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stellalisy

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[ "A 28-year-old woman presents with a recent history of severe headaches.", "The patient states that the headaches came on gradually about 1 week ago and have steadily worsened.", "She describes the headaches as severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings.", "Past medical history is significant for bacterial meningitis, approx.", "one month ago, that was successfully treated.", "Current medications are combined oral contraceptives and fluoxetine.", "A review of systems is significant for fatigue and daytime sleepiness.", "Family history is significant for her mother and aunt who suffer from migraines with aura.", "Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 70/min, the respiratory rate is 16/min, and the oxygen saturation is 99% on room air.", "The cardiac exam is normal.", "Lungs are clear to auscultation.", "The neurological exam is normal.", "The ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally." ]

[ "1. Patient is a 28-year-old woman.", "2. Patient has a recent history of severe headaches.", "3. Headaches came on gradually about 1 week ago.", "4. Headaches have steadily worsened.", "5. Headaches are severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings.", "6. Past medical history is significant for bacterial meningitis, approx. one month ago, that was successfully treated.", "7. Current medications are combined oral contraceptives and fluoxetine.", "8. Review of systems is significant for fatigue and daytime sleepiness.", "9. Family history is significant for her mother and aunt who suffer from migraines with aura.", "10. Temperature is 37.0°C (98.6°F).", "11. Blood pressure is 110/70 mm Hg.", "12. Pulse is 70/min.", "13. Respiratory rate is 16/min.", "14. Oxygen saturation is 99% on room air.", "15. Cardiac exam is normal.", "16. Lungs are clear to auscultation.", "17. Neurological exam is normal.", "18. Ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally." ]

[ "1. The patient's headaches started gradually about 1 week ago and have worsened.", "2. The patient describes the headaches as severe, diffuse, and causing nausea and vomiting, especially in the mornings.", "3. The patient had bacterial meningitis approximately one month ago, which was successfully treated.", "4. The patient's current medications are combined oral contraceptives and fluoxetine.", "5. The patient experiences fatigue and daytime sleepiness.", "6. The patient's mother and aunt suffer from migraines with aura.", "7. The patient's temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, pulse is 70/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air.", "8. The patient's cardiac exam is normal.", "9. The patient's lungs are clear to auscultation.", "10. The patient's neurological exam is normal.", "11. The patient's ophthalmic exam reveals indistinct margins of the optic disc bilaterally." ]

[ "A 72-year-old presents to the Emergency Room with hemoptysis.", "He has smoked 1 pack of cigarettes a day for the past 30 years.", "Physical examination of the face is shown in Image A and is accompanied by left upper extremity edema." ]

[ "1. A 72-year-old presents to the Emergency Room.", "2. The patient has a history of smoking 1 pack of cigarettes a day for the past 30 years.", "3. The patient has hemoptysis.", "4. Physical examination of the face is shown in Image A.", "5. The patient has left upper extremity edema." ]

[ "1. He has smoked 1 pack of cigarettes a day for the past 30 years.", "2. Physical examination of the face is shown in Image A.", "3. The physical examination is accompanied by left upper extremity edema." ]

[ "A 59-year-old man who was recently diagnosed with renal cell carcinoma comes to the physician for a follow-up evaluation.", "The physician recommends starting treatment with a chemotherapeutic agent that is also used to treat neovascular age-related macular degeneration." ]

[ "1. A 59-year-old man has been diagnosed with renal cell carcinoma.", "2. The man is coming to the physician for a follow-up evaluation.", "3. The physician is recommending starting treatment with a chemotherapeutic agent.", "4. The chemotherapeutic agent is also used to treat neovascular age-related macular degeneration." ]

[ "1. The physician recommends starting treatment.", "2. The treatment involves a chemotherapeutic agent.", "3. The chemotherapeutic agent is used to treat neovascular age-related macular degeneration." ]

[ "A 36-year-old woman presents with a persistent cough productive of blood-streaked sputum, night sweats, and weight loss.", "No significant past medical history.", "She denies any history of smoking, alcohol consumption, or recreational drug use.", "She works as a nurse at a local hospital and lives in an apartment with her extended family.", "Her vital signs are a blood pressure of 100/80 mm Hg, heart rate of 94/min, respiratory rate of 17/min, and temperature of 35.9℃ (96.6℉).", "Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung.", "During the discussion regarding the required workup, the patient tells the physician about recent contact with a patient with tuberculosis.", "She asks the physician not to report her case because she is concerned she will lose her job." ]

[ "1. Patient is a 36-year-old woman.", "2. Patient has a persistent cough productive of blood-streaked sputum, night sweats, and weight loss.", "3. Patient has no significant past medical history.", "4. Patient denies any history of smoking, alcohol consumption, or recreational drug use.", "5. Patient works as a nurse at a local hospital.", "6. Patient lives in an apartment with her extended family.", "7. Patient's blood pressure is 100/80 mm Hg.", "8. Patient's heart rate is 94/min.", "9. Patient's respiratory rate is 17/min.", "10. Patient's temperature is 35.9℃ (96.6℉).", "11. Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung.", "12. Patient recently had contact with a patient with tuberculosis.", "13. Patient is concerned she will lose her job if her case is reported." ]

[ "1. No significant past medical history.", "2. She denies any history of smoking, alcohol consumption, or recreational drug use.", "3. She works as a nurse at a local hospital and lives in an apartment with her extended family.", "4. Her vital signs are a blood pressure of 100/80 mm Hg, heart rate of 94/min, respiratory rate of 17/min, and temperature of 35.9℃ (96.6℉).", "5. Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung.", "6. During the discussion regarding the required workup, the patient tells the physician about recent contact with a patient with tuberculosis.", "7. She asks the physician not to report her case because she is concerned she will lose her job." ]

