After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine. ", "5. 20% of diseased study participants in the control group that did not receive the vaccine developed shingles. ", "6. If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained. ", "7. This would be true regardless of the different baseline risk for shingles development." ]

[ "1. After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine.", "2. Shingles developed in 20% of diseased study participants in the control group that did not receive the vaccine.", "3. The new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation.", "4. For example, 40% and 10% risk.", "5. The calculated protective proportion of 25% would be maintained, regardless of the different baseline risk for shingles development." ]

[ "A 55-year-old gentleman has been working in a sand blasting factory for over 25 years.", "He presents to his primary care physician with what he describes as increasing shortness of breath.", "PFTs are performed describing a restrictive lung process." ]

[ "1. A 55-year-old gentleman has been working in a sand blasting factory for over 25 years.", "2. He presents to his primary care physician with what he describes as increasing shortness of breath.", "3. PFTs are performed.", "4. PFTs describe a restrictive lung process." ]

[ "1. The patient presents to his primary care physician.", "2. He describes increasing shortness of breath.", "3. Pulmonary function tests (PFTs) are performed.", "4. The PFTs describe a restrictive lung process." ]

[ "A 37-year-old man presents to the emergency department with acute loss of vision, slurred speech, and agitation.", "Past medical history is significant for HIV and hepatitis C, diagnosed 10 years ago for which he is non-compliant with medication.", "A T1 MRI of the brain shows asymmetric, hypointense white matter lesions." ]

[ "1. A 37-year-old man presents to the emergency department.", "2. Symptoms include acute loss of vision, slurred speech, and agitation.", "3. Patient has a past medical history of HIV and hepatitis C.", "4. HIV and hepatitis C were diagnosed 10 years ago.", "5. Patient is non-compliant with medication.", "6. A T1 MRI of the brain was performed.", "7. MRI shows asymmetric, hypointense white matter lesions." ]

[ "1. Past medical history includes HIV and hepatitis C.", "2. HIV and hepatitis C were diagnosed 10 years ago.", "3. The patient is non-compliant with medication for HIV and hepatitis C.", "4. A T1 MRI of the brain shows asymmetric, hypointense white matter lesions." ]

[ "A 4-year-old girl is brought to the physician for evaluation of a rash that her mother noticed 5 months ago.", "The rash is not painful or itchy but she notices that her daughter sometimes picks at the “spots.” The girl's 2-year-old brother has also started developing similar skin lesions over the past month.", "The patient has no history of serious illness and takes no medications.", "She is in the 75th percentile for height and 50th percentile for weight.", "A photograph of the patient's rash is shown." ]

[ "1. A 4-year-old girl is brought to the physician for evaluation of a rash.", "2. The rash was noticed by the mother 5 months ago.", "3. The rash is not painful or itchy.", "4. The girl sometimes picks at the “spots.”", "5. The girl's 2-year-old brother has also started developing similar skin lesions over the past month.", "6. The patient has no history of serious illness.", "7. The patient takes no medications.", "8. The patient is in the 75th percentile for height.", "9. The patient is in the 50th percentile for weight.", "10. A photograph of the patient's rash is shown." ]

[ "1. The rash is not painful or itchy.", "2. The patient's daughter sometimes picks at the \"spots.\"", "3. The girl's 2-year-old brother has started developing similar skin lesions over the past month.", "4. The patient has no history of serious illness.", "5. The patient takes no medications.", "6. The patient is in the 75th percentile for height.", "7. The patient is in the 50th percentile for weight.", "8. A photograph of the patient's rash is shown." ]

[ "A 51-year-old police officer is brought to the emergency room after being shot in the abdomen.", "His wound was packed and bandaged by emergency medical services before he was transported to the hospital.", "His past medical history is notable for hypertension and diabetes.", "He takes metformin and lisinopril.", "He has a 20-pack-year smoking history and does not drink alcohol.", "His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min.", "On exam, he appears uncomfortable but is able to answer questions appropriately.", "He has a 1 cm x 1 cm wound in the left upper quadrant.", "There is an exit wound in the left lower back.", "After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy.", "No involvement of the colon or small intestine is noted intraoperatively.", "He is placed on the appropriate antibiotic and pain control regimens.", "Three days later, he experiences several episodes of non-bloody diarrhea.", "His temperature is 101°F (38.3°C).", "Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon." ]

[ "1. A 51-year-old police officer is brought to the emergency room after being shot in the abdomen.", "2. His wound was packed and bandaged by emergency medical services before he was transported to the hospital.", "3. His past medical history is notable for hypertension and diabetes.", "4. He takes metformin and lisinopril.", "5. He has a 20-pack-year smoking history and does not drink alcohol.", "6. His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min.", "7. On exam, he appears uncomfortable but is able to answer questions appropriately.", "8. He has a 1 cm x 1 cm wound in the left upper quadrant.", "9. There is an exit wound in the left lower back.", "10. After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy.", "11. No involvement of the colon or small intestine is noted intraoperatively.", "12. He is placed on the appropriate antibiotic and pain control regimens.", "13. Three days later, he experiences several episodes of non-bloody diarrhea.", "14. His temperature is 101°F (38.3°C).", "15. Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon." ]

[ "1. His wound was packed and bandaged by emergency medical services before he was transported to the hospital.", "2. His past medical history is notable for hypertension and diabetes.", "3. He takes metformin and lisinopril.", "4. He has a 20-pack-year smoking history and does not drink alcohol.", "5. His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min.", "6. On exam, he appears uncomfortable but is able to answer questions appropriately.", "7. He has a 1 cm x 1 cm wound in the left upper quadrant.", "8. There is an exit wound in the left lower back.", "9. After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy.", "10. No involvement of the colon or small intestine is noted intraoperatively.", "11. He is placed on the appropriate antibiotic and pain control regimens.", "12. Three days later, he experiences several episodes of non-bloody diarrhea.", "13. His temperature is 101°F (38.3°C).", "14. Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon." ]

[ "A 3-year-old girl is brought to the physician by her parents for the evaluation of vaginal discharge for one month.", "The discharge is foul-smelling and contains some blood.", "The patient sometimes has pain with urination.", "She has not had increased urinary frequency or abdominal pain.", "Topical vaginal cream application did not improve the patient's symptoms.", "There is no personal or family history of serious illness.", "She lives with her parents and attends a local daycare center.", "Vital signs are within normal limits.", "Examination of the vulva and vaginal entrance shows an intact hymen, vaginal erythema with blood-tinged, foul-smelling discharge, and the tip of a white object.", "The remainder of the examination shows no abnormalities." ]

[ "1. A 3-year-old girl is brought to the physician by her parents.", "2. The patient has had vaginal discharge for one month.", "3. The discharge is foul-smelling and contains some blood.", "4. The patient sometimes has pain with urination.", "5. She has not had increased urinary frequency or abdominal pain.", "6. Topical vaginal cream application did not improve the patient's symptoms.", "7. There is no personal or family history of serious illness.", "8. She lives with her parents and attends a local daycare center.", "9. Vital signs are within normal limits.", "10. Examination of the vulva and vaginal entrance shows an intact hymen.", "11. Examination of the vulva and vaginal entrance shows vaginal erythema with blood-tinged, foul-smelling discharge.", "12. Examination of the vulva and vaginal entrance shows the tip of a white object.", "13. The remainder of the examination shows no abnormalities." ]

[ "1. The discharge is foul-smelling and contains some blood.", "2. The patient sometimes has pain with urination.", "3. She has not had increased urinary frequency or abdominal pain.", "4. Topical vaginal cream application did not improve the patient's symptoms.", "5. There is no personal or family history of serious illness.", "6. She lives with her parents and attends a local daycare center.", "7. Vital signs are within normal limits.", "8. Examination of the vulva and vaginal entrance shows an intact hymen, vaginal erythema with blood-tinged, foul-smelling discharge, and the tip of a white object.", "9. The remainder of the examination shows no abnormalities." ]

[ "A 60-year-old man comes to the physician because of a 3-month history of a slowly enlarging painless ulcer on his lower lip.", "One year ago he had a painful rash near his upper lip that resolved completely with acyclovir therapy.", "He has a 10-year history of type 2 diabetes mellitus treated with metformin.", "He has worked in construction for the past 33 years.", "He has smoked one pack of cigarettes daily for 35 years.", "Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.", "The erythematous ulcer bleeds upon palpation.", "He has numerous moles of varying sizes all over his body.", "There are no palpable cervical lymph nodes." ]

[ "1. A 60-year-old man comes to the physician.", "2. He has a 3-month history of a slowly enlarging painless ulcer on his lower lip.", "3. One year ago he had a painful rash near his upper lip.", "4. The rash resolved completely with acyclovir therapy.", "5. He has a 10-year history of type 2 diabetes mellitus.", "6. He is treated with metformin.", "7. He has worked in construction for the past 33 years.", "8. He has smoked one pack of cigarettes daily for 35 years.", "9. Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.", "10. The erythematous ulcer bleeds upon palpation.", "11. He has numerous moles of varying sizes all over his body.", "12. There are no palpable cervical lymph nodes." ]

[ "1. One year ago, he had a painful rash near his upper lip that resolved completely with acyclovir therapy.", "2. He has a 10-year history of type 2 diabetes mellitus treated with metformin.", "3. He has worked in construction for the past 33 years.", "4. He has smoked one pack of cigarettes daily for 35 years.", "5. Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.", "6. The erythematous ulcer bleeds upon palpation.", "7. He has numerous moles of varying sizes all over his body.", "8. There are no palpable cervical lymph nodes." ]

[ "A 3-year-old girl is brought to the pediatrician by her father for fever and cough.", "The patient’s father states that she had a sore throat and runny nose 2 weeks ago.", "Then last night she developed a productive cough and a fever.", "The father is worried that this is pneumonia again, and reports that she has been hospitalized 5 times already with pneumonia.", "Her medical history is also significant for chronic diarrhea.", "The father reports that the patient has 2 older brothers who are both healthy.", "The patient’s temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air.", "On physical examination, decreased breath sounds are appreciated on the right.", "A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.", "An antibody panel and flow cytometry are obtained in the setting of the patient’s recurrent infections.", "The results show a normal lymphocyte count with low levels of IgA, IgG, and IgE and elevated levels of IgM." ]

[ "1. A 3-year-old girl is brought to the pediatrician by her father.", "2. The patient had a sore throat and runny nose 2 weeks ago.", "3. Last night she developed a productive cough and a fever.", "4. The father is worried that this is pneumonia again.", "5. The patient has been hospitalized 5 times already with pneumonia.", "6. The patient has a medical history of chronic diarrhea.", "7. The patient has 2 older brothers who are both healthy.", "8. The patient's temperature is 102°F (38.9°C).", "9. The patient's blood pressure is 102/60 mmHg.", "10. The patient's pulse is 110/min.", "11. The patient's respirations are 28/min with an oxygen saturation of 94% on room air.", "12. On physical examination, decreased breath sounds are appreciated on the right.", "13. A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.", "14. An antibody panel and flow cytometry are obtained in the setting of the patient's recurrent infections.", "15. The results show a normal lymphocyte count.", "16. The results show low levels of IgA, IgG, and IgE.", "17. The results show elevated levels of IgM." ]

[ "1. The patient had a sore throat and runny nose 2 weeks ago.", "2. Last night, the patient developed a productive cough and a fever.", "3. The patient has been hospitalized 5 times already with pneumonia.", "4. The patient's medical history is significant for chronic diarrhea.", "5. The patient has 2 older brothers who are both healthy.", "6. The patient's temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air.", "7. On physical examination, decreased breath sounds are appreciated on the right.", "8. A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.", "9. An antibody panel and flow cytometry are obtained in the setting of the patient's recurrent infections.", "10. The results show a normal lymphocyte count with low levels of IgA, IgG, and IgE and elevated levels of IgM." ]

[ "A 72-year-old man presents with urinary frequency resulting in frequent awakening to urinate at night.", "He is a retired elite runner and does not have a history of any chronic medical conditions.", "The patient denies weight loss, bone pain, or pain with urination.", "The patient is not in distress.", "Vitals show: temperature 36.8°C (98.2°F), heart rate 98/min, respiratory rate 15/min, and blood pressure 100/75 mm Hg.", "Physical exam is significant for a smooth, non-tender, uniformly enlarged prostate on digital rectal exam.", "There is no CVA tenderness.", "CBC, CMP, urinalysis, and abdominal ultrasound are ordered.", "Significant findings include: bilateral hydronephrosis on ultrasound, BUN/creatinine > 20:1, specific gravity > 1,020, FENa < 1%, urine Na < 20, and urine osmolality > 450 mOsm/kg.", "Furthermore, post-void residual volume is > 100 mL." ]

[ "1. Patient is 72 years old.", "2. Patient is a retired elite runner.", "3. Patient has urinary frequency resulting in frequent awakening to urinate at night.", "4. Patient does not have a history of any chronic medical conditions.", "5. Patient denies weight loss, bone pain, or pain with urination.", "6. Patient is not in distress.", "7. Temperature is 36.8°C (98.2°F).", "8. Heart rate is 98/min.", "9. Respiratory rate is 15/min.", "10. Blood pressure is 100/75 mm Hg.", "11. Digital rectal exam reveals a smooth, non-tender, uniformly enlarged prostate.", "12. No CVA tenderness.", "13. Bilateral hydronephrosis on ultrasound.", "14. BUN/creatinine > 20:1.", "15. Specific gravity > 1,020.", "16. FENa < 1%.", "17. Urine Na < 20.", "18. Urine osmolality > 450 mOsm/kg.", "19. Post-void residual volume is > 100 mL." ]

[ "1. The patient is a retired elite runner.", "2. The patient does not have a history of any chronic medical conditions.", "3. The patient denies weight loss, bone pain, or pain with urination.", "4. The patient is not in distress.", "5. Vitals show: temperature 36.8°C (98.2°F), heart rate 98/min, respiratory rate 15/min, and blood pressure 100/75 mm Hg.", "6. Physical exam is significant for a smooth, non-tender, uniformly enlarged prostate on digital rectal exam.", "7. There is no CVA tenderness.", "8. CBC, CMP, urinalysis, and abdominal ultrasound are ordered.", "9. Significant findings include: bilateral hydronephrosis on ultrasound, BUN/creatinine > 20:1, specific gravity > 1,020, FENa < 1%, urine Na < 20, and urine osmolality > 450 mOsm/kg.", "10. Post-void residual volume is > 100 mL." ]

[ "An 82-year-old man with Alzheimer disease is brought to the physician by his daughter because of extensive bruising on his arms.", "He lives in an assisted living facility.", "Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.", "His hemoglobin concentration is 11.7 g/dL, mean corpuscular volume is 78 μm3, and platelet count is 180,000/mm3.", "Coagulation studies are within normal limits." ]

[ "1. An 82-year-old man has Alzheimer disease.", "2. He was brought to the physician by his daughter.", "3. He has extensive bruising on his arms.", "4. He lives in an assisted living facility.", "5. Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.", "6. His hemoglobin concentration is 11.7 g/dL.", "7. His mean corpuscular volume is 78 μm3.", "8. His platelet count is 180,000/mm3.", "9. Coagulation studies are within normal limits." ]

[ "1. He lives in an assisted living facility.", "2. Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.", "3. His hemoglobin concentration is 11.7 g/dL.", "4. Mean corpuscular volume is 78 μm3.", "5. Platelet count is 180,000/mm3.", "6. Coagulation studies are within normal limits." ]

[ "A 23-year-old woman presents to her gynecologist for a routine visit.", "She is nulliparous, does not report any gynecologic or systemic diseases, and has no complaints.", "She is sexually active with one partner and uses oral contraceptive pills.", "Her vital signs are as follows: blood pressure 125/70 mm Hg, heart rate 81/min, respiratory rate 12/min, and temperature 36.6℃ (97.9℉).", "The physical examination is within normal limits.", "The breast examination is normal.", "No pathology is noted in the external genitalia and a speculum examination reveals a normal cervix with a closed external os and no discharge.", "A specimen is obtained from the cervical portion for a Pap smear." ]

[ "1. A 23-year-old woman presents to her gynecologist for a routine visit.", "2. She is nulliparous.", "3. She does not report any gynecologic or systemic diseases.", "4. She has no complaints.", "5. She is sexually active with one partner.", "6. She uses oral contraceptive pills.", "7. Her blood pressure is 125/70 mm Hg.", "8. Her heart rate is 81/min.", "9. Her respiratory rate is 12/min.", "10. Her temperature is 36.6℃ (97.9℉).", "11. The physical examination is within normal limits.", "12. The breast examination is normal.", "13. No pathology is noted in the external genitalia.", "14. A speculum examination reveals a normal cervix with a closed external os and no discharge.", "15. A specimen is obtained from the cervical portion for a Pap smear." ]

[ "1. She is nulliparous.", "2. She does not report any gynecologic or systemic diseases.", "3. She has no complaints.", "4. She is sexually active with one partner.", "5. She uses oral contraceptive pills.", "6. Her blood pressure is 125/70 mm Hg.", "7. Her heart rate is 81/min.", "8. Her respiratory rate is 12/min.", "9. Her temperature is 36.6℃ (97.9℉).", "10. The physical examination is within normal limits.", "11. The breast examination is normal.", "12. No pathology is noted in the external genitalia.", "13. A speculum examination reveals a normal cervix with a closed external os and no discharge.", "14. A specimen is obtained from the cervical portion for a Pap smear." ]

[ "A 57-year-old woman presents to the emergency department with acute pain in the left lower abdomen associated with nausea and vomiting for the past 24 hours.", "Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems except for occasional constipation and indigestion after heavy meals.", "She has had hypertension and hypercholesterolemia for the past 7 years.", "Her family history is negative for GI disorders.", "Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.", "On physical examination, there is tenderness in the left lower abdominal quadrant.", "Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat." ]

[ "1. A 57-year-old woman presents to the emergency department with acute pain in the left lower abdomen associated with nausea and vomiting for the past 24 hours.", "2. Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems except for occasional constipation and indigestion after heavy meals.", "3. She has had hypertension and hypercholesterolemia for the past 7 years.", "4. Her family history is negative for GI disorders.", "5. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.", "6. On physical examination, there is tenderness in the left lower abdominal quadrant.", "7. Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat." ]

[ "1. The patient had occasional constipation and indigestion after heavy meals prior to the current episode.", "2. The patient has had hypertension and hypercholesterolemia for the past 7 years.", "3. The patient's family history is negative for GI disorders.", "4. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.", "5. On physical examination, there is tenderness in the left lower abdominal quadrant.", "6. Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat." ]

[ "A 35-year-old woman comes to the emergency department because of a 3-day history of pain in the left cheek.", "The pain occurs every few hours, lasts 30–60 seconds, and is aggravated by chewing and brushing.", "She has a history of pain with a vesicular rash in the right axillary area one year ago.", "She had an upper respiratory infection 2 weeks ago.", "Physical examination shows no abnormalities." ]

[ "1. A 35-year-old woman comes to the emergency department.", "2. She has a 3-day history of pain in the left cheek.", "3. The pain occurs every few hours.", "4. The pain lasts 30–60 seconds.", "5. The pain is aggravated by chewing and brushing.", "6. She has a history of pain with a vesicular rash in the right axillary area one year ago.", "7. She had an upper respiratory infection 2 weeks ago.", "8. Physical examination shows no abnormalities." ]

[ "1. The pain occurs every few hours.", "2. The pain lasts 30–60 seconds.", "3. The pain is aggravated by chewing and brushing.", "4. She has a history of pain with a vesicular rash in the right axillary area one year ago.", "5. She had an upper respiratory infection 2 weeks ago.", "6. Physical examination shows no abnormalities." ]

[ "A 45 year old male presents to clinic complaining of a ringing in his ears.", "The patient's vitals are: BP 120/65, RR 16, 100% on room air, HR 78 bpm and he appears to be in no acute distress.", "Upon obtaining a history you learn that this patient also complains that at times the \"room feels like it's spinning.\" You also notice throughout the interview that you have to speak loudly as the patient has difficulty hearing.", "The patient is then lost to follow up for his current condition.", "The patient returns several years later with worsening symptoms and as part of this patient's workup a MRI is obtained (Image A)." ]

[ "1. A 45 year old male presents to clinic complaining of a ringing in his ears.", "2. BP 120/65, RR 16, 100% on room air, HR 78 bpm.", "3. Patient appears to be in no acute distress.", "4. Patient also complains that at times the \"room feels like it's spinning.\"", "5. Patient has difficulty hearing.", "6. Patient is then lost to follow up for his current condition.", "7. Patient returns several years later with worsening symptoms.", "8. MRI is obtained (Image A)." ]

[ "1. The patient's vitals are: BP 120/65, RR 16, 100% on room air, HR 78 bpm.", "2. The patient appears to be in no acute distress.", "3. The patient complains of feeling like the \"room feels like it's spinning.\"", "4. The patient has difficulty hearing.", "5. The patient is lost to follow up for his current condition.", "6. The patient returns several years later with worsening symptoms.", "7. A MRI is obtained as part of the patient's workup (Image A)." ]

[ "A 35-year-old is brought into the emergency room after a bicycle vs motored vehicle accident.", "He was unconscious after hitting the side of his head on the road, but recovered consciousness after a few minutes.", "He started to ride his bicycle again, but then developed a severe headache with nausea and vomiting, at which time he called EMS.", "While in the hospital, the patient is confused and cannot provide a history.", "He quickly loses consciousness and his CT scan is displayed in Figure 1." ]

[ "1. A 35-year-old was brought into the emergency room.", "2. The patient was involved in a bicycle vs motored vehicle accident.", "3. He was unconscious after hitting the side of his head on the road.", "4. He recovered consciousness after a few minutes.", "5. He started to ride his bicycle again.", "6. He then developed a severe headache with nausea and vomiting.", "7. He called EMS at this time.", "8. While in the hospital, the patient was confused and could not provide a history.", "9. He quickly lost consciousness.", "10. His CT scan is displayed in Figure 1." ]

[ "1. He was unconscious after hitting the side of his head on the road.", "2. He recovered consciousness after a few minutes.", "3. He started to ride his bicycle again.", "4. He developed a severe headache with nausea and vomiting.", "5. He called EMS at the time of developing severe symptoms.", "6. While in the hospital, the patient is confused.", "7. He cannot provide a history.", "8. He quickly loses consciousness.", "9. His CT scan is displayed in Figure 1." ]

[ "A 39-year-old man comes to the physician because of a 2-month history of shortness of breath with exertion.", "He immigrated to the United States from Ghana 20 years ago.", "His pulse is 88/min, respirations are 18/min, and blood pressure is 120/80 mm Hg.", "Echocardiography shows thickened mitral valve leaflets with reduced motion and a narrowed mitral valve orifice diameter." ]

[ "1. A 39-year-old man comes to the physician.", "2. He has a 2-month history of shortness of breath with exertion.", "3. He immigrated to the United States from Ghana 20 years ago.", "4. His pulse is 88/min.", "5. His respirations are 18/min.", "6. His blood pressure is 120/80 mm Hg.", "7. Echocardiography shows thickened mitral valve leaflets.", "8. Echocardiography shows reduced motion of the mitral valve leaflets.", "9. Echocardiography shows a narrowed mitral valve orifice diameter." ]

[ "1. He immigrated to the United States from Ghana 20 years ago.", "2. His pulse is 88/min.", "3. His respirations are 18/min.", "4. His blood pressure is 120/80 mm Hg.", "5. Echocardiography shows thickened mitral valve leaflets.", "6. Echocardiography shows reduced motion of the mitral valve.", "7. Echocardiography shows a narrowed mitral valve orifice diameter." ]

[ "A 6-year-old boy is brought to the physician because of worsening fatigue for the past 4 weeks.", "Examination of the head and neck shows conjunctival pallor, grayish-brown spots on the irises, prominent epicanthal folds, and a broad nasal bridge.", "He has a single transverse palmar crease, and there are scattered petechiae over the chest.", "An ultrasound of the abdomen shows enlargement of the liver and spleen." ]

[ "1. A 6-year-old boy is brought to the physician.", "2. The boy has been experiencing worsening fatigue for the past 4 weeks.", "3. Examination of the head and neck shows conjunctival pallor.", "4. Examination of the head and neck shows grayish-brown spots on the irises.", "5. Examination of the head and neck shows prominent epicanthal folds.", "6. Examination of the head and neck shows a broad nasal bridge.", "7. The boy has a single transverse palmar crease.", "8. There are scattered petechiae over the chest.", "9. An ultrasound of the abdomen shows enlargement of the liver.", "10. An ultrasound of the abdomen shows enlargement of the spleen." ]

[ "1. Examination of the head and neck shows conjunctival pallor.", "2. Examination of the head and neck shows grayish-brown spots on the irises.", "3. Examination of the head and neck shows prominent epicanthal folds.", "4. Examination of the head and neck shows a broad nasal bridge.", "5. He has a single transverse palmar crease.", "6. There are scattered petechiae over the chest.", "7. An ultrasound of the abdomen shows enlargement of the liver and spleen." ]

[ "A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever.", "The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks.", "On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding.", "The patient is noticeably jaundiced.", "Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL." ]

[ "1. A 42-year-old female presents to the emergency department.", "2. She has two days of severe abdominal pain and fever.", "3. She has a history of gallstones.", "4. She was scheduled to have a cholecystectomy in two weeks.", "5. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding.", "6. The patient is noticeably jaundiced.", "7. Laboratory evaluation is notable for a leukocytosis.", "8. Laboratory evaluation is notable for a total bilirubin of 6.4 mg/dL." ]

[ "1. The patient has a history of gallstones.", "2. The patient was scheduled to have a cholecystectomy in two weeks.", "3. On physical exam, the patient's abdomen is tender to palpation over the epigastrium.", "4. There is no rebound or guarding on physical exam.", "5. The patient is noticeably jaundiced.", "6. Laboratory evaluation shows leukocytosis.", "7. Laboratory evaluation shows a total bilirubin of 6.4 mg/dL." ]

[ "A 52-year-old woman presents to her primary care physician because she has been feeling pain in her right leg.", "Specifically, she says that an area on her right thigh has been feeling tender and swollen over the past few weeks.", "Her past medical history is significant for obesity, poorly controlled diabetes, and hypertension.", "She also has been taking estrogen replacement therapy and drinking alcohol to cope with her symptoms of menopause.", "Her family history is significant for cardiomyopathy.", "On physical exam, there is erythema and edema along a cord-like lesion in her thigh.", "This lesion feels thick and hardened on palpation and is tender to the touch.", "She is started on compression therapy as well as NSAIDs for pain management." ]

[ "1. A 52-year-old woman presents to her primary care physician.", "2. She has been feeling pain in her right leg.", "3. Specifically, she says that an area on her right thigh has been feeling tender and swollen over the past few weeks.", "4. Her past medical history is significant for obesity, poorly controlled diabetes, and hypertension.", "5. She has been taking estrogen replacement therapy.", "6. She has been drinking alcohol to cope with her symptoms of menopause.", "7. Her family history is significant for cardiomyopathy.", "8. On physical exam, there is erythema and edema along a cord-like lesion in her thigh.", "9. This lesion feels thick and hardened on palpation.", "10. This lesion is tender to the touch.", "11. She is started on compression therapy.", "12. She is started on NSAIDs for pain management." ]

[ "1. The patient reports tenderness and swelling in an area on her right thigh.", "2. The patient has a past medical history of obesity, poorly controlled diabetes, and hypertension.", "3. The patient has been taking estrogen replacement therapy and drinking alcohol to cope with menopausal symptoms.", "4. The patient's family history includes cardiomyopathy.", "5. On physical exam, there is erythema and edema along a cord-like lesion in her thigh.", "6. The lesion feels thick and hardened on palpation and is tender to the touch.", "7. The patient is started on compression therapy and NSAIDs for pain management." ]

[ "A 34-year-old woman presents to the clinic complaining of constipation and dry mouth.", "She had uncontrollable diarrhea for 1 day and took some medications afterwards.", "Patient denies any recent hospitalizations or antibiotic use.", "She also denies melena, hematochezia, nausea, or vomiting.", "Vitals are within normal limits." ]

[ "1. A 34-year-old woman presents to the clinic.", "2. She is complaining of constipation and dry mouth.", "3. She had uncontrollable diarrhea for 1 day.", "4. She took some medications afterwards.", "5. Patient denies any recent hospitalizations or antibiotic use.", "6. Patient denies melena, hematochezia, nausea, or vomiting.", "7. Vitals are within normal limits." ]

[ "1. The patient had uncontrollable diarrhea for 1 day.", "2. The patient took some medications afterwards.", "3. The patient denies any recent hospitalizations.", "4. The patient denies any recent antibiotic use.", "5. The patient denies melena.", "6. The patient denies hematochezia.", "7. The patient denies nausea.", "8. The patient denies vomiting.", "9. The patient's vitals are within normal limits." ]

[ "A 25-year-old arrives at a gynecology clinic for a consult as she and her husband plan to conceive a baby soon.", "She is currently taking no medications, doesn’t smoke, and drinks alcohol socially.", "Her father passed away at the age of 51 due to heart failure.", "Her vital signs include blood pressure 150/100 mm Hg, heart rate 67/min, respiratory rate 16/min, and temperature 36.7°C (98.0°F).", "Physical examination is unremarkable.", "When asked about her high blood pressure, the patient says that her primary care physician once told her that her blood pressure was elevated on most of her visits; the physician emphasized that she should exercise and control her diet, but she never followed up with him as she always felt good.", "A number of tests are run to find out the etiology of her elevated blood pressure.", "Everything is within the normal range except for a renal angiogram shown in the picture." ]

[ "1. A 25-year-old is at a gynecology clinic for a consult.", "2. The patient and her husband plan to conceive a baby soon.", "3. The patient is not taking any medications.", "4. The patient does not smoke.", "5. The patient drinks alcohol socially.", "6. The patient's father passed away at the age of 51 due to heart failure.", "7. The patient's blood pressure is 150/100 mm Hg.", "8. The patient's heart rate is 67/min.", "9. The patient's respiratory rate is 16/min.", "10. The patient's temperature is 36.7°C (98.0°F).", "11. The physical examination is unremarkable.", "12. The patient's primary care physician told her that her blood pressure was elevated on most of her visits.", "13. The primary care physician emphasized that the patient should exercise and control her diet.", "14. The patient never followed up with her primary care physician as she always felt good.", "15. Tests are run to find out the etiology of the patient's elevated blood pressure.", "16. Everything is within the normal range except for a renal angiogram shown in the picture." ]

[ "1. She is currently taking no medications.", "2. She doesn’t smoke.", "3. She drinks alcohol socially.", "4. Her father passed away at the age of 51 due to heart failure.", "5. Her vital signs include blood pressure 150/100 mm Hg.", "6. Her heart rate is 67/min.", "7. Her respiratory rate is 16/min.", "8. Her temperature is 36.7°C (98.0°F).", "9. Physical examination is unremarkable.", "10. The patient's primary care physician once told her that her blood pressure was elevated on most of her visits.", "11. The physician emphasized that she should exercise and control her diet.", "12. She never followed up with her physician as she always felt good.", "13. A number of tests are run to find out the etiology of her elevated blood pressure.", "14. Everything is within the normal range except for a renal angiogram shown in the picture." ]

[ "A 73-year-old man is found to have an early stage hepatocellular carcinoma in the left lobe of his liver.", "He decides to undergo surgery to remove the tumor through partial liver resection.", "During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall.", "Since part of this ligament lies over the part of the liver that needs to be resected, the ligament is incised to allow for removal of the tumor.", "The free edge of the ligament is found to have a thickening with small remnant blood vessels." ]

[ "1. A 73-year-old man is found to have an early stage hepatocellular carcinoma in the left lobe of his liver.", "2. He decides to undergo surgery to remove the tumor through partial liver resection.", "3. During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall.", "4. Part of this ligament lies over the part of the liver that needs to be resected.", "5. The ligament is incised to allow for removal of the tumor.", "6. The free edge of the ligament is found to have a thickening.", "7. The thickening has small remnant blood vessels." ]

[ "1. He decides to undergo surgery to remove the tumor through partial liver resection.", "2. During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall.", "3. Part of the ligament lies over the part of the liver that needs to be resected.", "4. The ligament is incised to allow for removal of the tumor.", "5. The free edge of the ligament is found to have a thickening with small remnant blood vessels." ]

[ "A researcher is conducting an experiment on the physiology of body fluids.", "He documents specific observations and plots some of them as a Darrow-Yannet diagram.", "In his study, some diagrams are normal, while most are abnormal.", "The abnormalities in the diagram are mostly in the form of changes in the x-axis, changes in the y-axis or changes in both axes of the diagram." ]