[ "A 33-year-old woman gravida 2, para 1, at 35 weeks gestation is admitted to the hospital with fever and active labor.", "She reports a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.", "Her pregnancy has otherwise been uncomplicated.", "She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.", "Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation.", "The patient reports a 10-pack-year history of smoking before pregnancy and smoked 4 cigarettes daily during pregnancy.", "At the hospital, her temperature is 39.6°C (103.3°F), blood pressure is 108/60 mm Hg, and pulse is 125/min.", "Her BMI is 18.2 kg/m2.", "Uterine palpation reveals tenderness.", "Cervical examination indicates 100% effacement and 10 cm dilation.", "Her lungs are clear to auscultation.", "The baseline fetal heart rate is 180/min." ]

[ "1. A 33-year-old woman is admitted to the hospital.", "2. She is gravida 2, para 1, at 35 weeks gestation.", "3. She has a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.", "4. Her pregnancy has otherwise been uncomplicated.", "5. She has attended many prenatal appointments.", "6. She followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.", "7. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation.", "8. She has a 10-pack-year history of smoking before pregnancy.", "9. She smoked 4 cigarettes daily during pregnancy.", "10. Her temperature is 39.6°C (103.3°F).", "11. Her blood pressure is 108/60 mm Hg.", "12. Her pulse is 125/min.", "13. Her BMI is 18.2 kg/m2.", "14. Uterine palpation reveals tenderness.", "15. Cervical examination indicates 100% effacement and 10 cm dilation.", "16. Her lungs are clear to auscultation.", "17. The baseline fetal heart rate is 180/min." ]

[ "1. The patient reports a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.", "2. Her pregnancy has otherwise been uncomplicated.", "3. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.", "4. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation.", "5. The patient reports a 10-pack-year history of smoking before pregnancy and smoked 4 cigarettes daily during pregnancy.", "6. At the hospital, her temperature is 39.6°C (103.3°F), blood pressure is 108/60 mm Hg, and pulse is 125/min.", "7. Her BMI is 18.2 kg/m2.", "8. Uterine palpation reveals tenderness.", "9. Cervical examination indicates 100% effacement and 10 cm dilation.", "10. Her lungs are clear to auscultation.", "11. The baseline fetal heart rate is 180/min." ]

[ "A 49-year-old man, with a history of alcohol abuse over the last 2 decades, presents with a complaint of epigastric pain for about a year.", "He previously had one episode of acute pancreatitis for which he was hospitalized.", "He continued to drink 4–5 beers/day after he was discharged.", "His appetite is good, but he has a history of weight loss.", "He also complains of oily and bulky stools.", "He takes aluminum hydroxide gel and ranitidine for partial pain relief.", "Vital signs are stable.", "Routine physical exam and blood work are normal except for mild hypocalcemia.", "Abdominal CT scan is shown below." ]

[ "1. Patient is a 49-year-old man.", "2. Patient has a history of alcohol abuse for the last 2 decades.", "3. Patient presents with a complaint of epigastric pain for about a year.", "4. Patient had one episode of acute pancreatitis for which he was hospitalized.", "5. Patient continued to drink 4–5 beers/day after he was discharged.", "6. Patient's appetite is good.", "7. Patient has a history of weight loss.", "8. Patient complains of oily and bulky stools.", "9. Patient takes aluminum hydroxide gel and ranitidine for partial pain relief.", "10. Vital signs are stable.", "11. Routine physical exam and blood work are normal except for mild hypocalcemia.", "12. Abdominal CT scan is shown below." ]

[ "1. He previously had one episode of acute pancreatitis.", "2. He was hospitalized for the acute pancreatitis.", "3. He continued to drink 4–5 beers/day after he was discharged.", "4. His appetite is good.", "5. He has a history of weight loss.", "6. He complains of oily and bulky stools.", "7. He takes aluminum hydroxide gel for partial pain relief.", "8. He takes ranitidine for partial pain relief.", "9. Vital signs are stable.", "10. Routine physical exam is normal.", "11. Blood work is normal except for mild hypocalcemia.", "12. Abdominal CT scan is shown below." ]

[ "A 34-year-old woman presents to the office due to a pulmonary embolism confirmed by computed tomography (CT) chest angiogram, which she was recently hospitalized for.", "She does not have any recent surgical trauma or travel history.", "She complains of having episodes where her fingers become white and then blue, and they are usually accompanied by pain in the same region.", "These episodes tend to happen more frequently during winter and have been ongoing for about 2 years now.", "She also had a spontaneous abortion at 12 weeks of gestation last year.", "She does not have a family history of venous thromboembolic disease.", "The vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.", "Physical examination is non-contributory.", "The complete blood count (CBC) results are as follows: | Hemoglobin 14.2 g/dL | Hematocrit 39% | Leukocyte count 4,950/mm3 | Neutrophils 59% | Bands 3% | Eosinophils 1% | Basophils 0% | Lymphocytes 31% | Monocytes 4% | Platelet count 120,000/mm3 | The coagulation test results are as follows: | Partial thromboplastin time (activated) 56 seconds | Prothrombin time 15 seconds | Reticulocyte count 1.0% | Thrombin time < 2 seconds deviation from control | ." ]

[ "1. Patient is a 34-year-old woman.", "2. Patient was recently hospitalized for a pulmonary embolism confirmed by CT chest angiogram.", "3. Patient does not have any recent surgical trauma or travel history.", "4. Patient complains of episodes where her fingers become white and then blue, accompanied by pain in the same region.", "5. Episodes tend to happen more frequently during winter and have been ongoing for about 2 years.", "6. Patient had a spontaneous abortion at 12 weeks of gestation last year.", "7. Patient does not have a family history of venous thromboembolic disease.", "8. Vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.", "9. Physical examination is non-contributory.", "10. CBC results: Hemoglobin 14.2 g/dL, Hematocrit 39%, Leukocyte count 4,950/mm3, Neutrophils 59%, Bands 3%, Eosinophils 1%, Basophils 0%, Lymphocytes 31%, Monocytes 4%, Platelet count 120,000/mm3.", "11. Coagulation test results: Partial thromboplastin time (activated) 56 seconds, Prothrombin time 15 seconds, Reticulocyte count 1.0%, Thrombin time < 2 seconds deviation from control." ]