[ "1. A researcher is conducting an experiment on the physiology of body fluids.", "2. He documents specific observations.", "3. He plots some of the observations as a Darrow-Yannet diagram.", "4. Some diagrams are normal.", "5. Most diagrams are abnormal.", "6. The abnormalities in the diagram are mostly in the form of changes in the x-axis.", "7. The abnormalities in the diagram are mostly in the form of changes in the y-axis.", "8. The abnormalities in the diagram are mostly in the form of changes in both axes of the diagram." ]

[ "1. He documents specific observations.", "2. He plots some observations as a Darrow-Yannet diagram.", "3. In his study, some diagrams are normal.", "4. Most diagrams in his study are abnormal.", "5. The abnormalities in the diagram are mostly in the form of changes in the x-axis.", "6. The abnormalities in the diagram are mostly in the form of changes in the y-axis.", "7. The abnormalities in the diagram are mostly in the form of changes in both axes of the diagram." ]

[ "An 11-year-old girl is brought to a pediatrician by her parents with recurrent wheezing for the last 3 years.", "After a detailed history, complete physical examination, and thorough diagnostic evaluation, the pediatrician informs the parents that the girl has mild persistent asthma, which will be most effectively treated with inhaled corticosteroids (ICS).", "However, her parents firmly object to the use of corticosteroids in any form, despite being told that the side effects associated with ICS are negligible.", "Therefore, the pediatrician suggests the regular use of a drug that does not contain a corticosteroid.", "The pediatrician mentions that the drug is used as prophylaxis only and will not be useful to treat acute bronchospasm." ]

[ "1. An 11-year-old girl is brought to a pediatrician by her parents.", "2. The girl has had recurrent wheezing for the last 3 years.", "3. The pediatrician has conducted a detailed history, complete physical examination, and thorough diagnostic evaluation.", "4. The pediatrician has informed the parents that the girl has mild persistent asthma.", "5. The most effective treatment for the girl's asthma is inhaled corticosteroids (ICS).", "6. The parents object to the use of corticosteroids in any form.", "7. The pediatrician has informed the parents that the side effects associated with ICS are negligible.", "8. The pediatrician has suggested the regular use of a drug that does not contain a corticosteroid.", "9. The drug is used as prophylaxis only and will not be useful to treat acute bronchospasm." ]

[ "1. The girl has mild persistent asthma.", "2. The most effective treatment for her asthma is inhaled corticosteroids (ICS).", "3. The parents object to the use of corticosteroids in any form.", "4. The side effects associated with ICS are negligible.", "5. The pediatrician suggests the regular use of a drug that does not contain a corticosteroid.", "6. The drug is used as prophylaxis only.", "7. The drug will not be useful to treat acute bronchospasm." ]

[ "A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients by a novel mechanism of action.", "The drug A is an inactive prodrug and enters hepatocytes, reacts with reactant B, a native material in the cell, and creates products C and D.", "D has a blood pressure lowering effects.", "The reaction requires the presence of enzyme E.", "The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes whereas, in hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason." ]

[ "1. A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients.", "2. The drug A is an inactive prodrug and enters hepatocytes.", "3. The drug A reacts with reactant B, a native material in the cell.", "4. The reaction creates products C and D.", "5. Product D has a blood pressure lowering effect.", "6. The reaction requires the presence of enzyme E.", "7. The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes.", "8. In hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason." ]

[ "1. Drug A is an inactive prodrug.", "2. Drug A enters hepatocytes.", "3. Drug A reacts with reactant B.", "4. Reactant B is a native material in the cell.", "5. The reaction of A and B creates products C and D.", "6. Product D has blood pressure lowering effects.", "7. The reaction requires the presence of enzyme E.", "8. In normal hepatocytes, the Gibbs free energy change (ΔG) for the reaction is less than zero.", "9. In hepatocytes of patients with fatty liver, ΔG for the reaction is more than 0.", "10. The reason for the change in ΔG in fatty liver patients is unknown." ]

[ "A 70-year-old man comes to the physician because of a 4-month history of progressively worsening lower back pain.", "He describes the pain as a constant, dull ache that interferes with his sleep and is only partially relieved with ibuprofen.", "Two years ago, he was diagnosed with advanced prostate cancer, for which he underwent radiation therapy of the prostate and bilateral orchiectomy.", "One year postoperatively, serum prostate-specific antigen (PSA) was undetectable.", "He missed his previous follow-up visit.", "Current medications include over-the-counter ibuprofen.", "Vital signs are within normal limits.", "Physical examination shows tenderness of the spinous process of the third lumbar vertebra.", "Digital rectal examination shows a hard, nontender prostate.", "The remainder of the examination shows no abnormalities.", "The serum PSA concentration is 16 ng/mL (N<4).", "A technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies." ]

[ "1. Patient is 70 years old.", "2. Patient has 4-month history of progressively worsening lower back pain.", "3. Patient describes pain as constant, dull ache.", "4. Pain interferes with sleep and is only partially relieved with ibuprofen.", "5. Two years ago, patient was diagnosed with advanced prostate cancer.", "6. Patient underwent radiation therapy of the prostate and bilateral orchiectomy.", "7. One year postoperatively, serum prostate-specific antigen (PSA) was undetectable.", "8. Patient missed previous follow-up visit.", "9. Current medications include over-the-counter ibuprofen.", "10. Vital signs are within normal limits.", "11. Physical examination shows tenderness of the spinous process of the third lumbar vertebra.", "12. Digital rectal examination shows a hard, nontender prostate.", "13. The remainder of the examination shows no abnormalities.", "14. Serum PSA concentration is 16 ng/mL (N<4).", "15. Technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies." ]

[ "1. Patient describes pain as constant, dull ache interfering with sleep", "2. Pain partially relieved with ibuprofen", "3. Diagnosed with advanced prostate cancer two years ago", "4. Underwent radiation therapy of the prostate and bilateral orchiectomy", "5. One year postoperatively, serum PSA was undetectable", "6. Missed previous follow-up visit", "7. Current medications include over-the-counter ibuprofen", "8. Vital signs are within normal limits", "9. Physical examination shows tenderness of the spinous process of the third lumbar vertebra", "10. Digital rectal examination shows hard, nontender prostate", "11. Remainder of the examination shows no abnormalities", "12. Serum PSA concentration is 16 ng/mL (N<4)", "13. Technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies" ]

[ "A 24-year-old woman presents complaining of a new onset vaginal odor.", "She reports that she is sexually active in a monogamous relationship with the same partner for two years.", "You perform a KOH prep, and notice an abnormal smell.", "On microscopy in your office, you observe the findings in figure A. | | ." ]

[ "1. A 24-year-old woman presents complaining of a new onset vaginal odor.", "2. She reports that she is sexually active in a monogamous relationship with the same partner for two years.", "3. You perform a KOH prep.", "4. You notice an abnormal smell.", "5. On microscopy in your office, you observe the findings in figure A." ]

[ "1. The patient reports being sexually active.", "2. The patient is in a monogamous relationship.", "3. The relationship has lasted for two years.", "4. A KOH prep was performed.", "5. An abnormal smell was noticed during the KOH prep.", "6. Microscopy was performed in the office.", "7. Abnormal findings were observed in figure A." ]

[ "A 22-year-old woman is brought to the emergency department 4 hours after the ingestion of 25 tablets of an unknown drug in an attempt to commit suicide.", "Her temperature is 36.7°C (98°F), pulse is 41/min, respirations are 14/min, and blood pressure is 88/55 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 93%.", "She is confused and oriented only to person.", "The pupils are equal and reactive to light.", "Examination shows cold, clammy extremities.", "Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.", "The abdomen is soft.", "Fingerstick blood glucose concentration is 65 mg/dL.", "ECG shows prolonged PR intervals and narrow QRS complexes.", "Two large bore cannulas are inserted and intravenous normal saline, dextrose, and atropine are administered.", "Five minutes later, pulse is 51/min and blood pressure is 95/61 mm Hg." ]

[ "1. A 22-year-old woman was brought to the emergency department.", "2. She had ingested 25 tablets of an unknown drug 4 hours prior.", "3. The attempt was in an attempt to commit suicide.", "4. Her temperature was 36.7°C (98°F).", "5. Her pulse was 41/min.", "6. Her respirations were 14/min.", "7. Her blood pressure was 88/55 mm Hg.", "8. Pulse oximetry on room air showed an oxygen saturation of 93%.", "9. She was confused and oriented only to person.", "10. Her pupils were equal and reactive to light.", "11. Examination showed cold, clammy extremities.", "12. Scattered expiratory wheezing and rhonchi were heard throughout both lung fields.", "13. Her abdomen was soft.", "14. Fingerstick blood glucose concentration was 65 mg/dL.", "15. ECG showed prolonged PR intervals and narrow QRS complexes.", "16. Two large bore cannulas were inserted.", "17. Intravenous normal saline, dextrose, and atropine were administered.", "18. Five minutes later, pulse was 51/min.", "19. Five minutes later, blood pressure was 95/61 mm Hg." ]

[ "1. Her temperature is 36.7°C (98°F).", "2. Pulse is 41/min.", "3. Respirations are 14/min.", "4. Blood pressure is 88/55 mm Hg.", "5. Pulse oximetry on room air shows an oxygen saturation of 93%.", "6. She is confused and oriented only to person.", "7. The pupils are equal and reactive to light.", "8. Examination shows cold, clammy extremities.", "9. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.", "10. The abdomen is soft.", "11. Fingerstick blood glucose concentration is 65 mg/dL.", "12. ECG shows prolonged PR intervals and narrow QRS complexes.", "13. Two large bore cannulas are inserted and intravenous normal saline, dextrose, and atropine are administered.", "14. Five minutes later, pulse is 51/min and blood pressure is 95/61 mm Hg." ]

[ "A 56-year-old patient reports a history of recurrent dental caries." ]

[ "1. Patient is 56 years old.", "2. Patient has a history of recurrent dental caries." ]

[ "1. The patient is 56 years old.", "2. The patient has a history of recurrent dental caries." ]

[ "A 40-year-old woman comes to the physician for a follow-up examination.", "She says she has felt fatigued for about 3 months.", "She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts.", "She no longer adheres to her usual exercise routine because of exhaustion.", "During this time, she has noticed that her stools are sometimes pale and foul smelling.", "She also has generalized itching.", "The patient does not have abdominal pain, fever, or weight loss.", "She takes levothyroxine for hypothyroidism.", "She has smoked one pack of cigarettes weekly for 20 years.", "Physical examination shows no abnormalities.", "Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 7,200/mm3 | Erythrocyte sedimentation rate 26 mm/h | Serum | Thyroid-stimulating hormone 4.2 μU/ml | Bilirubin | Total 1.7 mg/dL | Direct 1.0 mg/dL | Alkaline phosphatase 370 U/L | Aspartate aminotransferase 80 U/L | Alanine aminotransferase 46 U/L | Cholesterol 320 mg/dL | Gamma-glutamyl transferase 98 U/L (N = 5–50) | Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.", "Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas." ]

[ "1. A 40-year-old woman comes to the physician for a follow-up examination.", "2. She says she has felt fatigued for about 3 months.", "3. She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts.", "4. She no longer adheres to her usual exercise routine because of exhaustion.", "5. During this time, she has noticed that her stools are sometimes pale and foul smelling.", "6. She also has generalized itching.", "7. The patient does not have abdominal pain, fever, or weight loss.", "8. She takes levothyroxine for hypothyroidism.", "9. She has smoked one pack of cigarettes weekly for 20 years.", "10. Physical examination shows no abnormalities.", "11. Laboratory studies show: Hemoglobin 14.1 g/dL, Leukocyte count 7,200/mm3, Erythrocyte sedimentation rate 26 mm/h, Serum Thyroid-stimulating hormone 4.2 μU/ml, Bilirubin Total 1.7 mg/dL, Direct 1.0 mg/dL, Alkaline phosphatase 370 U/L, Aspartate aminotransferase 80 U/L, Alanine aminotransferase 46 U/L, Cholesterol 320 mg/dL, Gamma-glutamyl transferase 98 U/L (N = 5–50).", "12. Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.", "13. Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas." ]

[ "1. The patient has felt fatigued for about 3 months.", "2. She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts.", "3. She no longer adheres to her usual exercise routine because of exhaustion.", "4. The patient has noticed that her stools are sometimes pale and foul smelling.", "5. She also has generalized itching.", "6. The patient does not have abdominal pain, fever, or weight loss.", "7. She takes levothyroxine for hypothyroidism.", "8. She has smoked one pack of cigarettes weekly for 20 years.", "9. Physical examination shows no abnormalities.", "10. Laboratory studies show: Hemoglobin 14.1 g/dL, Leukocyte count 7,200/mm3, Erythrocyte sedimentation rate 26 mm/h, Serum Thyroid-stimulating hormone 4.2 μU/ml, Bilirubin Total 1.7 mg/dL, Direct 1.0 mg/dL, Alkaline phosphatase 370 U/L, Aspartate aminotransferase 80 U/L, Alanine aminotransferase 46 U/L, Cholesterol 320 mg/dL, Gamma-glutamyl transferase 98 U/L (N = 5–50).", "11. Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.", "12. Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas." ]

[ "A 73-year-old man seeks evaluation for difficulty developing and maintaining erections.", "He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb) but his erectile symptoms have not improved.", "He was prescribed a drug by his physician." ]

[ "1. A 73-year-old man seeks evaluation for difficulty developing and maintaining erections.", "2. He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb).", "3. His erectile symptoms have not improved.", "4. He was prescribed a drug by his physician." ]

[ "1. He has recently made lifestyle modifications.", "2. He has lost 4.5 kg (10 lb).", "3. His erectile symptoms have not improved.", "4. He was prescribed a drug by his physician." ]

[ "A 65-year-old woman with hypertension comes to the emergency department because of sudden onset of a severe headache 2 hours ago.", "Her temperature is 35°C (95°F) and blood pressure is 189/115 mm Hg.", "A CT scan of the head shows a subarachnoid hemorrhage and she is started on appropriate pharmacotherapy." ]

[ "1. A 65-year-old woman comes to the emergency department.", "2. She has hypertension.", "3. She has sudden onset of a severe headache 2 hours ago.", "4. Her temperature is 35°C (95°F).", "5. Her blood pressure is 189/115 mm Hg.", "6. A CT scan of the head shows a subarachnoid hemorrhage.", "7. She is started on appropriate pharmacotherapy." ]

[ "1. Her temperature is 35°C (95°F).", "2. Her blood pressure is 189/115 mm Hg.", "3. A CT scan of the head shows a subarachnoid hemorrhage.", "4. She is started on appropriate pharmacotherapy." ]

[ "A 35-year-old woman with a one-year history of auditory hallucinations and periods of anhedonia and amotivation is being seen by her psychiatrist.", "She was started on haloperidol at her last visit, but she was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug.", "Today, her temperature is 97.7°F (36.5°C), blood pressure is 132/76 mmHg, pulse is 98/min, and respirations are 12/min.", "The patient is now started on a new medication that will seek to avoid the same side effects as her previous one; however, she will need to come in for weekly testing." ]

[ "1. A 35-year-old woman has a one-year history of auditory hallucinations and periods of anhedonia and amotivation.", "2. She was started on haloperidol at her last visit.", "3. She was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug.", "4. Today, her temperature is 97.7°F (36.5°C).", "5. Her blood pressure is 132/76 mmHg.", "6. Her pulse is 98/min.", "7. Her respirations are 12/min.", "8. She is now started on a new medication that will seek to avoid the same side effects as her previous one.", "9. She will need to come in for weekly testing." ]

[ "1. The patient was started on haloperidol at her last visit.", "2. She was told to stop taking the medication due to developing muscle stiffness and spasms soon after taking the drug.", "3. Her temperature is 97.7°F (36.5°C).", "4. Her blood pressure is 132/76 mmHg.", "5. Her pulse is 98/min.", "6. Her respirations are 12/min.", "7. The patient is now started on a new medication.", "8. The new medication aims to avoid the same side effects as her previous one.", "9. The patient will need to come in for weekly testing." ]

[ "A 9-year-old boy is brought to the emergency room by his concerned mother after he \"urinated blood.\" The boy reports that, starting this morning, he experienced significant pain with urination and his urine appeared a bright red color.", "These symptoms were not present before today; however, he reports a cough, runny nose, and sore throat that started approximately 3 days ago.", "Vital signs are as follows: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%.", "Physical examination is significant for bilateral conjunctivitis, tenderness to suprapubic palpation, and a small amount of clotted blood is noted surrounding the urethral meatus.", "A urine sample is obtained, and urinalysis shows 3+ blood, and urine microscopy demonstrates gross blood with too many cells to count per high powered field." ]