[ "1. The patient does not have recent surgical trauma or travel history.", "2. She experiences episodes where her fingers become white and then blue, accompanied by pain in the same region.", "3. These episodes occur more frequently during winter and have been ongoing for about 2 years.", "4. The patient had a spontaneous abortion at 12 weeks of gestation last year.", "5. There is no family history of venous thromboembolic disease.", "6. Vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.", "7. Physical examination is non-contributory.", "8. Complete blood count (CBC) results: Hemoglobin 14.2 g/dL, Hematocrit 39%, Leukocyte count 4,950/mm3, Neutrophils 59%, Bands 3%, Eosinophils 1%, Basophils 0%, Lymphocytes 31%, Monocytes 4%, Platelet count 120,000/mm3.", "9. Coagulation test results: Partial thromboplastin time (activated) 56 seconds, Prothrombin time 15 seconds, Reticulocyte count 1.0%, Thrombin time < 2 seconds deviation from control." ]

[ "A 36-year-old woman, gravida 3, para 2, at 34 weeks' gestation is brought to the emergency department for the evaluation of continuous, dark, vaginal bleeding that started one hour ago.", "She also reports severe lower abdominal pain.", "Her current pregnancy was complicated by preeclampsia.", "Her first two children were delivered vaginally.", "Current medications include methyldopa and a multivitamin.", "Her pulse is 100/min, respirations are 16/min, and blood pressure is 90/60 mm Hg.", "The abdomen is tender, and hypertonic contractions are felt.", "There is blood on the vulva and on the medial aspect of both thighs bilaterally.", "The fetus is in a cephalic presentation.", "The fetal heart rate is 170/min with several decelerations." ]

[ "1. Patient is a 36-year-old woman.", "2. Gravida 3, para 2.", "3. 34 weeks' gestation.", "4. Brought to the emergency department for evaluation of continuous, dark, vaginal bleeding that started one hour ago.", "5. Severe lower abdominal pain.", "6. Pregnancy complicated by preeclampsia.", "7. First two children delivered vaginally.", "8. Current medications include methyldopa and a multivitamin.", "9. Pulse is 100/min.", "10. Respirations are 16/min.", "11. Blood pressure is 90/60 mm Hg.", "12. Abdomen is tender.", "13. Hypertonic contractions are felt.", "14. Blood on the vulva and on the medial aspect of both thighs bilaterally.", "15. Fetus in cephalic presentation.", "16. Fetal heart rate is 170/min with several decelerations." ]

[ "1. She reports severe lower abdominal pain.", "2. Her current pregnancy was complicated by preeclampsia.", "3. Her first two children were delivered vaginally.", "4. Current medications include methyldopa and a multivitamin.", "5. Her pulse is 100/min.", "6. Her respirations are 16/min.", "7. Her blood pressure is 90/60 mm Hg.", "8. The abdomen is tender.", "9. Hypertonic contractions are felt.", "10. There is blood on the vulva and on the medial aspect of both thighs bilaterally.", "11. The fetus is in a cephalic presentation.", "12. The fetal heart rate is 170/min with several decelerations." ]

[ "A 16-year-old boy is brought to the emergency department because of severe left flank pain and nausea for 3 hours.", "The pain is colicky and radiates towards his groin.", "He drinks multiple glasses of iced tea every day.", "He has had similar episodes of abdominal pain in the past.", "His maternal uncle has a similar history of abdominal pain.", "His temperature is 37.1°C (98.8°F), pulse is 103/min, and blood pressure is 108/72 mm Hg.", "Examination shows a soft and nontender abdomen.", "Left costovertebral angle tenderness is present.", "An x-ray of the abdomen shows no abnormalities.", "A urinary cyanide nitroprusside test is positive." ]

[ "1. A 16-year-old boy is brought to the emergency department.", "2. He has severe left flank pain and nausea for 3 hours.", "3. The pain is colicky and radiates towards his groin.", "4. He drinks multiple glasses of iced tea every day.", "5. He has had similar episodes of abdominal pain in the past.", "6. His maternal uncle has a similar history of abdominal pain.", "7. His temperature is 37.1°C (98.8°F).", "8. His pulse is 103/min.", "9. His blood pressure is 108/72 mm Hg.", "10. Examination shows a soft and nontender abdomen.", "11. Left costovertebral angle tenderness is present.", "12. An x-ray of the abdomen shows no abnormalities.", "13. A urinary cyanide nitroprusside test is positive." ]

[ "1. The pain is colicky and radiates towards his groin.", "2. He drinks multiple glasses of iced tea every day.", "3. He has had similar episodes of abdominal pain in the past.", "4. His maternal uncle has a similar history of abdominal pain.", "5. His temperature is 37.1°C (98.8°F), pulse is 103/min, and blood pressure is 108/72 mm Hg.", "6. Examination shows a soft and nontender abdomen.", "7. Left costovertebral angle tenderness is present.", "8. An x-ray of the abdomen shows no abnormalities.", "9. A urinary cyanide nitroprusside test is positive." ]

[ "A 57-year-old woman comes to the emergency department because of severe dyspnea, cough, and pleuritic chest pain for 20 minutes.", "Three weeks ago, she underwent surgery for a total right knee replacement.", "The patient appears distressed.", "Her pulse is 112/min, respirations are 24/min, and blood pressure is 88/55 mm Hg.", "Examination shows jugular venous distention.", "There is a mildly tender surgical scar on her right knee.", "A CT scan of the chest is shown." ]

[ "1. A 57-year-old woman comes to the emergency department.", "2. She has severe dyspnea, cough, and pleuritic chest pain for 20 minutes.", "3. Three weeks ago, she underwent surgery for a total right knee replacement.", "4. The patient appears distressed.", "5. Her pulse is 112/min.", "6. Her respirations are 24/min.", "7. Her blood pressure is 88/55 mm Hg.", "8. Examination shows jugular venous distention.", "9. There is a mildly tender surgical scar on her right knee.", "10. A CT scan of the chest is shown." ]