[ "1. Patient is a 9-year-old boy.", "2. Patient was brought to the emergency room by his concerned mother.", "3. Patient urinated blood.", "4. Patient experienced significant pain with urination.", "5. Patient's urine appeared a bright red color.", "6. Symptoms were not present before today.", "7. Patient reports a cough, runny nose, and sore throat that started approximately 3 days ago.", "8. Vital signs: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%.", "9. Physical examination is significant for bilateral conjunctivitis.", "10. Physical examination is significant for tenderness to suprapubic palpation.", "11. A small amount of clotted blood is noted surrounding the urethral meatus.", "12. Urine sample obtained, and urinalysis shows 3+ blood.", "13. Urine microscopy demonstrates gross blood with too many cells to count per high powered field." ]

[ "1. Symptoms include cough, runny nose, and sore throat that started approximately 3 days ago.", "2. Vital signs: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%.", "3. Physical examination shows bilateral conjunctivitis, tenderness to suprapubic palpation, and clotted blood surrounding the urethral meatus.", "4. Urinalysis shows 3+ blood.", "5. Urine microscopy demonstrates gross blood with too many cells to count per high powered field." ]

[ "A young researcher wants to develop a method of increasing oxygen delivery to the peripheral tissues.", "He brainstorms several ideas but is informed by his mentor that only one of his ideas will most likely help him achieve the desired result." ]

[ "1. A young researcher wants to develop a method of increasing oxygen delivery to the peripheral tissues.", "2. He brainstorms several ideas.", "3. His mentor informs him that only one of his ideas will most likely help him achieve the desired result." ]

[ "1. He brainstorms several ideas.", "2. His mentor informs him.", "3. Only one of his ideas will most likely help him achieve the desired result." ]

[ "A 29-year-old man comes to the physician for a follow-up examination.", "He has had numbness and tingling of his legs for the past 10 days.", "Three months ago, he was diagnosed with pulmonary tuberculosis and started on antituberculosis therapy.", "Examination shows dry scaly lips and cracks at the corner of the mouth.", "Sensation to pinprick and light touch is decreased over the lower extremities.", "His hemoglobin concentration is 10.4 g/dL and mean corpuscular volume is 76 μm3." ]

[ "1. A 29-year-old man comes to the physician for a follow-up examination.", "2. He has had numbness and tingling of his legs for the past 10 days.", "3. Three months ago, he was diagnosed with pulmonary tuberculosis.", "4. He started on antituberculosis therapy three months ago.", "5. Examination shows dry scaly lips and cracks at the corner of the mouth.", "6. Sensation to pinprick and light touch is decreased over the lower extremities.", "7. His hemoglobin concentration is 10.4 g/dL.", "8. His mean corpuscular volume is 76 μm3." ]

[ "1. He has had numbness and tingling of his legs for the past 10 days.", "2. Three months ago, he was diagnosed with pulmonary tuberculosis.", "3. He started on antituberculosis therapy.", "4. Examination shows dry scaly lips and cracks at the corner of the mouth.", "5. Sensation to pinprick is decreased over the lower extremities.", "6. Sensation to light touch is decreased over the lower extremities.", "7. His hemoglobin concentration is 10.4 g/dL.", "8. His mean corpuscular volume is 76 μm3." ]

[ "A 36-year-old woman presents with a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria.", "Her symptoms are present day and night and have no known triggers.", "She was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago, which is managed with pelvic floor training exercises and a vaginal pessary.", "She is otherwise healthy and does not take any medications.", "The blood pressure is 120/80 mm Hg, the heart rate is 67/min, the respiratory rate is 14/min, and the temperature is 36.8℃ (98.2℉).", "The physical examination is significant for suprapubic tenderness.", "No costovertebral angle tenderness is present.", "There are no signs of vulvar inflammation, and no urethral or vaginal discharge.", "The vaginal mucosa is normal and there is no cervical discharge.", "A vaginal pessary is placed.", "The cervix is non-tender and mobile, the uterus is not enlarged, and the adnexa have no masses. | The urinalysis shows the following findings: | Color: Pale yellow | Clarity: Clear | pH: 6.2 | Specific gravity: 1.023 | Glucose: Negative | Ketones: Negative | Nitrites: Positive | Leukocyte esterase: Positive | Bilirubin: Negative | Urinary bilirubin: Negative | Protein: Negative | RBCs: 47 RBCs/hpf | WBCs: 21 WBCs/hpf | Epithelial cells: 27 squamous epithelial cells/hpf | Casts: 5 hyaline casts/lpf | Crystals: Occasional urates | Bacteria: None noted | Yeast: None noted | The urinary culture is negative." ]

[ "1. Patient is a 36-year-old woman.", "2. Patient has a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria.", "3. Symptoms are present day and night and have no known triggers.", "4. Patient was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago.", "5. Patient is managed with pelvic floor training exercises and a vaginal pessary.", "6. Patient is otherwise healthy and does not take any medications.", "7. Blood pressure is 120/80 mm Hg.", "8. Heart rate is 67/min.", "9. Respiratory rate is 14/min.", "10. Temperature is 36.8℃ (98.2℉).", "11. Physical examination is significant for suprapubic tenderness.", "12. No costovertebral angle tenderness is present.", "13. No signs of vulvar inflammation.", "14. No urethral or vaginal discharge.", "15. Vaginal mucosa is normal.", "16. No cervical discharge.", "17. A vaginal pessary is placed.", "18. Cervix is non-tender and mobile.", "19. Uterus is not enlarged.", "20. Adnexa have no masses.", "21. Urinalysis shows pale yellow color, clear clarity, pH 6.2, specific gravity 1.023, negative glucose, negative ketones, positive nitrites, positive leukocyte esterase, negative bilirubin, negative urinary bilirubin, negative protein, 47 RBCs/hpf, 21 WBCs/hpf, 27 squamous epithelial cells/hpf, 5 hyaline casts/lpf, occasional urates, no bacteria, and no yeast.", "22. Urinary culture is negative." ]

[ "1. The patient's symptoms are present day and night and have no known triggers.", "2. She was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago, which is managed with pelvic floor training exercises and a vaginal pessary.", "3. She is otherwise healthy and does not take any medications.", "4. The blood pressure is 120/80 mm Hg, the heart rate is 67/min, the respiratory rate is 14/min, and the temperature is 36.8℃ (98.2℉).", "5. The physical examination is significant for suprapubic tenderness.", "6. No costovertebral angle tenderness is present.", "7. There are no signs of vulvar inflammation, and no urethral or vaginal discharge.", "8. The vaginal mucosa is normal and there is no cervical discharge.", "9. A vaginal pessary is placed.", "10. The cervix is non-tender and mobile, the uterus is not enlarged, and the adnexa have no masses.", "11. The urinalysis shows the following findings: ", "12. Color: Pale yellow", "13. Clarity: Clear", "14. pH: 6.2", "15. Specific gravity: 1.023", "16. Glucose: Negative", "17. Ketones: Negative", "18. Nitrites: Positive", "19. Leukocyte esterase: Positive", "20. Bilirubin: Negative", "21. Urinary bilirubin: Negative", "22. Protein: Negative", "23. RBCs: 47 RBCs/hpf", "24. WBCs: 21 WBCs/hpf", "25. Epithelial cells: 27 squamous epithelial cells/hpf", "26. Casts: 5 hyaline casts/lpf", "27. Crystals: Occasional urates", "28. Bacteria: None noted", "29. Yeast: None noted", "30. The urinary culture is negative." ]

[ "The incidence of red-green color blindness in males in a certain population is 1/100." ]

[ "1. The incidence of red-green color blindness is 1/100.", "2. The population is a certain population.", "3. The incidence is in males." ]

[ "1. The incidence of red-green color blindness in males is 1/100.", "2. The incidence is in a certain population." ]

[ "A 31-year-old man comes to the physician for evaluation of chronic cough, sinus pain, and nasal discharge.", "He has a history of frequent upper respiratory infections and recurrent sinusitis since childhood.", "He is also concerned about fertility, as he and his wife have been trying to conceive for 5 years unsuccessfully.", "Pulmonary examination shows crackles and wheezing throughout both lung fields.", "A CT scan of the chest is shown." ]

[ "1. A 31-year-old man comes to the physician for evaluation of chronic cough, sinus pain, and nasal discharge.", "2. He has a history of frequent upper respiratory infections and recurrent sinusitis since childhood.", "3. He and his wife have been trying to conceive for 5 years unsuccessfully.", "4. Pulmonary examination shows crackles and wheezing throughout both lung fields.", "5. A CT scan of the chest is shown." ]

[ "1. He has a history of frequent upper respiratory infections since childhood.", "2. He has a history of recurrent sinusitis since childhood.", "3. He and his wife have been trying to conceive for 5 years unsuccessfully.", "4. Pulmonary examination shows crackles throughout both lung fields.", "5. Pulmonary examination shows wheezing throughout both lung fields.", "6. A CT scan of the chest is shown." ]

[ "A 3-year-old boy is brought to the emergency department because of abdominal pain and watery diarrhea for the past 3 days.", "This morning he also had nausea and his stool had a red tint.", "Four days ago, he and his parents returned home from a vacation, during which they visited a petting zoo and consumed many new foods.", "He lives with his family and they have cats and dogs at home.", "The patient attends daycare.", "His immunizations are up-to-date.", "His temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg.", "Examination shows dry mucus membranes.", "The abdomen is soft, and there is tenderness to palpation of the right lower quadrant with rebound.", "Stool culture grows Yersinia enterocolitica." ]

[ "1. Patient is a 3-year-old boy.", "2. Patient has had abdominal pain and watery diarrhea for the past 3 days.", "3. Patient had nausea this morning.", "4. Patient's stool had a red tint.", "5. Patient and his parents returned home from a vacation 4 days ago.", "6. Patient and his family visited a petting zoo during the vacation.", "7. Patient and his family consumed many new foods during the vacation.", "8. Patient lives with his family.", "9. Patient's family has cats and dogs at home.", "10. Patient attends daycare.", "11. Patient's immunizations are up-to-date.", "12. Patient's temperature is 38°C (100.4°F).", "13. Patient's pulse is 140/min.", "14. Patient's blood pressure is 80/45 mm Hg.", "15. Patient's mucus membranes are dry.", "16. Patient's abdomen is soft.", "17. Patient has tenderness to palpation of the right lower quadrant with rebound.", "18. Stool culture grows Yersinia enterocolitica." ]

[ "1. This morning he had nausea.", "2. His stool had a red tint.", "3. Four days ago, he and his parents returned home from a vacation.", "4. During the vacation, they visited a petting zoo.", "5. During the vacation, they consumed many new foods.", "6. He lives with his family.", "7. They have cats and dogs at home.", "8. The patient attends daycare.", "9. His immunizations are up-to-date.", "10. His temperature is 38°C (100.4°F).", "11. His pulse is 140/min.", "12. His blood pressure is 80/45 mm Hg.", "13. Examination shows dry mucus membranes.", "14. The abdomen is soft.", "15. There is tenderness to palpation of the right lower quadrant with rebound.", "16. Stool culture grows Yersinia enterocolitica." ]

[ "A 61-year-old woman dies unexpectedly.", "She had not seen a physician in 10 years.", "Examination of the heart during autopsy shows hypertrophy of the left ventricular wall and enlargement of the left ventricular chamber.", "Microscopic examination shows lengthening of individual muscle fibers due to duplication of sarcomeres in series." ]

[ "1. A 61-year-old woman dies unexpectedly.", "2. She had not seen a physician in 10 years.", "3. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall.", "4. Examination of the heart during autopsy shows enlargement of the left ventricular chamber.", "5. Microscopic examination shows lengthening of individual muscle fibers.", "6. Microscopic examination shows duplication of sarcomeres in series." ]

[ "1. She had not seen a physician in 10 years.", "2. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall.", "3. Examination of the heart during autopsy shows enlargement of the left ventricular chamber.", "4. Microscopic examination shows lengthening of individual muscle fibers.", "5. Microscopic examination shows duplication of sarcomeres in series." ]

[ "A 57-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea presents to your office for routine screening.", "He reports compliance with his medications but admits to difficulty maintaining the diet and exercise routines discussed during his last visit.", "He does not have any other complaints.", "He drinks 3-4 beers on the weekends and does not smoke cigarettes.", "His current medications include metformin, atorvastatin, and hydrochlorothiazide.", "On physical examination, his temperature is 99°F (37.2°C), blood pressure is 130/85 mmHg, pulse is 85/min, and respirations are 18/min.", "Laboratory results are shown below: | | Serum: | Na+: 138 mEq/L | Cl-: 100 mEq/L | K+: 3.9 mEq/L | HCO3-: 23 mEq/L | BUN: 13 mg/dL | Glucose: 160 mg/dL | | You decide to start the patient on a medication that triggers insulin release." ]

[ "1. Patient is 57 years old.", "2. Patient has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea.", "3. Patient reports compliance with medications.", "4. Patient has difficulty maintaining diet and exercise routines.", "5. Patient does not have any other complaints.", "6. Patient drinks 3-4 beers on the weekends.", "7. Patient does not smoke cigarettes.", "8. Patient's current medications include metformin, atorvastatin, and hydrochlorothiazide.", "9. Patient's temperature is 99°F (37.2°C).", "10. Patient's blood pressure is 130/85 mmHg.", "11. Patient's pulse is 85/min.", "12. Patient's respirations are 18/min.", "13. Patient's serum Na+ is 138 mEq/L.", "14. Patient's serum Cl- is 100 mEq/L.", "15. Patient's serum K+ is 3.9 mEq/L.", "16. Patient's serum HCO3- is 23 mEq/L.", "17. Patient's BUN is 13 mg/dL.", "18. Patient's glucose is 160 mg/dL.", "19. Patient is to be started on a medication that triggers insulin release." ]

[ "1. Patient reports compliance with medications", "2. Patient admits difficulty maintaining diet and exercise routines", "3. Patient does not have any other complaints", "4. Patient drinks 3-4 beers on weekends", "5. Patient does not smoke cigarettes", "6. Patient's current medications: metformin, atorvastatin, hydrochlorothiazide", "7. Physical examination: temperature 99°F, blood pressure 130/85 mmHg, pulse 85/min, respirations 18/min", "8. Laboratory results: Na+ 138 mEq/L, Cl- 100 mEq/L, K+ 3.9 mEq/L, HCO3- 23 mEq/L, BUN 13 mg/dL, Glucose 160 mg/dL", "9. Decision to start patient on a medication that triggers insulin release" ]

[ "A 28-year-old woman presents to the emergency department with fever and abdominal pain for the past several days.", "She says she feels like she has a slight fever.", "She denies nausea or vomiting.", "Physical examination shows pain in the right upper quadrant to deep palpation with rebound tenderness and guarding.", "A laparoscopy is performed which shows string-like, fibrous scar tissue in the perihepatic recesses." ]

[ "1. A 28-year-old woman presents to the emergency department.", "2. She has had fever and abdominal pain for several days.", "3. She feels like she has a slight fever.", "4. She denies nausea or vomiting.", "5. Physical examination shows pain in the right upper quadrant to deep palpation.", "6. Physical examination also shows rebound tenderness and guarding.", "7. A laparoscopy is performed.", "8. The laparoscopy shows string-like, fibrous scar tissue in the perihepatic recesses." ]

[ "1. The patient feels like she has a slight fever.", "2. The patient denies nausea or vomiting.", "3. Physical examination shows pain in the right upper quadrant to deep palpation.", "4. Physical examination shows rebound tenderness and guarding.", "5. Laparoscopy reveals string-like, fibrous scar tissue in the perihepatic recesses." ]

[ "A 30-year-old woman comes to the emergency department because of a 1-day history of sharp chest pain radiating to the left shoulder.", "The pain worsens when she coughs, breathes deeply, or lies down.", "She has had a mild fever and a cough for the past 2 days.", "She takes ibuprofen for hip and knee pain, which started 4 months ago.", "Examination shows a symmetric, erythematous rash on her nose and cheeks, and erythematous patches with scaling and plugged follicles over her hands." ]