[ "1. Three weeks ago, she underwent surgery for a total right knee replacement.", "2. The patient appears distressed.", "3. Her pulse is 112/min.", "4. Her respirations are 24/min.", "5. Her blood pressure is 88/55 mm Hg.", "6. Examination shows jugular venous distention.", "7. There is a mildly tender surgical scar on her right knee.", "8. A CT scan of the chest is shown." ]

[ "A group of multidisciplinary researchers from a tertiary hospital decides to investigate whether there is an association between splenectomy and pulmonary tuberculosis.", "From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis, as well as 72,000 patients without pulmonary tuberculosis for comparison purposes.", "Both of these groups are matched for age, gender, and an index year when the condition was initially diagnosed.", "The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities is estimated.", "After controlling for all relevant confounders, the results show that splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development.", "There is also a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis." ]

[ "1. A group of multidisciplinary researchers from a tertiary hospital decides to investigate whether there is an association between splenectomy and pulmonary tuberculosis. ", "2. From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis. ", "3. From the hospital database, they identify 72,000 patients without pulmonary tuberculosis for comparison purposes. ", "4. Both of these groups are matched for age, gender, and an index year when the condition was initially diagnosed. ", "5. The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities is estimated. ", "6. After controlling for all relevant confounders, the results show that splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development. ", "7. There is also a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis." ]

[ "1. 19,000 patients over the age of 20 have newly diagnosed pulmonary tuberculosis.", "2. 72,000 patients without pulmonary tuberculosis are identified for comparison.", "3. Both groups are matched for age, gender, and an index year of diagnosis.", "4. The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities are estimated.", "5. After controlling for relevant confounders, splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development.", "6. There is a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis." ]

[ "A 53-year-old woman presents to the clinic with complaints of fatigue.", "She reports that over the past several months she has been lethargic and tired.", "She has gained 10 pounds over the past month but attributes it to her menopause.", "Her last menstrual period (LMP) was 1 year ago.", "Past medical history is significant for asthma and seasonal allergies, and medications include a rescue inhaler and cetirizine as need.", "Review of systems is negative except for cold intolerance and constipation." ]

[ "1. A 53-year-old woman presents to the clinic with complaints of fatigue.", "2. She reports that over the past several months she has been lethargic and tired.", "3. She has gained 10 pounds over the past month.", "4. She attributes her weight gain to her menopause.", "5. Her last menstrual period (LMP) was 1 year ago.", "6. Past medical history is significant for asthma.", "7. Past medical history is significant for seasonal allergies.", "8. Medications include a rescue inhaler.", "9. Medications include cetirizine as needed.", "10. Review of systems is negative except for cold intolerance.", "11. Review of systems is negative except for constipation." ]

[ "1. The patient reports feeling lethargic and tired over the past several months.", "2. She has gained 10 pounds in the past month and attributes it to her menopause.", "3. Her last menstrual period (LMP) was 1 year ago.", "4. Her past medical history includes asthma and seasonal allergies.", "5. Her medications include a rescue inhaler and cetirizine as needed.", "6. Review of systems is negative except for cold intolerance and constipation." ]

[ "A 33-year-old man presents to his primary care physician for fatigue, weight loss, and diffuse pruritus.", "The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea as well as several episodes of ascending cholangitis which were successfully treated.", "He is currently a member of Alcoholics Anonymous.", "His temperature is 98.2°F (36.8°C), blood pressure is 124/75 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "Urinalysis is notable only for a dark urine sample with no red blood cells present.", "A rectal exam reveals pale stool and grossly visible blood.", "Physical exam is otherwise notable for pruritis, jaundice, and scleral icterus." ]

[ "1. Patient is 33 years old.", "2. Patient presents with fatigue, weight loss, and diffuse pruritus.", "3. Patient has past medical history of multiple admissions for severe abdominal pain and bloody diarrhea.", "4. Patient has past medical history of several episodes of ascending cholangitis.", "5. Patient is currently a member of Alcoholics Anonymous.", "6. Patient's temperature is 98.2°F (36.8°C).", "7. Patient's blood pressure is 124/75 mmHg.", "8. Patient's pulse is 100/min.", "9. Patient's respirations are 13/min.", "10. Patient's oxygen saturation is 99% on room air.", "11. Urinalysis is notable only for a dark urine sample with no red blood cells present.", "12. Rectal exam reveals pale stool and grossly visible blood.", "13. Physical exam is notable for pruritis, jaundice, and scleral icterus." ]

[ "1. The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea.", "2. The patient has a past medical history of several episodes of ascending cholangitis which were successfully treated.", "3. The patient is currently a member of Alcoholics Anonymous.", "4. The patient's temperature is 98.2°F (36.8°C).", "5. The patient's blood pressure is 124/75 mmHg.", "6. The patient's pulse is 100/min.", "7. The patient's respirations are 13/min.", "8. The patient's oxygen saturation is 99% on room air.", "9. Urinalysis is notable only for a dark urine sample with no red blood cells present.", "10. A rectal exam reveals pale stool and grossly visible blood.", "11. Physical exam is notable for pruritis, jaundice, and scleral icterus." ]

[ "A 43-year-old female presents with several years of pain and stiffness in her wrists and hands.", "Her symptoms have been getting progressively worse.", "She reports that her hands feel stiff for an hour or more after awaking in the morning.", "She undergoes subsequent testing, and is found to have anti-citrullinated protein antibodies.", "Her physician is concerned for rheumatoid arthritis, and discusses treatment with a biologic disease-modifying anti-rheumatic agent. | | ." ]

[ "1. A 43-year-old female presents with several years of pain and stiffness in her wrists and hands.", "2. Her symptoms have been getting progressively worse.", "3. She reports that her hands feel stiff for an hour or more after awaking in the morning.", "4. She undergoes subsequent testing.", "5. She is found to have anti-citrullinated protein antibodies.", "6. Her physician is concerned for rheumatoid arthritis.", "7. Her physician discusses treatment with a biologic disease-modifying anti-rheumatic agent." ]

[ "1. Her symptoms have been getting progressively worse.", "2. She reports that her hands feel stiff for an hour or more after awaking in the morning.", "3. She undergoes subsequent testing.", "4. She is found to have anti-citrullinated protein antibodies.", "5. Her physician is concerned for rheumatoid arthritis.", "6. Her physician discusses treatment with a biologic disease-modifying anti-rheumatic agent." ]

[ "A 65-year-old man is brought to the emergency department with a complaint of right-sided numbness for 5 hours.", "The numbness started in the right-side of the face and has progressed to the same side arm and leg within 30 minutes.", "He denies limb weakness, walking difficulty, vision problem, or vertigo.", "He had similar symptoms 5 months ago that were resolved within 10 minutes.", "The past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.", "The medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.", "The blood pressure is 165/102 mm Hg, and the rest of the vital signs are within normal limits.", "On examination, there are no facial droop and slurring of the speech noted.", "The muscle strength is normal in all 4 limbs with a normal tone and deep tendon reflexes.", "There is a decreased pinprick sensation and proprioception on the right arm and leg.", "The gait is normal.", "The blood sugar is 221 mg/dL.", "The CT scan of the head is normal.", "The MRI of the head with diffusion-weighted imaging reveals a 15 mm diffusion restriction in the left thalamus." ]

[ "1. Patient is 65 years old.", "2. Patient has right-sided numbness for 5 hours.", "3. Numbness started in right-side of face and progressed to same side arm and leg within 30 minutes.", "4. Patient denies limb weakness, walking difficulty, vision problem, or vertigo.", "5. Patient had similar symptoms 5 months ago that were resolved within 10 minutes.", "6. Past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.", "7. Medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.", "8. Blood pressure is 165/102 mm Hg.", "9. Other vital signs are within normal limits.", "10. No facial droop or slurring of speech noted on examination.", "11. Muscle strength is normal in all 4 limbs with normal tone and deep tendon reflexes.", "12. Decreased pinprick sensation and proprioception on right arm and leg.", "13. Gait is normal.", "14. Blood sugar is 221 mg/dL.", "15. CT scan of head is normal.", "16. MRI of head with diffusion-weighted imaging reveals 15 mm diffusion restriction in left thalamus." ]

[ "1. The numbness started in the right-side of the face and has progressed to the same side arm and leg within 30 minutes.", "2. He denies limb weakness, walking difficulty, vision problem, or vertigo.", "3. He had similar symptoms 5 months ago that were resolved within 10 minutes.", "4. The past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.", "5. The medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.", "6. The blood pressure is 165/102 mm Hg, and the rest of the vital signs are within normal limits.", "7. On examination, there are no facial droop and slurring of the speech noted.", "8. The muscle strength is normal in all 4 limbs with a normal tone and deep tendon reflexes.", "9. There is a decreased pinprick sensation and proprioception on the right arm and leg.", "10. The gait is normal.", "11. The blood sugar is 221 mg/dL.", "12. The CT scan of the head is normal.", "13. The MRI of the head with diffusion-weighted imaging reveals a 15 mm diffusion restriction in the left thalamus." ]

[ "A 23-year-old man presents to a psychiatrist for evaluation of situational anxiety.", "He reports that he recently started a new job that involves regular public speaking and is very stressed before every public speaking event.", "He describes developing a rapid heart rate and diaphoresis that interferes with his ability to speak well.", "He has no past medical history and takes no medications.", "He does not smoke or drink alcohol.", "His temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 17/min.", "On exam, he is well-appearing and appropriately conversational.", "He is alert and fully oriented.", "The patient is prescribed propranolol to take before major public speaking events." ]

[ "1. A 23-year-old man presents to a psychiatrist for evaluation of situational anxiety.", "2. He reports that he recently started a new job that involves regular public speaking.", "3. He is very stressed before every public speaking event.", "4. He describes developing a rapid heart rate and diaphoresis that interferes with his ability to speak well.", "5. He has no past medical history and takes no medications.", "6. He does not smoke or drink alcohol.", "7. His temperature is 98.6°F (37°C).", "8. His blood pressure is 110/65 mmHg.", "9. His pulse is 85/min.", "10. His respirations are 17/min.", "11. On exam, he is well-appearing and appropriately conversational.", "12. He is alert and fully oriented.", "13. The patient is prescribed propranolol to take before major public speaking events." ]

[ "1. The patient recently started a new job involving regular public speaking.", "2. The patient experiences stress before every public speaking event.", "3. The patient reports developing a rapid heart rate and diaphoresis during public speaking.", "4. The patient has no past medical history.", "5. The patient takes no medications.", "6. The patient does not smoke or drink alcohol.", "7. The patient's temperature is 98.6°F (37°C).", "8. The patient's blood pressure is 110/65 mmHg.", "9. The patient's pulse is 85/min.", "10. The patient's respirations are 17/min.", "11. On exam, the patient is well-appearing and appropriately conversational.", "12. The patient is alert and fully oriented.", "13. The patient is prescribed propranolol to take before major public speaking events." ]

[ "A 69-year-old woman is brought into the emergency room by family members after they noted that she had become increasingly lethargic over the past 3 days.", "Her temperature is 39.5°C (103.1°F), the blood pressure is 75/40 mm Hg, the heart rate 130/min, the respiratory rate 24/min, and the oxygen saturation is 89% on room air.", "On examination, she is severely ill, drowsy, and unable to speak.", "Her skin is warm to the touch.", "White blood cell count is 15,000/mm3 and her urinalysis is positive for nitrites and leukocyte esterase." ]