[ "1. A 30-year-old woman comes to the emergency department.", "2. She has a 1-day history of sharp chest pain radiating to the left shoulder.", "3. The pain worsens when she coughs, breathes deeply, or lies down.", "4. She has had a mild fever and a cough for the past 2 days.", "5. She takes ibuprofen for hip and knee pain, which started 4 months ago.", "6. Examination shows a symmetric, erythematous rash on her nose and cheeks.", "7. Examination shows erythematous patches with scaling and plugged follicles over her hands." ]

[ "1. The pain worsens when she coughs, breathes deeply, or lies down.", "2. She has had a mild fever and a cough for the past 2 days.", "3. She takes ibuprofen for hip and knee pain, which started 4 months ago.", "4. Examination shows a symmetric, erythematous rash on her nose and cheeks.", "5. Examination shows erythematous patches with scaling and plugged follicles over her hands." ]

[ "A 22-year-old man comes to the physician because he has been increasingly worried and stressed in recent weeks.", "He started a marketing job three months ago, which involves traveling between Washington and California several times a year.", "Two months ago, he was supposed to fly to Seattle, but he experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane, causing him great embarrassment.", "He had never been on a plane before; his parents died in a plane crash when he was younger.", "A week ago, he called in sick when he was supposed to go on a business trip.", "He worries that he will lose his job.", "He is otherwise well and has no history of serious illness.", "He takes no medications.", "His temperature is 37.2°C (99°F), pulse is 85/min, respirations are 12/min, and blood pressure is 130/80 mm Hg.", "Physical examination shows no abnormalities.", "On mental status examination, he is alert and cooperative.", "His speech is normal and his thought process is organized.", "His memory, attention, and concentration are intact." ]

[ "1. Patient is a 22-year-old male.", "2. Patient has been increasingly worried and stressed in recent weeks.", "3. Patient started a marketing job three months ago.", "4. Job involves traveling between Washington and California several times a year.", "5. Two months ago, patient experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane.", "6. Patient had never been on a plane before.", "7. Patient's parents died in a plane crash when he was younger.", "8. A week ago, patient called in sick when he was supposed to go on a business trip.", "9. Patient worries that he will lose his job.", "10. Patient is otherwise well and has no history of serious illness.", "11. Patient takes no medications.", "12. Patient's temperature is 37.2°C (99°F).", "13. Patient's pulse is 85/min.", "14. Patient's respirations are 12/min.", "15. Patient's blood pressure is 130/80 mm Hg.", "16. Physical examination shows no abnormalities.", "17. On mental status examination, patient is alert and cooperative.", "18. Patient's speech is normal.", "19. Patient's thought process is organized.", "20. Patient's memory, attention, and concentration are intact." ]

[ "1. He started a marketing job three months ago.", "2. The job involves traveling between Washington and California several times a year.", "3. Two months ago, he was supposed to fly to Seattle.", "4. He experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane.", "5. This caused him great embarrassment.", "6. He had never been on a plane before.", "7. His parents died in a plane crash when he was younger.", "8. A week ago, he called in sick when he was supposed to go on a business trip.", "9. He worries that he will lose his job.", "10. He is otherwise well and has no history of serious illness.", "11. He takes no medications.", "12. His temperature is 37.2°C (99°F).", "13. His pulse is 85/min.", "14. His respirations are 12/min.", "15. His blood pressure is 130/80 mm Hg.", "16. Physical examination shows no abnormalities.", "17. On mental status examination, he is alert and cooperative.", "18. His speech is normal.", "19. His thought process is organized.", "20. His memory, attention, and concentration are intact." ]

[ "A 52-year-old man presents to the office complaining of a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet.", "His past medical history is only significant for slightly elevated blood pressure.", "The patient denies tobacco use although he does admit to drinking 8-10 beers, daily, for the past 10 years.", "He takes a low dose of aspirin daily, ever since he had an anterior myocardial infarction 2 years ago.", "The patient works as a financial consultant and frequently travels for work.", "The current temperature is 36.8°C (98.3°F), the pulse rate is 68/min, the blood pressure is 152/84 mm Hg, and the respiratory rate is 16/min.", "His weight is 102 kg (224 lb) and height 180 cm (5 ft 9 in).", "Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall." ]

[ "1. Patient is a 52-year-old man.", "2. Patient has a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet.", "3. Patient's past medical history is only significant for slightly elevated blood pressure.", "4. Patient denies tobacco use.", "5. Patient admits to drinking 8-10 beers daily for the past 10 years.", "6. Patient takes a low dose of aspirin daily since he had an anterior myocardial infarction 2 years ago.", "7. Patient works as a financial consultant and frequently travels for work.", "8. Current temperature is 36.8°C (98.3°F).", "9. Pulse rate is 68/min.", "10. Blood pressure is 152/84 mm Hg.", "11. Respiratory rate is 16/min.", "12. Weight is 102 kg (224 lb).", "13. Height is 180 cm (5 ft 9 in).", "14. Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall." ]

[ "1. His past medical history is only significant for slightly elevated blood pressure.", "2. The patient denies tobacco use.", "3. He admits to drinking 8-10 beers daily for the past 10 years.", "4. He takes a low dose of aspirin daily.", "5. He had an anterior myocardial infarction 2 years ago.", "6. The patient works as a financial consultant.", "7. He frequently travels for work.", "8. The current temperature is 36.8°C (98.3°F).", "9. The pulse rate is 68/min.", "10. The blood pressure is 152/84 mm Hg.", "11. The respiratory rate is 16/min.", "12. His weight is 102 kg (224 lb).", "13. His height is 180 cm (5 ft 9 in).", "14. Echocardiography demonstrates an ejection fraction of 35%.", "15. Echocardiography demonstrates a thin left ventricular wall." ]

[ "A 70-year-old man comes to the physician for a follow-up evaluation.", "Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream.", "Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture.", "Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL.", "Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening.", "The patient received appropriate treatment.", "His vital signs are within normal limits.", "Laboratory studies now show a PSA level of 1 ng/mL." ]

[ "1. A 70-year-old man comes to the physician for a follow-up evaluation.", "2. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream.", "3. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture.", "4. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL.", "5. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening.", "6. The patient received appropriate treatment.", "7. His vital signs are within normal limits.", "8. Laboratory studies now show a PSA level of 1 ng/mL." ]

[ "1. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream.", "2. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture.", "3. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL.", "4. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening.", "5. The patient received appropriate treatment.", "6. His vital signs are within normal limits.", "7. Laboratory studies now show a PSA level of 1 ng/mL." ]

[ "A 53-year-old man presents to the office complaining of persistent abdominal pain.", "He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating.", "The patient also admits that he has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.", "He has taken some over the counter antacids without relief or change in symptoms.", "His blood pressure is 132/76 mm Hg, respiratory rate is 14/min, and heart rate is 75/min.", "Physical examination reveals mild tenderness to palpation of the upper abdomen." ]

[ "1. A 53-year-old man presents to the office complaining of persistent abdominal pain.", "2. He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating.", "3. The patient has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.", "4. He has taken some over the counter antacids without relief or change in symptoms.", "5. His blood pressure is 132/76 mm Hg.", "6. His respiratory rate is 14/min.", "7. His heart rate is 75/min.", "8. Physical examination reveals mild tenderness to palpation of the upper abdomen." ]

[ "1. The patient has gained 4.5 kg (10.0 lb) due to pain relief from eating.", "2. The patient has experienced numerous loose, foul-smelling stools over the last few weeks with associated nausea.", "3. The patient has taken over the counter antacids without relief or change in symptoms.", "4. The patient's blood pressure is 132/76 mm Hg.", "5. The patient's respiratory rate is 14/min.", "6. The patient's heart rate is 75/min.", "7. Physical examination reveals mild tenderness to palpation of the upper abdomen." ]

[ "A 68-year-old man with advanced dementia is brought to the preoperative unit prior to an elective cholecystectomy for biliary colic.", "He says he does not want the surgery anymore.", "He begins yelling at unit staff and requests to leave.", "His designated medical power of attorney, who had previously signed the surgery consent forms, is present." ]

[ "1. A 68-year-old man has advanced dementia.", "2. He was brought to the preoperative unit prior to an elective cholecystectomy for biliary colic.", "3. He says he does not want the surgery anymore.", "4. He begins yelling at unit staff.", "5. He requests to leave.", "6. His designated medical power of attorney is present.", "7. The medical power of attorney had previously signed the surgery consent forms." ]

[ "1. He does not want the surgery anymore.", "2. He begins yelling at unit staff.", "3. He requests to leave.", "4. His designated medical power of attorney is present.", "5. The medical power of attorney had previously signed the surgery consent forms." ]

[ "A 67-year-old man presents to his physician’s office with a progressive cough.", "It has been increasing in intensity over the past week.", "He has also been noticing an increase in the amount of sputum he usually produces, which is thick and yellow.", "He also complains of increased difficulty in breathing, more so than he previously experienced.", "He was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then.", "He doesn’t report any fever, chills, or night sweats.", "He has observed a foul smell to his sputum.", "His blood pressure is 100/65 mm Hg, the respirations are 23/min and the pulse is about 110/min.", "Currently, his FEV1 is around 48% of the normal predicted value.", "He is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis.", "In spite of this, he has had acute exacerbations of his symptoms 4 times over the last year.", "His last episode was 2 months ago, for which he was treated with a short course of antibiotics.", "He is also currently receiving treatment for diabetes." ]

[ "1. Patient is 67 years old.", "2. Patient has a progressive cough for the past week.", "3. Patient has increased sputum production, which is thick and yellow.", "4. Patient has increased difficulty in breathing.", "5. Patient was diagnosed with COPD 3 years ago and has been on treatment since then.", "6. Patient does not report fever, chills, or night sweats.", "7. Patient's sputum has a foul smell.", "8. Patient's blood pressure is 100/65 mm Hg.", "9. Patient's respirations are 23/min.", "10. Patient's pulse is 110/min.", "11. Patient's FEV1 is 48% of the normal predicted value.", "12. Patient receives a yearly influenza shot.", "13. Patient has taken the pneumococcal vaccination at the time of diagnosis.", "14. Patient has had 4 acute exacerbations of symptoms in the last year.", "15. Patient's last episode was 2 months ago and was treated with a short course of antibiotics.", "16. Patient is currently receiving treatment for diabetes." ]

[ "1. The patient's symptoms have been increasing in intensity over the past week.", "2. The patient has noticed an increase in the amount of sputum he usually produces, which is thick and yellow.", "3. The patient complains of increased difficulty in breathing, more so than he previously experienced.", "4. The patient was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then.", "5. The patient doesn’t report any fever, chills, or night sweats.", "6. The patient has observed a foul smell to his sputum.", "7. The patient's blood pressure is 100/65 mm Hg, the respirations are 23/min, and the pulse is about 110/min.", "8. Currently, the patient's FEV1 is around 48% of the normal predicted value.", "9. The patient is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis.", "10. The patient has had acute exacerbations of his symptoms 4 times over the last year.", "11. The patient's last episode was 2 months ago, for which he was treated with a short course of antibiotics.", "12. The patient is also currently receiving treatment for diabetes." ]

[ "A 27-year-old man who was involved in a motor vehicle collision is brought into the emergency room with a fractured skull.", "The paramedics report that the patient was conscious and lucid on the way to the hospital but now is unresponsive.", "His vitals are a blood pressure of 122/78 mm Hg, temperature of 37.0°C (98.6°F), pulse rate of 88/min, and respiratory rate of 14/min.", "A noncontrast CT scan of the head shows an epidural hematoma." ]

[ "1. A 27-year-old man was involved in a motor vehicle collision.", "2. The patient was conscious and lucid on the way to the hospital.", "3. The patient is now unresponsive.", "4. The patient's blood pressure is 122/78 mm Hg.", "5. The patient's temperature is 37.0°C (98.6°F).", "6. The patient's pulse rate is 88/min.", "7. The patient's respiratory rate is 14/min.", "8. A noncontrast CT scan of the head shows an epidural hematoma.", "9. The patient has a fractured skull." ]

[ "1. The paramedics reported the patient was conscious and lucid on the way to the hospital.", "2. The patient is now unresponsive.", "3. The patient's blood pressure is 122/78 mm Hg.", "4. The patient's temperature is 37.0°C (98.6°F).", "5. The patient's pulse rate is 88/min.", "6. The patient's respiratory rate is 14/min.", "7. A noncontrast CT scan of the head shows an epidural hematoma." ]

[ "A 54-year-old woman presents to the emergency department due to recent onset of a high fever, accompanied by severe headache and neck stiffness.", "Her past medical history is significant for rapidly progressive glomerulonephritis.", "She is currently on immunosuppressants after a kidney transplant performed 6 months ago.", "On presentation, her temperature is 102.2°F (39°C), blood pressure is 112/71 mmHg, pulse is 107/min, and respirations are 22/min.", "Physical exam reveals severe pain with neck flexion and reciprocal knee flexion.", "Laboratory tests reveal a gram-positive organism with endotoxin." ]

[ "1. A 54-year-old woman presents to the emergency department.", "2. She has a high fever, severe headache, and neck stiffness.", "3. Her past medical history is significant for rapidly progressive glomerulonephritis.", "4. She is currently on immunosuppressants after a kidney transplant 6 months ago.", "5. Her temperature is 102.2°F (39°C).", "6. Her blood pressure is 112/71 mmHg.", "7. Her pulse is 107/min.", "8. Her respirations are 22/min.", "9. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion.", "10. Laboratory tests reveal a gram-positive organism with endotoxin." ]

[ "1. Past medical history includes rapidly progressive glomerulonephritis.", "2. Currently on immunosuppressants after a kidney transplant performed 6 months ago.", "3. On presentation, temperature is 102.2°F (39°C).", "4. On presentation, blood pressure is 112/71 mmHg.", "5. On presentation, pulse is 107/min.", "6. On presentation, respirations are 22/min.", "7. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion.", "8. Laboratory tests reveal a gram-positive organism with endotoxin." ]

[ "A 2-year-old boy is brought to see the pediatrician by his mother due to a “bad” cough.", "The mother reports that he has been coughing so hard that he threw up on several occasions.", "He is adopted and the mother does not know his vaccination history.", "He has no known allergies.", "His temperature is 38.5°C (100.5°F), pulse is 120/min, respirations are 33/min, blood pressure is 101/54 mm Hg, and oxygen saturation is 96% on room air.", "The boy looks unwell with mild difficulty breathing and a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.", "He has scattered petechiae on his face.", "A nasopharyngeal swab is sent for culture and PCR." ]

[ "1. A 2-year-old boy is brought to see the pediatrician by his mother.", "2. The mother reports that he has been coughing so hard that he threw up on several occasions.", "3. He is adopted and the mother does not know his vaccination history.", "4. He has no known allergies.", "5. His temperature is 38.5°C (100.5°F).", "6. His pulse is 120/min.", "7. His respirations are 33/min.", "8. His blood pressure is 101/54 mm Hg.", "9. His oxygen saturation is 96% on room air.", "10. The boy looks unwell with mild difficulty breathing.", "11. He has a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.", "12. He has scattered petechiae on his face.", "13. A nasopharyngeal swab is sent for culture and PCR." ]

[ "1. The mother reports that he has been coughing so hard that he threw up on several occasions.", "2. He is adopted and the mother does not know his vaccination history.", "3. He has no known allergies.", "4. His temperature is 38.5°C (100.5°F).", "5. His pulse is 120/min.", "6. His respirations are 33/min.", "7. His blood pressure is 101/54 mm Hg.", "8. His oxygen saturation is 96% on room air.", "9. The boy looks unwell with mild difficulty breathing and a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.", "10. He has scattered petechiae on his face.", "11. A nasopharyngeal swab is sent for culture and PCR." ]

[ "A 19-year-old man returns from travel in South America.", "He presents complaining of profuse, watery diarrhea.", "You suspect the causative organism to be Enterotoxigenic E.coli." ]

[ "1. A 19-year-old man returns from travel.", "2. He presents complaining of profuse, watery diarrhea.", "3. You suspect the causative organism to be Enterotoxigenic E. coli." ]

[ "1. Patient presents with profuse, watery diarrhea.", "2. Suspected causative organism is Enterotoxigenic E.coli." ]

[ "A 38-year-old man presents to the clinic for complaints of abdominal pain and diarrhea.", "He reports a long-standing history of the symptoms except for the time when he attempted a carbohydrate-free diet 5 years ago.", "The pain is described as stabbing, diffuse, 8/10, and is especially worse following food intake.", "Recently, he noticed some numbness and tingling of his feet but denies any bloody stool, nausea, vomiting, fevers, weight loss, or focal neurological deficits." ]