[ "1. A 69-year-old woman is brought into the emergency room by family members.", "2. She had become increasingly lethargic over the past 3 days.", "3. Her temperature is 39.5°C (103.1°F).", "4. Her blood pressure is 75/40 mm Hg.", "5. Her heart rate is 130/min.", "6. Her respiratory rate is 24/min.", "7. Her oxygen saturation is 89% on room air.", "8. On examination, she is severely ill, drowsy, and unable to speak.", "9. Her skin is warm to the touch.", "10. Her white blood cell count is 15,000/mm3.", "11. Her urinalysis is positive for nitrites and leukocyte esterase." ]

[ "1. Her temperature is 39.5°C (103.1°F).", "2. The blood pressure is 75/40 mm Hg.", "3. The heart rate is 130/min.", "4. The respiratory rate is 24/min.", "5. The oxygen saturation is 89% on room air.", "6. On examination, she is severely ill.", "7. On examination, she is drowsy.", "8. On examination, she is unable to speak.", "9. Her skin is warm to the touch.", "10. White blood cell count is 15,000/mm3.", "11. Her urinalysis is positive for nitrites.", "12. Her urinalysis is positive for leukocyte esterase." ]

[ "A 28-year-old G2P1 woman at 29 weeks gestation presents to the obstetrician after noticing red spots on her undergarments over the past week.", "Her vaginal bleeding has not been painful; however, she is concerned that it has persisted.", "Her previous child was born by cesarean section and she is currently taking folate and a multivitamin.", "She endorses feeling fetal movements.", "Her temperature is 98.9°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 88/min, respirations are 17/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for a gravid uterus and non-tender abdomen.", "Speculum exam reveals a closed cervical os and a small amount of blood." ]

[ "1. Patient is a 28-year-old G2P1 woman.", "2. Patient is at 29 weeks gestation.", "3. Patient has noticed red spots on her undergarments over the past week.", "4. Patient's vaginal bleeding has not been painful.", "5. Patient's previous child was born by cesarean section.", "6. Patient is currently taking folate and a multivitamin.", "7. Patient endorses feeling fetal movements.", "8. Patient's temperature is 98.9°F (37.2°C).", "9. Patient's blood pressure is 120/84 mmHg.", "10. Patient's pulse is 88/min.", "11. Patient's respirations are 17/min.", "12. Patient's oxygen saturation is 99% on room air.", "13. Physical exam is notable for a gravid uterus and non-tender abdomen.", "14. Speculum exam reveals a closed cervical os and a small amount of blood." ]

[ "1. Her vaginal bleeding has not been painful.", "2. She is concerned that the bleeding has persisted.", "3. Her previous child was born by cesarean section.", "4. She is currently taking folate and a multivitamin.", "5. She endorses feeling fetal movements.", "6. Her temperature is 98.9°F (37.2°C).", "7. Her blood pressure is 120/84 mmHg.", "8. Her pulse is 88/min.", "9. Her respirations are 17/min.", "10. Her oxygen saturation is 99% on room air.", "11. Physical exam is notable for a gravid uterus.", "12. Physical exam is notable for a non-tender abdomen.", "13. Speculum exam reveals a closed cervical os.", "14. Speculum exam reveals a small amount of blood." ]

[ "A 57-year-old woman comes to the emergency department 1 hour after experiencing a distressing 10-minute episode of stuttering during a business meeting.", "She has hypertension.", "She has smoked 2 packs of cigarettes daily for 30 years.", "Current medications include fosinopril and hydrochlorothiazide.", "Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 16/min, and blood pressure is 134/88 mm Hg.", "She is oriented to person, place, and time.", "Her speech is clear.", "When she is asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards." ]

[ "1. A 57-year-old woman comes to the emergency department 1 hour after experiencing a distressing 10-minute episode of stuttering during a business meeting.", "2. She has hypertension.", "3. She has smoked 2 packs of cigarettes daily for 30 years.", "4. Current medications include fosinopril and hydrochlorothiazide.", "5. Her temperature is 37°C (98.6°F).", "6. Pulse is 90/min.", "7. Respirations are 16/min.", "8. Blood pressure is 134/88 mm Hg.", "9. She is oriented to person, place, and time.", "10. Her speech is clear.", "11. When she is asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards." ]

[ "1. She has hypertension.", "2. She has smoked 2 packs of cigarettes daily for 30 years.", "3. Current medications include fosinopril and hydrochlorothiazide.", "4. Her temperature is 37°C (98.6°F).", "5. Her pulse is 90/min.", "6. Her respirations are 16/min.", "7. Her blood pressure is 134/88 mm Hg.", "8. She is oriented to person, place, and time.", "9. Her speech is clear.", "10. When asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards." ]

[ "A 40-year-old man comes to the physician because of a 5-kg (11-lb) weight loss over the past month and easy bruising.", "He has not changed his diet significantly.", "He also noticed that his arms now bruise more easily.", "He appears pale.", "His pulse is 70/min, his blood pressure is 125/75 mm Hg, and his temperature is 38°C (100.4°F).", "Examination shows a palm-sized hematoma on his right arm.", "His spleen is palpable 5 cm below the costal margin.", "His liver is enlarged.", "Laboratory results show: | Leukocytes 10,500/mm3 | Hemoglobin 10.2 g/dL | Platelets 52,000/mm3 | Fibrinogen 110 mg/dL (Reference: 150-400 mg/dL) | Cytogenetic analysis shows leukocytes with a reciprocal translocation of chromosomes 15 and 17." ]

[ "1. A 40-year-old man comes to the physician.", "2. He has experienced a 5-kg (11-lb) weight loss over the past month.", "3. He has experienced easy bruising.", "4. He has not changed his diet significantly.", "5. He has noticed that his arms now bruise more easily.", "6. He appears pale.", "7. His pulse is 70/min.", "8. His blood pressure is 125/75 mm Hg.", "9. His temperature is 38°C (100.4°F).", "10. Examination shows a palm-sized hematoma on his right arm.", "11. His spleen is palpable 5 cm below the costal margin.", "12. His liver is enlarged.", "13. Laboratory results show leukocytes 10,500/mm3.", "14. Laboratory results show hemoglobin 10.2 g/dL.", "15. Laboratory results show platelets 52,000/mm3.", "16. Laboratory results show fibrinogen 110 mg/dL (Reference: 150-400 mg/dL).", "17. Laboratory results show cytogenetic analysis with leukocytes with a reciprocal translocation of chromosomes 15 and 17." ]

[ "1. He has not changed his diet significantly.", "2. He also noticed that his arms now bruise more easily.", "3. He appears pale.", "4. His pulse is 70/min.", "5. His blood pressure is 125/75 mm Hg.", "6. His temperature is 38°C (100.4°F).", "7. Examination shows a palm-sized hematoma on his right arm.", "8. His spleen is palpable 5 cm below the costal margin.", "9. His liver is enlarged.", "10. Laboratory results show: Leukocytes 10,500/mm3.", "11. Hemoglobin 10.2 g/dL.", "12. Platelets 52,000/mm3.", "13. Fibrinogen 110 mg/dL (Reference: 150-400 mg/dL).", "14. Cytogenetic analysis shows leukocytes with a reciprocal translocation of chromosomes 15 and 17." ]

[ "At a routine exam, a 68-year-old female patient is discovered to have a serum calcium level of 11.5 mg/dL.", "Follow-up laboratory tests show a high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.", "24-hour urine calcium level is elevated.", "Review of symptoms includes complaints of fatigue, constipation, and diffuse bone pain for which she takes vitamin D.", "Past medical history is significant for type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.", "The patient has a history of kidney stones.", "Family history is irrelevant." ]

[ "1. Patient is 68-year-old female.", "2. Serum calcium level is 11.5 mg/dL.", "3. Follow-up laboratory tests show high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.", "4. 24-hour urine calcium level is elevated.", "5. Patient has complaints of fatigue, constipation, and diffuse bone pain.", "6. Patient takes vitamin D.", "7. Patient has past medical history of type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.", "8. Patient has history of kidney stones.", "9. Family history is irrelevant." ]

[ "1. Follow-up laboratory tests show high parathyroid hormone.", "2. Follow-up laboratory tests show low phosphorus.", "3. Follow-up laboratory tests show mildly elevated alkaline phosphatase.", "4. 24-hour urine calcium level is elevated.", "5. Review of symptoms includes complaints of fatigue.", "6. Review of symptoms includes complaints of constipation.", "7. Review of symptoms includes complaints of diffuse bone pain.", "8. The patient takes vitamin D for diffuse bone pain.", "9. Past medical history is significant for type 2 diabetes mellitus for 25 years.", "10. Past medical history is significant for essential hypertension for 15 years.", "11. The patient has a history of kidney stones.", "12. Family history is irrelevant." ]

[ "A 27-year-old man and his wife present to an infertility clinic for evaluation after they tried unsuccessfully to conceive for 2 years.", "He has no prior medical history and does not currently take any medications.", "On evaluation, he is found to have long extremities and gynecomastia.", "In addition, he has testicular atrophy and very little body hair, which is distributed primarily in the pubic region.", "Further analysis reveals azoospermia, and appropriate tests confirming the diagnosis are performed.", "The couple is told about the cause of their inability to conceive and given further options to pursue." ]

[ "1. A 27-year-old man and his wife present to an infertility clinic for evaluation.", "2. They have been trying unsuccessfully to conceive for 2 years.", "3. He has no prior medical history and does not currently take any medications.", "4. On evaluation, he is found to have long extremities and gynecomastia.", "5. He also has testicular atrophy and very little body hair, which is distributed primarily in the pubic region.", "6. Further analysis reveals azoospermia.", "7. Appropriate tests confirming the diagnosis are performed.", "8. The couple is told about the cause of their inability to conceive.", "9. The couple is given further options to pursue." ]

[ "1. He has no prior medical history.", "2. He does not currently take any medications.", "3. On evaluation, he is found to have long extremities.", "4. On evaluation, he is found to have gynecomastia.", "5. He has testicular atrophy.", "6. He has very little body hair.", "7. The body hair is distributed primarily in the pubic region.", "8. Further analysis reveals azoospermia.", "9. Appropriate tests confirming the diagnosis are performed.", "10. The couple is told about the cause of their inability to conceive.", "11. The couple is given further options to pursue." ]

[ "A 32-year-old GP2 presents to an outpatient clinic for a routine gynecologic examination.", "The patient appears well, although she mentions that during the past 6 months she has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles.", "Her last pregnancy was 3 years ago.", "Her subsequent menstrual cycles have been regular, lasting about 2–3 days.", "She mentions that she is up to date with her Pap smear; all of her Pap smears have been normal.", "She denies any recent travel or history of trauma.", "The patient is sexually active with her husband and they use condoms consistently.", "She does not smoke, drinks alcohol occasionally, and has never used illicit drugs.", "The physical examination is essentially normal.", "An ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.", "The uterine lining measures 5 mm in thickness and is homogeneous.", "Multiple small leiomyomas are also observed.", "The patient is otherwise asymptomatic and has no other complaints.", "The rest of the physical examination is unremarkable." ]

[ "1. Patient is 32 years old.", "2. Patient is a GP2.", "3. Patient is presenting to an outpatient clinic for a routine gynecologic examination.", "4. Patient has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles for the past 6 months.", "5. Patient's last pregnancy was 3 years ago.", "6. Patient's menstrual cycles have been regular, lasting about 2–3 days.", "7. Patient is up to date with her Pap smear.", "8. All of patient's Pap smears have been normal.", "9. Patient denies any recent travel or history of trauma.", "10. Patient is sexually active with her husband and they use condoms consistently.", "11. Patient does not smoke.", "12. Patient drinks alcohol occasionally.", "13. Patient has never used illicit drugs.", "14. Physical examination is essentially normal.", "15. Ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.", "16. Uterine lining measures 5 mm in thickness and is homogeneous.", "17. Multiple small leiomyomas are also observed.", "18. Patient is otherwise asymptomatic and has no other complaints.", "19. Rest of the physical examination is unremarkable." ]