[ "1. A 38-year-old man presents to the clinic.", "2. He has abdominal pain and diarrhea.", "3. He has had these symptoms for a long time.", "4. Five years ago, he attempted a carbohydrate-free diet.", "5. The pain is described as stabbing, diffuse, 8/10.", "6. The pain is worse following food intake.", "7. He has noticed some numbness and tingling of his feet.", "8. He denies any bloody stool.", "9. He denies any nausea.", "10. He denies any vomiting.", "11. He denies any fevers.", "12. He denies any weight loss.", "13. He denies any focal neurological deficits." ]

[ "1. Patient reports long-standing history of symptoms", "2. Symptoms improved when attempted carbohydrate-free diet 5 years ago", "3. Pain is stabbing, diffuse, 8/10", "4. Pain worsens following food intake", "5. Patient noticed numbness and tingling in feet", "6. Denies bloody stool", "7. Denies nausea", "8. Denies vomiting", "9. Denies fevers", "10. Denies weight loss", "11. Denies focal neurological deficits" ]

[ "A 25-year-old male presents for a new primary-care visit.", "He has never been seen by a physician and reports that he has been in good health.", "You note a very tall, very thin male whose arm span is greater than his height.", "The patient reports that his father had a similar build but passed away suddenly in his 40s.", "You suspect a genetic disorder characterized by a defect in fibrillin-1." ]

[ "1. A 25-year-old male presents for a new primary-care visit.", "2. He has never been seen by a physician.", "3. He reports that he has been in good health.", "4. The patient is very tall and very thin.", "5. His arm span is greater than his height.", "6. The patient's father had a similar build.", "7. The patient's father passed away suddenly in his 40s.", "8. You suspect a genetic disorder characterized by a defect in fibrillin-1." ]

[ "1. The patient has never been seen by a physician.", "2. The patient reports being in good health.", "3. The patient is very tall and very thin.", "4. The patient's arm span is greater than his height.", "5. The patient's father had a similar build.", "6. The patient's father passed away suddenly in his 40s.", "7. The medical assistant suspects a genetic disorder.", "8. The genetic disorder is characterized by a defect in fibrillin-1." ]

[ "A group of investigators is evaluating the efficacy of intranasal ketamine in decreasing acute suicidality in teenagers admitted to inpatient psychiatric units.", "They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine while 15 participants were randomized to receive placebo.", "The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up with the level of significance fixed at 5%.", "They suspect inadequate statistical power." ]

[ "1. A group of investigators is evaluating the efficacy of intranasal ketamine in decreasing acute suicidality in teenagers admitted to inpatient psychiatric units.", "2. They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine.", "3. 15 participants were randomized to receive placebo.", "4. The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up.", "5. The level of significance was fixed at 5%.", "6. They suspect inadequate statistical power." ]

[ "1. A pilot study was conducted.", "2. 15 participants received intranasal ketamine.", "3. 15 participants received placebo.", "4. No statistically significant difference in suicidality was found after 30 days of follow-up.", "5. The level of significance was fixed at 5%.", "6. The investigators suspect inadequate statistical power." ]

[ "A 56-year-old man presents with severe back pain for the past hour.", "He says the pain started about 1 hour ago and has not improved.", "The patient describes the pain as sharp, 10/10, and located between his scapula.", "Past medical history is significant for hypertension, which he is noncompliant with medication.", "His vital signs are a blood pressure of 180/95 mm Hg and a pulse of 108/min.", "On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally.", "Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally.", "A contrast CT of the chest reveals findings consistent with a type B aortic dissection." ]

[ "1. Patient is 56 years old.", "2. Patient has severe back pain for the past hour.", "3. Patient says pain started 1 hour ago and has not improved.", "4. Patient describes pain as sharp, 10/10, and located between scapula.", "5. Patient has past medical history of hypertension.", "6. Patient is noncompliant with medication.", "7. Patient's blood pressure is 180/95 mm Hg.", "8. Patient's pulse is 108/min.", "9. Patient has loss of pain and temperature sensation in lower trunk and extremities bilaterally.", "10. Patient has strength of 4 out of 5 in all muscle groups in lower extremities bilaterally.", "11. Contrast CT of chest reveals findings consistent with type B aortic dissection." ]

[ "1. The patient reports that the pain started about 1 hour ago and has not improved.", "2. The patient describes the pain as sharp and rates it as 10/10.", "3. The pain is located between the patient's scapula.", "4. The patient has a past medical history significant for hypertension.", "5. The patient is noncompliant with medication for hypertension.", "6. The patient's blood pressure is 180/95 mm Hg.", "7. The patient's pulse is 108/min.", "8. On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally.", "9. Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally.", "10. A contrast CT of the chest reveals findings consistent with a type B aortic dissection." ]

[ "A 7-year-old girl is brought to the physician by her mother because of a 6-month history of worsening fatigue and frequent upper respiratory tract infections.", "She is at the 2nd percentile for height and 10th percentile for weight.", "Physical examination shows pallor, diffuse hyperpigmented macules, absence of the radial bones, and hypoplastic thumbs.", "Her hemoglobin concentration of 8.7 g/dL, leukocyte count is 2,500/mm3, and platelet count is 30,000/mm3." ]

[ "1. A 7-year-old girl is brought to the physician by her mother.", "2. She has a 6-month history of worsening fatigue and frequent upper respiratory tract infections.", "3. She is at the 2nd percentile for height.", "4. She is at the 10th percentile for weight.", "5. Physical examination shows pallor.", "6. Physical examination shows diffuse hyperpigmented macules.", "7. Physical examination shows absence of the radial bones.", "8. Physical examination shows hypoplastic thumbs.", "9. Her hemoglobin concentration is 8.7 g/dL.", "10. Her leukocyte count is 2,500/mm3.", "11. Her platelet count is 30,000/mm3." ]

[ "1. She is at the 2nd percentile for height.", "2. She is at the 10th percentile for weight.", "3. Physical examination shows pallor.", "4. Physical examination shows diffuse hyperpigmented macules.", "5. Physical examination shows absence of the radial bones.", "6. Physical examination shows hypoplastic thumbs.", "7. Her hemoglobin concentration is 8.7 g/dL.", "8. Her leukocyte count is 2,500/mm3.", "9. Her platelet count is 30,000/mm3." ]

[ "A 36-year-old woman is brought to the emergency department because of loss of consciousness.", "Her husband says that she complained of vomiting and dizziness for 2 days, but did not seek medical care.", "She has a history of acral vitiligo.", "Her blood pressure is 90/60 mm Hg, temperature is 35.9°C (96.6°F), and pulse is 90/min.", "On physical examination, she is obtunded, skin turgor is reduced, and her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.", "Lab results are shown: | Random plasma glucose 40 mg/dL | Serum osmolarity 275 mOsm/kg H₂O | Serum sodium 130 mEq/L | Serum potassium 6 mEq/L | Urine sodium level 30 mEq/L | ECG shows normal sinus rhythm without ST-T wave changes.", "Dextrose 5% is given and random plasma glucose becomes 60 mg/dL, but her blood pressure is still the same." ]

[ "1. A 36-year-old woman is brought to the emergency department because of loss of consciousness.", "2. Her husband says that she complained of vomiting and dizziness for 2 days, but did not seek medical care.", "3. She has a history of acral vitiligo.", "4. Her blood pressure is 90/60 mm Hg.", "5. Her temperature is 35.9°C (96.6°F).", "6. Her pulse is 90/min.", "7. On physical examination, she is obtunded.", "8. Skin turgor is reduced.", "9. Her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.", "10. Random plasma glucose is 40 mg/dL.", "11. Serum osmolarity is 275 mOsm/kg H₂O.", "12. Serum sodium is 130 mEq/L.", "13. Serum potassium is 6 mEq/L.", "14. Urine sodium level is 30 mEq/L.", "15. ECG shows normal sinus rhythm without ST-T wave changes.", "16. Dextrose 5% is given.", "17. Random plasma glucose becomes 60 mg/dL.", "18. Her blood pressure is still the same." ]

[ "1. Her husband says she complained of vomiting and dizziness for 2 days but did not seek medical care.", "2. She has a history of acral vitiligo.", "3. Her blood pressure is 90/60 mm Hg.", "4. Her temperature is 35.9°C (96.6°F).", "5. Her pulse is 90/min.", "6. On physical examination, she is obtunded.", "7. Her skin turgor is reduced.", "8. Her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.", "9. Lab results: Random plasma glucose 40 mg/dL.", "10. Lab results: Serum osmolarity 275 mOsm/kg H₂O.", "11. Lab results: Serum sodium 130 mEq/L.", "12. Lab results: Serum potassium 6 mEq/L.", "13. Lab results: Urine sodium level 30 mEq/L.", "14. ECG shows normal sinus rhythm without ST-T wave changes.", "15. Dextrose 5% is given and random plasma glucose becomes 60 mg/dL.", "16. Her blood pressure is still the same." ]

[ "A 4-year-old girl is seen by her pediatrician for developmental delay.", "One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences.", "Now, she is unable to feed herself and has recently started to point to objects she wants rather than asking.", "Physical exam reveals a well nourished child sitting in a stroller wringing her hands.", "Vital signs are normal.", "The patient's mother reports that her 7-year-old son is doing well, and that they have no family history of mental retardation or other cognitive disorders." ]

[ "1. A 4-year-old girl is seen by her pediatrician for developmental delay.", "2. One year prior, the patient was able to ride a tricycle.", "3. One year prior, the patient was able to stack 3 blocks.", "4. One year prior, the patient was able to speak in short sentences.", "5. Now, she is unable to feed herself.", "6. Now, she has recently started to point to objects she wants rather than asking.", "7. Physical exam reveals a well nourished child sitting in a stroller wringing her hands.", "8. Vital signs are normal.", "9. The patient's mother reports that her 7-year-old son is doing well.", "10. The patient's mother reports that they have no family history of mental retardation.", "11. The patient's mother reports that they have no family history of other cognitive disorders." ]

[ "1. One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences.", "2. Now, she is unable to feed herself.", "3. She has recently started to point to objects she wants rather than asking.", "4. Physical exam reveals a well nourished child sitting in a stroller wringing her hands.", "5. Vital signs are normal.", "6. The patient's mother reports that her 7-year-old son is doing well.", "7. They have no family history of mental retardation or other cognitive disorders." ]

[ "A 49-year-old woman visits the emergency department with the acute onset of severe shortness of breath.", "She also reports right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles, and that, several hours after she felt pain in her calf, she began to have trouble breathing.", "Currently, her shortness of breath is so severe that she is unable to speak clearly or quickly, but she manages to deny any recent surgery or history of recent bleeding.", "The vital signs include: blood pressure 111/69 mm Hg, pulse 142/min, and respiratory rate 33/min.", "On observation, she is using accessory muscles to breathe.", "On auscultation, her lungs are clear and her heart rate is rapid but regular.", "Her right calf is swollen, warm, and tender.", "The arterial blood gas test result reveals a pH of 7.5, partial pressure of carbon dioxide (PCO2) 22 mm Hg, and a partial pressure of oxygen (PaO2) 47 mm Hg on 6 L of oxygen by nasal cannula." ]

[ "1. Patient is a 49-year-old woman.", "2. Patient has acute onset of severe shortness of breath.", "3. Patient has right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles.", "4. Patient felt pain in her calf several hours before having trouble breathing.", "5. Patient denies any recent surgery or history of recent bleeding.", "6. Patient's blood pressure is 111/69 mm Hg.", "7. Patient's pulse is 142/min.", "8. Patient's respiratory rate is 33/min.", "9. Patient is using accessory muscles to breathe.", "10. Patient's lungs are clear on auscultation.", "11. Patient's heart rate is rapid but regular.", "12. Patient's right calf is swollen, warm, and tender.", "13. Arterial blood gas test result reveals a pH of 7.5.", "14. Arterial blood gas test result reveals a PCO2 of 22 mm Hg.", "15. Arterial blood gas test result reveals a PaO2 of 47 mm Hg on 6 L of oxygen by nasal cannula." ]

[ "1. Patient reports right-sided calf pain after a 22-hour flight from Beijing to Los Angeles.", "2. Patient developed trouble breathing several hours after feeling pain in her calf.", "3. Patient's shortness of breath is severe, making it difficult for her to speak clearly or quickly.", "4. Patient denies any recent surgery or history of recent bleeding.", "5. Vital signs: blood pressure 111/69 mm Hg, pulse 142/min, respiratory rate 33/min.", "6. Patient is using accessory muscles to breathe.", "7. On auscultation, lungs are clear and heart rate is rapid but regular.", "8. Patient's right calf is swollen, warm, and tender.", "9. Arterial blood gas test result: pH 7.5, PCO2 22 mm Hg, PaO2 47 mm Hg on 6 L of oxygen by nasal cannula." ]

[ "A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor.", "She has had no prenatal care.", "Her three children were delivered by lower segment transverse cesarean section.", "The patient appears in acute distress.", "Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg.", "The abdomen is nontender and contractions are felt.", "The fetus is in a cephalic presentation.", "The fetal heart rate is reactive with no decelerations.", "One hour following vaginal delivery, the placenta is not delivered.", "Manual separation of the placenta leads to profuse vaginal bleeding.", "A firm, nontender uterine fundus is palpated at the level of the umbilicus." ]

[ "1. A 37-year-old woman is admitted to the hospital in active labor.", "2. She has had no prenatal care.", "3. Her gravida is 4.", "4. Her para is 3.", "5. She is at 35 weeks' gestation.", "6. Her three children were delivered by lower segment transverse cesarean section.", "7. The patient appears in acute distress.", "8. Her pulse is 98/min.", "9. Her respirations are 15/min.", "10. Her blood pressure is 130/80 mm Hg.", "11. The abdomen is nontender.", "12. Contractions are felt.", "13. The fetus is in a cephalic presentation.", "14. The fetal heart rate is reactive with no decelerations.", "15. One hour following vaginal delivery, the placenta is not delivered.", "16. Manual separation of the placenta leads to profuse vaginal bleeding.", "17. A firm, nontender uterine fundus is palpated at the level of the umbilicus." ]

[ "1. She has had no prenatal care.", "2. Her three children were delivered by lower segment transverse cesarean section.", "3. The patient appears in acute distress.", "4. Her pulse is 98/min.", "5. Her respirations are 15/min.", "6. Her blood pressure is 130/80 mm Hg.", "7. The abdomen is nontender.", "8. Contractions are felt.", "9. The fetus is in a cephalic presentation.", "10. The fetal heart rate is reactive with no decelerations.", "11. One hour following vaginal delivery, the placenta is not delivered.", "12. Manual separation of the placenta leads to profuse vaginal bleeding.", "13. A firm, nontender uterine fundus is palpated at the level of the umbilicus." ]

[ "A 40-year-old man is brought to the clinic by his wife with a complaint of behavioral changes for the past few months.", "He is irritable and gets angry with trivial matters.", "He sometimes screams in the middle of the night and remains restless.", "His wife has recently noticed that he is forgetting things and repeats the same question multiple times.", "For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands.", "The past medical history is unremarkable.", "His father died at the age of 28 years old in a road traffic accident.", "His grandmother had similar symptoms after her retirement.", "He does not smoke, drinks alcohol, or uses illicit drugs.", "The physical examination reveals a restless ill-groomed man.", "He is having intermittent involuntary dance-like movements.", "The slit-lamp ophthalmic examination is normal.", "His mini-mental state examination (MMSE) score is 22/30.", "The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range." ]

[ "1. A 40-year-old man is brought to the clinic by his wife.", "2. He has been exhibiting behavioral changes for the past few months.", "3. He is irritable and gets angry with trivial matters.", "4. He sometimes screams in the middle of the night and remains restless.", "5. His wife has recently noticed that he is forgetting things and repeats the same question multiple times.", "6. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands.", "7. His past medical history is unremarkable.", "8. His father died at the age of 28 years old in a road traffic accident.", "9. His grandmother had similar symptoms after her retirement.", "10. He does not smoke, drink alcohol, or use illicit drugs.", "11. The physical examination reveals a restless ill-groomed man.", "12. He is having intermittent involuntary dance-like movements.", "13. The slit-lamp ophthalmic examination is normal.", "14. His mini-mental state examination (MMSE) score is 22/30.", "15. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range." ]

[ "1. He is irritable and gets angry with trivial matters.", "2. He sometimes screams in the middle of the night and remains restless.", "3. His wife has recently noticed that he is forgetting things and repeats the same question multiple times.", "4. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands.", "5. The past medical history is unremarkable.", "6. His father died at the age of 28 years old in a road traffic accident.", "7. His grandmother had similar symptoms after her retirement.", "8. He does not smoke, drinks alcohol, or uses illicit drugs.", "9. The physical examination reveals a restless ill-groomed man.", "10. He is having intermittent involuntary dance-like movements.", "11. The slit-lamp ophthalmic examination is normal.", "12. His mini-mental state examination (MMSE) score is 22/30.", "13. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range." ]

[ "A researcher is studying the association between hemoglobin levels and BMI.", "He divides volunteers who wish to participate into 2 groups based on their BMI, a normal weight group and an overweight group.", "He then measures the hemoglobin level of all of the volunteers.", "His null hypothesis is that there is no association between hemoglobin levels and body weight.", "The mean hemoglobin level for the normal weight group is 13.4 g/dL and 13.8 g/dL for the overweight group.", "He obtains a mean difference of 0.4 g/dL between the 2 groups.", "He does an unpaired t-test and gets a p-value of 0.10." ]

[ "1. A researcher is studying the association between hemoglobin levels and BMI.", "2. He divides volunteers who wish to participate into 2 groups based on their BMI, a normal weight group and an overweight group.", "3. He then measures the hemoglobin level of all of the volunteers.", "4. His null hypothesis is that there is no association between hemoglobin levels and body weight.", "5. The mean hemoglobin level for the normal weight group is 13.4 g/dL.", "6. The mean hemoglobin level for the overweight group is 13.8 g/dL.", "7. He obtains a mean difference of 0.4 g/dL between the 2 groups.", "8. He does an unpaired t-test and gets a p-value of 0.10." ]

[ "1. Volunteers are divided into 2 groups based on their BMI: normal weight and overweight.", "2. Hemoglobin levels of all volunteers are measured.", "3. The null hypothesis is that there is no association between hemoglobin levels and body weight.", "4. The mean hemoglobin level for the normal weight group is 13.4 g/dL.", "5. The mean hemoglobin level for the overweight group is 13.8 g/dL.", "6. The mean difference in hemoglobin levels between the 2 groups is 0.4 g/dL.", "7. An unpaired t-test is conducted.", "8. The p-value obtained from the t-test is 0.10." ]

[ "A 51-year-old female with a history of papillary thyroid carcinoma who is two weeks status-post thyroidectomy presents to her surgeon complaining of difficulty with her voice.", "Following the operation, she developed immediate hoarseness and difficulty speaking.", "The hoarseness has not improved since the operation.", "Her past medical history is notable for hypertension and obesity.", "Her temperature is 99°F (37.2°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 16/min.", "Physical examination reveals a healing surgical scar without evidence of infection or dehiscence." ]

[ "1. Patient is a 51-year-old female.", "2. Patient has a history of papillary thyroid carcinoma.", "3. Patient is two weeks status-post thyroidectomy.", "4. Patient presents to her surgeon complaining of difficulty with her voice.", "5. Patient developed immediate hoarseness and difficulty speaking following the operation.", "6. Hoarseness has not improved since the operation.", "7. Patient's past medical history is notable for hypertension and obesity.", "8. Patient's temperature is 99°F (37.2°C).", "9. Patient's blood pressure is 120/80 mmHg.", "10. Patient's pulse is 90/min.", "11. Patient's respirations are 16/min.", "12. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence." ]

[ "1. Following the operation, she developed immediate hoarseness and difficulty speaking.", "2. The hoarseness has not improved since the operation.", "3. Her past medical history is notable for hypertension and obesity.", "4. Her temperature is 99°F (37.2°C).", "5. Her blood pressure is 120/80 mmHg.", "6. Her pulse is 90/min.", "7. Her respirations are 16/min.", "8. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence." ]

[ "Six days after admission to the hospital for treatment of infective endocarditis, a 64-year-old woman develops persistent ringing in both ears, lightheadedness, and nausea.", "When she turns her head, she sees the light on the ceiling swinging from side to side.", "She has congestive heart disease, hypertension, and coronary artery disease.", "She was treated for a cerebrovascular accident 7 years ago and has no residual deficits.", "Current medications include intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.", "Her vital signs are within normal limits.", "Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.", "While the patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.", "She has an unsteady gait.", "Muscle strength and sensation are normal." ]

[ "1. Patient is 64 years old.", "2. Patient has been admitted to the hospital for 6 days for treatment of infective endocarditis.", "3. Patient has persistent ringing in both ears, lightheadedness, and nausea.", "4. When patient turns her head, she sees the light on the ceiling swinging from side to side.", "5. Patient has congestive heart disease, hypertension, and coronary artery disease.", "6. Patient was treated for a cerebrovascular accident 7 years ago and has no residual deficits.", "7. Patient is currently taking intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.", "8. Patient's vital signs are within normal limits.", "9. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.", "10. When patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.", "11. Patient has an unsteady gait.", "12. Patient's muscle strength and sensation are normal." ]

[ "1. She sees the light on the ceiling swinging from side to side when she turns her head.", "2. She has congestive heart disease.", "3. She has hypertension.", "4. She has coronary artery disease.", "5. She was treated for a cerebrovascular accident 7 years ago.", "6. She has no residual deficits from the cerebrovascular accident.", "7. Her current medications include intravenous vancomycin.", "8. Her current medications include intravenous gentamicin.", "9. Her current medications include oral aspirin.", "10. Her current medications include oral atenolol.", "11. Her current medications include oral furosemide.", "12. Her current medications include oral lisinopril.", "13. Her vital signs are within normal limits.", "14. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.", "15. Administration of brisk, horizontal head rotations to both sides results in corrective saccades while the patient fixates on a target.", "16. She has an unsteady gait.", "17. Her muscle strength is normal.", "18. Her sensation is normal." ]

[ "A patient with congestive heart failure with viral myocarditis due to coxsackievirus infection presents to a local hospital for treatment and then returns home." ]

[ "1. A patient presents to a local hospital.", "2. The patient has congestive heart failure.", "3. The patient has viral myocarditis.", "4. The cause of the viral myocarditis is coxsackievirus infection.", "5. The patient returns home." ]

[ "1. The patient has congestive heart failure.", "2. The patient has viral myocarditis.", "3. The viral myocarditis is due to coxsackievirus infection.", "4. The patient presents to a local hospital for treatment.", "5. The patient returns home after treatment." ]

[ "A 5-year-old male presents to the pediatrician with his mother for a well child visit.", "His mother has no complaints.", "The patient is doing well in preschool and appears to be ready for kindergarten.", "He can begin to sound out letters and write out his first name.", "He has many friends at school and enjoys playing with his older siblings.", "The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life.", "The patient’s mother denies any family history of genetic syndromes or malignancy.", "The patient’s height and weight are in the 99th percentile.", "On physical exam, the patient has an enlarged tongue with no other dysmorphic features.", "He also has the physical exam findings seen in Figures A and B." ]

[ "1. A 5-year-old male presents to the pediatrician with his mother for a well child visit.", "2. His mother has no complaints.", "3. The patient is doing well in preschool and appears to be ready for kindergarten.", "4. He can begin to sound out letters and write out his first name.", "5. He has many friends at school and enjoys playing with his older siblings.", "6. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life.", "7. The patient’s mother denies any family history of genetic syndromes or malignancy.", "8. The patient’s height and weight are in the 99th percentile.", "9. On physical exam, the patient has an enlarged tongue with no other dysmorphic features.", "10. He also has the physical exam findings seen in Figures A and B." ]

[ "1. His mother has no complaints.", "2. The patient is doing well in preschool and appears to be ready for kindergarten.", "3. He can begin to sound out letters and write out his first name.", "4. He has many friends at school and enjoys playing with his older siblings.", "5. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life.", "6. The patient’s mother denies any family history of genetic syndromes or malignancy.", "7. The patient’s height and weight are in the 99th percentile.", "8. On physical exam, the patient has an enlarged tongue with no other dysmorphic features.", "9. He also has the physical exam findings seen in Figures A and B." ]

[ "A first-year medical student undergoes a surgical procedure involving a midline laporotomy incision.", "The patient presents back to the surgeon approximately 3 months later and asks the surgeon: \"." ]

[ "1. A first-year medical student underwent a surgical procedure.", "2. The surgical procedure involved a midline laporotomy incision.", "3. The patient presented back to the surgeon approximately 3 months later.", "4. The patient asked the surgeon a question." ]

[ "1. The patient presents back to the surgeon.", "2. The patient presents approximately 3 months later.", "3. The patient asks the surgeon a question." ]

[ "A 40-year-old female complains of muscle weakness.", "Her blood pressure is 180/140 mm Hg, and serum potassium is 3.2 mEq/L.", "Plasma renin levels are abnormally low.", "A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland." ]

[ "1. A 40-year-old female complains of muscle weakness.", "2. Her blood pressure is 180/140 mm Hg.", "3. Her serum potassium is 3.2 mEq/L.", "4. Her plasma renin levels are abnormally low.", "5. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland." ]

[ "1. Her blood pressure is 180/140 mm Hg.", "2. Her serum potassium is 3.2 mEq/L.", "3. Plasma renin levels are abnormally low.", "4. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland." ]

[ "A 75-year-old woman is brought to the physician by her daughter because of a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.", "The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.", "She lives with her daughter and requires assistance with all of her banking and meal preparation.", "Her daughter has hypothyroidism but there is no other history of serious illness in the family.", "She does not remember the names of her medications but says she takes them every day.", "Her pulse is 114/min and blood pressure is 148/101 mm Hg.", "Physical examination shows warm skin and a tremor.", "The thyroid gland is not palpable.", "The serum thyroid stimulating hormone level is undetectable.", "Histological examination of a thyroid biopsy shows follicular atrophy." ]

[ "1. A 75-year-old woman is brought to the physician by her daughter.", "2. She has a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.", "3. She has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.", "4. She lives with her daughter and requires assistance with all of her banking and meal preparation.", "5. Her daughter has hypothyroidism.", "6. There is no other history of serious illness in the family.", "7. She does not remember the names of her medications but says she takes them every day.", "8. Her pulse is 114/min and blood pressure is 148/101 mm Hg.", "9. Physical examination shows warm skin and a tremor.", "10. The thyroid gland is not palpable.", "11. The serum thyroid stimulating hormone level is undetectable.", "12. Histological examination of a thyroid biopsy shows follicular atrophy." ]

[ "1. The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.", "2. She lives with her daughter and requires assistance with all of her banking and meal preparation.", "3. Her daughter has hypothyroidism but there is no other history of serious illness in the family.", "4. She does not remember the names of her medications but says she takes them every day.", "5. Her pulse is 114/min and blood pressure is 148/101 mm Hg.", "6. Physical examination shows warm skin and a tremor.", "7. The thyroid gland is not palpable.", "8. The serum thyroid stimulating hormone level is undetectable.", "9. Histological examination of a thyroid biopsy shows follicular atrophy." ]

[ "A 42-year-old man is brought to the emergency department by EMS from the scene of an automobile accident, where he appeared to be an unrestrained passenger.", "The patient is confused and unable to answer questions.", "His temperature is 98.6°F (37°C), pulse is 120/min, blood pressure is 75/44 mmHg, and respiratory rate is 22/min.", "On physical exam, there is bruising over his sternum and left chest, with tenderness to palpation.", "Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops.", "He has marked jugular venous distention and bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.", "Abdominal and cranial nerve exams are within normal limits.", "His extremities are cool with prolonged capillary refill, and he is diaphoretic.", "The patient is admitted to the intensive care unit and hemodynamic monitoring is established, which reveals a pulmonary capillary wedge pressure (PCWP) of 22 mmHg (normal range 8-12 mmHg), central venous pressure (CVP) of 12 cmH2O (normal range 4-12 cmH2O), cardiac output (CO) of 2.2 L/min (normal range 4-8 L/min), and systemic vascular resistance (SVR) of 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5)." ]

[ "1. Patient is 42 years old.", "2. Patient was brought to the emergency department by EMS from the scene of an automobile accident.", "3. Patient appeared to be an unrestrained passenger.", "4. Patient is confused and unable to answer questions.", "5. Patient's temperature is 98.6°F (37°C).", "6. Patient's pulse is 120/min.", "7. Patient's blood pressure is 75/44 mmHg.", "8. Patient's respiratory rate is 22/min.", "9. Patient has bruising over his sternum and left chest, with tenderness to palpation.", "10. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops.", "11. Patient has marked jugular venous distention.", "12. Patient has bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.", "13. Abdominal and cranial nerve exams are within normal limits.", "14. Patient's extremities are cool with prolonged capillary refill.", "15. Patient is diaphoretic.", "16. Patient is admitted to the intensive care unit.", "17. Hemodynamic monitoring is established.", "18. Pulmonary capillary wedge pressure (PCWP) is 22 mmHg (normal range 8-12 mmHg).", "19. Central venous pressure (CVP) is 12 cmH2O (normal range 4-12 cmH2O).", "20. Cardiac output (CO) is 2.2 L/min (normal range 4-8 L/min).", "21. Systemic vascular resistance (SVR) is 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5)." ]

[ "1. The patient is confused and unable to answer questions.", "2. His temperature is 98.6°F (37°C).", "3. His pulse is 120/min.", "4. His blood pressure is 75/44 mmHg.", "5. His respiratory rate is 22/min.", "6. On physical exam, there is bruising over his sternum and left chest, with tenderness to palpation.", "7. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops.", "8. He has marked jugular venous distention.", "9. He has bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.", "10. Abdominal and cranial nerve exams are within normal limits.", "11. His extremities are cool with prolonged capillary refill, and he is diaphoretic.", "12. The patient is admitted to the intensive care unit.", "13. Hemodynamic monitoring is established.", "14. The pulmonary capillary wedge pressure (PCWP) is 22 mmHg (normal range 8-12 mmHg).", "15. The central venous pressure (CVP) is 12 cmH2O (normal range 4-12 cmH2O).", "16. The cardiac output (CO) is 2.2 L/min (normal range 4-8 L/min).", "17. The systemic vascular resistance (SVR) is 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5)." ]

[ "A 23-year-old man comes to the emergency department complaining of 10/10 abdominal pain.", "He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.", "It started about 3 hours ago with no obvious precipitating factor.", "He reports multiple similar episodes in the past but they have all resolved within 1 hour or so.", "He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day.", "He just returned from an extensive hiking trip in Colorado.", "A radiograph of the abdomen was unremarkable." ]

[ "1. A 23-year-old man comes to the emergency department.", "2. He is complaining of 10/10 abdominal pain.", "3. He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.", "4. The pain started about 3 hours ago with no obvious precipitating factor.", "5. He reports multiple similar episodes in the past but they have all resolved within 1 hour or so.", "6. He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes.", "7. He endorses “red-colored urine” for the past day.", "8. He just returned from an extensive hiking trip in Colorado.", "9. A radiograph of the abdomen was unremarkable." ]

[ "1. The patient describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.", "2. The pain started about 3 hours ago with no obvious precipitating factor.", "3. The patient reports multiple similar episodes in the past, but they have all resolved within 1 hour or so.", "4. The patient denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day.", "5. The patient just returned from an extensive hiking trip in Colorado.", "6. A radiograph of the abdomen was unremarkable." ]

[ "A 33-year-old African American woman presents to the emergency department due to diffuse pain and fatigue.", "The woman states that she feels like her bones and muscles diffusely hurt.", "She also has experienced some abdominal pain as well and states that she has trouble focusing.", "The patient has a past medical history of sickle cell disease for which she takes hydroxyurea.", "Her temperature is 98.1°F (36.7°C), blood pressure is 119/59 mmHg, pulse is 130/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Laboratory values are ordered and are currently pending." ]

[ "1. A 33-year-old African American woman presents to the emergency department.", "2. The woman states that she has diffuse pain and fatigue.", "3. She also has experienced some abdominal pain.", "4. The patient has difficulty focusing.", "5. The patient has a past medical history of sickle cell disease.", "6. The patient takes hydroxyurea for her sickle cell disease.", "7. The patient's temperature is 98.1°F (36.7°C).", "8. The patient's blood pressure is 119/59 mmHg.", "9. The patient's pulse is 130/min.", "10. The patient's respirations are 16/min.", "11. The patient's oxygen saturation is 98% on room air.", "12. Laboratory values are ordered and are currently pending." ]

[ "1. The woman feels diffuse bone and muscle pain.", "2. She has experienced abdominal pain.", "3. She has trouble focusing.", "4. The patient has a past medical history of sickle cell disease.", "5. She takes hydroxyurea for sickle cell disease.", "6. Her temperature is 98.1°F (36.7°C).", "7. Her blood pressure is 119/59 mmHg.", "8. Her pulse is 130/min.", "9. Her respirations are 16/min.", "10. Her oxygen saturation is 98% on room air.", "11. Laboratory values are ordered and pending." ]

[ "A 40-year-old man with psoriatic arthritis comes to the physician because of progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks.", "His psoriatic arthritis had been well-controlled with adalimumab for several years prior to this.", "His only other medication is omeprazole.", "Physical examination shows scaly plaques on both elbows and limited range of motion of most of the larger joints." ]

[ "1. A 40-year-old man has psoriatic arthritis.", "2. He has been experiencing progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks.", "3. His psoriatic arthritis had been well-controlled with adalimumab for several years prior to this.", "4. His only other medication is omeprazole.", "5. Physical examination shows scaly plaques on both elbows.", "6. Physical examination shows limited range of motion of most of the larger joints." ]

[ "1. His psoriatic arthritis had been well-controlled with adalimumab for several years.", "2. His only other medication is omeprazole.", "3. Physical examination shows scaly plaques on both elbows.", "4. Physical examination shows limited range of motion of most of the larger joints." ]

[ "A 35-year-old African American female presents to the emergency department with a three day history of cough, chest pain, and fever.", "Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C), blood pressure is 110/80 mmHg, pulse is 95/min, and respirations are 24/min.", "Lung auscultation reveals crackles over the left lung base.", "Chest radiograph reveals a dense consolidation in the left lower lung.", "The patient undergoes lab tests in the emergency department that demonstrate an elevated level of C-reactive protein." ]

[ "1. A 35-year-old African American female presents to the emergency department.", "2. She has a three day history of cough, chest pain, and fever.", "3. Her temperature is 101.4 °F (38.5 °C).", "4. Her blood pressure is 110/80 mmHg.", "5. Her pulse is 95/min.", "6. Her respirations are 24/min.", "7. Lung auscultation reveals crackles over the left lung base.", "8. Chest radiograph reveals a dense consolidation in the left lower lung.", "9. The patient undergoes lab tests in the emergency department.", "10. The lab tests demonstrate an elevated level of C-reactive protein." ]

[ "1. Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C).", "2. Her blood pressure is 110/80 mmHg.", "3. Her pulse is 95/min.", "4. Her respirations are 24/min.", "5. Lung auscultation reveals crackles over the left lung base.", "6. Chest radiograph reveals a dense consolidation in the left lower lung.", "7. The patient undergoes lab tests in the emergency department.", "8. The lab tests demonstrate an elevated level of C-reactive protein." ]

[ "A 50-year-old man comes to the physician after a fall on a flight of stairs earlier that day.", "He slipped, causing him to fall and hit the handrail with the lateral part of his chest.", "He has no shortness of breath.", "He returned from a 10-day trip to South Africa 4 weeks ago.", "He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago.", "He drinks 1–2 beers a week.", "His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 126/72 mm Hg.", "Examination shows normal breath sounds bilaterally.", "The left lateral chest wall is tender to palpation.", "An x-ray of the chest shows no fracture; there is a 5-mm lesion in the right upper lung field.", "There are no previous x-rays of the patient available." ]

[ "1. A 50-year-old man comes to the physician after a fall on a flight of stairs earlier that day.", "2. He slipped, causing him to fall and hit the handrail with the lateral part of his chest.", "3. He has no shortness of breath.", "4. He returned from a 10-day trip to South Africa 4 weeks ago.", "5. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago.", "6. He drinks 1–2 beers a week.", "7. His temperature is 37.1°C (98.8°F).", "8. His pulse is 78/min.", "9. His blood pressure is 126/72 mm Hg.", "10. Examination shows normal breath sounds bilaterally.", "11. The left lateral chest wall is tender to palpation.", "12. An x-ray of the chest shows no fracture.", "13. There is a 5-mm lesion in the right upper lung field.", "14. There are no previous x-rays of the patient available." ]

[ "1. He slipped, causing him to fall and hit the handrail with the lateral part of his chest.", "2. He has no shortness of breath.", "3. He returned from a 10-day trip to South Africa 4 weeks ago.", "4. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago.", "5. He drinks 1–2 beers a week.", "6. His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 126/72 mm Hg.", "7. Examination shows normal breath sounds bilaterally.", "8. The left lateral chest wall is tender to palpation.", "9. An x-ray of the chest shows no fracture; there is a 5-mm lesion in the right upper lung field.", "10. There are no previous x-rays of the patient available." ]

[ "A 62-year-old woman presents to a clinic with complaints of a worsening rash on her back, fevers with chills, and rigor for 2 days.", "She denies any headaches, nausea, or vomiting.", "She is currently on chemotherapy for multiple myeloma, which was diagnosed last year.", "On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back.", "Some of the lesions have black necrotic centers.", "The vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.", "Laboratory studies show: | Hemoglobin 8.4 g/dL | ." ]

[ "1. Patient is a 62-year-old woman.", "2. Patient has a worsening rash on her back, fevers with chills, and rigor for 2 days.", "3. Patient denies any headaches, nausea, or vomiting.", "4. Patient is currently on chemotherapy for multiple myeloma, which was diagnosed last year.", "5. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back. Some of the lesions have black necrotic centers.", "6. Vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.", "7. Laboratory studies show: Hemoglobin 8.4 g/dL." ]

[ "1. The patient denies any headaches, nausea, or vomiting.", "2. She is currently on chemotherapy for multiple myeloma, which was diagnosed last year.", "3. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back.", "4. Some of the lesions have black necrotic centers.", "5. The vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.", "6. Laboratory studies show: Hemoglobin 8.4 g/dL." ]

[ "An 8-year-old boy developed nausea, abdominal pain, and watery diarrhea 6 hours after consuming homemade mushroom soup.", "The boy is rushed to the emergency department.", "He is severely dehydrated and his blood pressure is 60/40 mm Hg.", "He is managed with intravenous fluids and other supportive treatment.", "The mushrooms in the soup had been picked from his family's backyard, and samples of mushrooms were sent to the lab for analysis.", "The lab reports confirmed that the mushrooms contained some kind of toxin." ]

[ "1. An 8-year-old boy developed nausea, abdominal pain, and watery diarrhea 6 hours after consuming homemade mushroom soup.", "2. The boy is rushed to the emergency department.", "3. He is severely dehydrated and his blood pressure is 60/40 mm Hg.", "4. He is managed with intravenous fluids and other supportive treatment.", "5. The mushrooms in the soup had been picked from his family's backyard.", "6. Samples of mushrooms were sent to the lab for analysis.", "7. The lab reports confirmed that the mushrooms contained some kind of toxin." ]

[ "1. The boy is rushed to the emergency department.", "2. He is severely dehydrated.", "3. His blood pressure is 60/40 mm Hg.", "4. He is managed with intravenous fluids and other supportive treatment.", "5. The mushrooms in the soup had been picked from his family's backyard.", "6. Samples of mushrooms were sent to the lab for analysis.", "7. The lab reports confirmed that the mushrooms contained some kind of toxin." ]

[ "A 6-year-old girl is brought to the physician because of generalized fatigue and dark urine for 4 days.", "Four weeks ago, she was treated with cephalexin for a skin infection.", "Her temperature is 37°C (98.6°F) and blood pressure is 132/89 mm Hg.", "Physical examination shows 1+ pretibial edema bilaterally.", "Her serum creatinine is 1.7 mg/dL.", "Urine studies show: | Blood 2+ | Protein 2+ | RBC 12–14/hpf with dysmorphic features | RBC casts numerous | ." ]

[ "1. A 6-year-old girl is brought to the physician.", "2. She has had generalized fatigue and dark urine for 4 days.", "3. Four weeks ago, she was treated with cephalexin for a skin infection.", "4. Her temperature is 37°C (98.6°F).", "5. Her blood pressure is 132/89 mm Hg.", "6. Physical examination shows 1+ pretibial edema bilaterally.", "7. Her serum creatinine is 1.7 mg/dL.", "8. Urine studies show: Blood 2+.", "9. Urine studies show: Protein 2+.", "10. Urine studies show: RBC 12–14/hpf with dysmorphic features.", "11. Urine studies show: RBC casts numerous." ]

[ "1. Four weeks ago, she was treated with cephalexin for a skin infection.", "2. Her temperature is 37°C (98.6°F).", "3. Her blood pressure is 132/89 mm Hg.", "4. Physical examination shows 1+ pretibial edema bilaterally.", "5. Her serum creatinine is 1.7 mg/dL.", "6. Urine studies show: Blood 2+.", "7. Urine studies show: Protein 2+.", "8. Urine studies show: RBC 12–14/hpf with dysmorphic features.", "9. Urine studies show: RBC casts numerous." ]

[ "A 7-year-old girl is brought to the physician by her mother for a 6-month history of irritability.", "She has no history of significant illness and is up-to-date on her immunizations.", "She appears markedly lethargic.", "Her vital signs are within normal limits.", "Physical examination shows subconjunctival pallor.", "Her hemoglobin concentration is 9.2 g/dL and mean corpuscular volume is 76 μm3.", "A photomicrograph of a wet stool mount is shown." ]

[ "1. A 7-year-old girl is brought to the physician by her mother.", "2. She has a 6-month history of irritability.", "3. She has no history of significant illness.", "4. She is up-to-date on her immunizations.", "5. She appears markedly lethargic.", "6. Her vital signs are within normal limits.", "7. Physical examination shows subconjunctival pallor.", "8. Her hemoglobin concentration is 9.2 g/dL.", "9. Her mean corpuscular volume is 76 μm3.", "10. A photomicrograph of a wet stool mount is shown." ]

[ "1. She has no history of significant illness.", "2. She is up-to-date on her immunizations.", "3. She appears markedly lethargic.", "4. Her vital signs are within normal limits.", "5. Physical examination shows subconjunctival pallor.", "6. Her hemoglobin concentration is 9.2 g/dL.", "7. Her mean corpuscular volume is 76 μm3.", "8. A photomicrograph of a wet stool mount is shown." ]

[ "A 15-year-old girl is brought to the physician by her mother because of a 3-day history of lower abdominal pain.", "Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days.", "Menarche has not yet occurred.", "Examination shows suprapubic tenderness to palpation.", "Pubic hair and breast development are Tanner stage 4.", "Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus." ]

[ "1. Patient is a 15-year-old girl.", "2. Patient was brought to the physician by her mother.", "3. Patient has a 3-day history of lower abdominal pain.", "4. Patient has had multiple similar episodes of abdominal pain over the past 9 months.", "5. Each episode of abdominal pain has lasted for 4–5 days.", "6. Patient has not yet experienced menarche.", "7. Examination shows suprapubic tenderness to palpation.", "8. Pubic hair and breast development are Tanner stage 4.", "9. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus." ]

[ "1. Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days.", "2. Menarche has not yet occurred.", "3. Examination shows suprapubic tenderness to palpation.", "4. Pubic hair and breast development are Tanner stage 4.", "5. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus." ]

[ "A 6-year-old boy presents with high fever, sore throat, and cough for the past day.", "The patient’s mother also says he is complaining of generalized muscle aches and chills.", "Past medical history is significant for childhood asthma, managed with inhaled mometasone furoate.", "The patient’s temperature is 39.1°C (102.3°F), pulse is 120/min, and respiratory rate is 20/min.", "On physical examination, his oropharynx is erythematous with mild swelling of the pharyngeal tonsils.", "Chest auscultation reveals crepitus over the lung bases bilaterally.", "There are no signs of respiratory distress.", "Rapid diagnostic testing for influenza B infection in this patient is positive." ]

[ "1. Patient is a 6-year-old boy.", "2. Patient has high fever, sore throat, and cough for the past day.", "3. Patient is complaining of generalized muscle aches and chills.", "4. Patient has past medical history of childhood asthma, managed with inhaled mometasone furoate.", "5. Patient's temperature is 39.1°C (102.3°F).", "6. Patient's pulse is 120/min.", "7. Patient's respiratory rate is 20/min.", "8. Patient's oropharynx is erythematous with mild swelling of the pharyngeal tonsils.", "9. Chest auscultation reveals crepitus over the lung bases bilaterally.", "10. Patient has no signs of respiratory distress.", "11. Rapid diagnostic testing for influenza B infection in this patient is positive." ]

[ "1. The patient's mother reports that he is complaining of generalized muscle aches and chills.", "2. The patient has a past medical history significant for childhood asthma, managed with inhaled mometasone furoate.", "3. The patient's temperature is 39.1°C (102.3°F).", "4. The patient's pulse is 120/min.", "5. The patient's respiratory rate is 20/min.", "6. On physical examination, the patient's oropharynx is erythematous with mild swelling of the pharyngeal tonsils.", "7. Chest auscultation reveals crepitus over the lung bases bilaterally.", "8. There are no signs of respiratory distress.", "9. Rapid diagnostic testing for influenza B infection in this patient is positive." ]

[ "A 38-year-old woman presents to the emergency department with nausea and progressive right upper quadrant abdominal pain for the past day.", "For the past year, she has had occasional pain in her right upper quadrant which is often relieved on its own after a few hours.", "She was recently diagnosed with multiple gallstones for which she underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.", "Past medical history is otherwise unremarkable.", "On physical examination, there is tenderness over the epigastrium with no guarding or rebound.", "Vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min.", "Laboratory tests are pending.", "An imaging study of the abdomen confirms the most likely diagnosis." ]

[ "1. Patient is a 38-year-old woman.", "2. Patient presents with nausea and progressive right upper quadrant abdominal pain for the past day.", "3. Patient has had occasional pain in her right upper quadrant for the past year, which is often relieved on its own after a few hours.", "4. Patient was recently diagnosed with multiple gallstones.", "5. Patient underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.", "6. Patient's past medical history is otherwise unremarkable.", "7. On physical examination, there is tenderness over the epigastrium with no guarding or rebound.", "8. Patient's vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min.", "9. Laboratory tests are pending.", "10. Imaging study of the abdomen confirms the most likely diagnosis." ]

[ "1. She has had occasional pain in her right upper quadrant for the past year.", "2. The pain is often relieved on its own after a few hours.", "3. She was recently diagnosed with multiple gallstones.", "4. She underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.", "5. Her past medical history is otherwise unremarkable.", "6. On physical examination, there is tenderness over the epigastrium.", "7. There is no guarding or rebound on physical examination.", "8. Her blood pressure is 110/68 mm Hg.", "9. Her pulse is 98/min.", "10. Her temperature is 36.2°C (97.2°F).", "11. Her respiratory rate is 11/min.", "12. Laboratory tests are pending.", "13. An imaging study of the abdomen confirms the most likely diagnosis." ]

[ "A 42-year-old woman comes to the emergency department because of hematuria and pain in both flanks.", "She has a history of recurrent urinary tract infections.", "She also complains of swelling of both feet and facial puffiness.", "She has passed urinary stones twice before.", "Her mother also has a history of urinary stone and underwent a kidney transplant.", "Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 150/98 mm Hg.", "Abdominal examination shows palpable, bilateral flank masses.", "Results of a complete blood count are within the reference range.", "Her serum creatinine concentration is 2.7 mg/dL." ]

[ "1. A 42-year-old woman comes to the emergency department.", "2. She has hematuria and pain in both flanks.", "3. She has a history of recurrent urinary tract infections.", "4. She complains of swelling of both feet and facial puffiness.", "5. She has passed urinary stones twice before.", "6. Her mother has a history of urinary stone and underwent a kidney transplant.", "7. Her temperature is 38.0°C (100.4°F).", "8. Her pulse is 110/min.", "9. Her blood pressure is 150/98 mm Hg.", "10. Abdominal examination shows palpable, bilateral flank masses.", "11. Results of a complete blood count are within the reference range.", "12. Her serum creatinine concentration is 2.7 mg/dL." ]

[ "1. She has a history of recurrent urinary tract infections.", "2. She complains of swelling of both feet and facial puffiness.", "3. She has passed urinary stones twice before.", "4. Her mother has a history of urinary stone and underwent a kidney transplant.", "5. Her temperature is 38.0°C (100.4°F).", "6. Her pulse is 110/min.", "7. Her blood pressure is 150/98 mm Hg.", "8. Abdominal examination shows palpable, bilateral flank masses.", "9. Results of a complete blood count are within the reference range.", "10. Her serum creatinine concentration is 2.7 mg/dL." ]