[ "1. The patient has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles over the past 6 months.", "2. Her last pregnancy was 3 years ago.", "3. Her subsequent menstrual cycles have been regular, lasting about 2–3 days.", "4. She is up to date with her Pap smear and all of her Pap smears have been normal.", "5. She denies any recent travel or history of trauma.", "6. The patient is sexually active with her husband and they use condoms consistently.", "7. She does not smoke, drinks alcohol occasionally, and has never used illicit drugs.", "8. An ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.", "9. The uterine lining measures 5 mm in thickness and is homogeneous.", "10. Multiple small leiomyomas are also observed.", "11. The patient is otherwise asymptomatic and has no other complaints.", "12. The rest of the physical examination is unremarkable." ]

[ "An 11-year-old girl presents to her pediatrician with complaints of headache and rapid leg fatigue with exercise.", "Her vital signs are: HR 77, BP in left arm 155/100, RR 14, SpO2 100%, T 37.0 C.", "On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse.", "Her lower extremities feel slightly cool.", "Blood pressure obtained on the left lower extremity is 120/80." ]

[ "1. An 11-year-old girl presents to her pediatrician.", "2. She has complaints of headache and rapid leg fatigue with exercise.", "3. Her HR is 77.", "4. Her BP in left arm is 155/100.", "5. Her RR is 14.", "6. Her SpO2 is 100%.", "7. Her T is 37.0 C.", "8. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse.", "9. Her lower extremities feel slightly cool.", "10. Blood pressure obtained on the left lower extremity is 120/80." ]

[ "1. Her vital signs: HR 77", "2. Her vital signs: BP in left arm 155/100", "3. Her vital signs: RR 14", "4. Her vital signs: SpO2 100%", "5. Her vital signs: T 37.0 C", "6. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse", "7. Her lower extremities feel slightly cool", "8. Blood pressure obtained on the left lower extremity is 120/80" ]

[ "A 34-year-old woman comes to the gynecologist complaining of vaginal swelling and discomfort.", "She states that over the past 2 weeks she has noticed swelling of her right labia.", "The swelling continued to grow in size and now causes her discomfort when walking.", "She denies abnormal discharge or bleeding from the swelling or from the vulva.", "She normally shaves the area, but with the recent pain, she has been unable to.", "She denies any history of known trauma.", "The patient is relatively healthy and takes only a multivitamin.", "She never received the vaccine for human papillomavirus (HPV).", "On physical exam, there is a fluctuant, swelling of the right labia, most prominently at the posterior vestibule." ]

[ "1. A 34-year-old woman comes to the gynecologist.", "2. She is complaining of vaginal swelling and discomfort.", "3. She has noticed swelling of her right labia over the past 2 weeks.", "4. The swelling has continued to grow in size.", "5. The swelling causes her discomfort when walking.", "6. She denies abnormal discharge or bleeding from the swelling or from the vulva.", "7. She normally shaves the area, but with the recent pain, she has been unable to.", "8. She denies any history of known trauma.", "9. The patient is relatively healthy and takes only a multivitamin.", "10. She never received the vaccine for human papillomavirus (HPV).", "11. On physical exam, there is a fluctuant, swelling of the right labia.", "12. The swelling is most prominently at the posterior vestibule." ]

[ "1. The patient has noticed swelling of her right labia over the past 2 weeks.", "2. The swelling causes discomfort when walking.", "3. There is no abnormal discharge or bleeding from the swelling or from the vulva.", "4. The patient normally shaves the area but has been unable to due to recent pain.", "5. There is no history of known trauma.", "6. The patient is relatively healthy and takes only a multivitamin.", "7. The patient has not received the vaccine for human papillomavirus (HPV).", "8. On physical exam, there is a fluctuant swelling of the right labia, most prominently at the posterior vestibule." ]

[ "A 4-month-old boy is brought to the physician because of noisy breathing for 2 months that has progressively become louder.", "The noisy breathing improves when he is in the prone position.", "It is worse when he is agitated, feeding, or lying on his back.", "He was born at term and has been healthy since.", "His temperature is 37.1°C (98.8°F), pulse is 120/min, and respirations are 50/min.", "Pulse oximetry on room air shows an oxygen saturation of 98%.", "Examination shows inspiratory stridor." ]

[ "1. A 4-month-old boy is brought to the physician.", "2. Noisy breathing has been present for 2 months and has progressively become louder.", "3. Noisy breathing improves when he is in the prone position.", "4. Noisy breathing is worse when he is agitated, feeding, or lying on his back.", "5. He was born at term and has been healthy since.", "6. His temperature is 37.1°C (98.8°F).", "7. His pulse is 120/min.", "8. His respirations are 50/min.", "9. Pulse oximetry on room air shows an oxygen saturation of 98%.", "10. Examination shows inspiratory stridor." ]

[ "1. The noisy breathing improves in the prone position.", "2. Noisy breathing is worse when he is agitated, feeding, or lying on his back.", "3. He was born at term and has been healthy since.", "4. His temperature is 37.1°C (98.8°F).", "5. His pulse is 120/min.", "6. His respirations are 50/min.", "7. Pulse oximetry on room air shows an oxygen saturation of 98%.", "8. Examination shows inspiratory stridor." ]

[ "A 16-year-old girl comes to the physician with a 4-day history of painful vulvar lesions, generalized fatigue, and malaise.", "During this period, she has also had dysuria.", "She is sexually active with 2 male partners and uses condoms inconsistently.", "Her immunizations are up-to-date; she completed the vaccination course for human papilloma virus 2 months ago.", "Her temperature is 38.1°C (100.6°F), pulse is 100/min, respirations are 12/min, and blood pressure is 110/70 mm Hg.", "Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora.", "There is bilateral, tender inguinal lymphadenopathy." ]

[ "1. Patient is 16 years old.", "2. Patient has a 4-day history of painful vulvar lesions, generalized fatigue, and malaise.", "3. Patient has had dysuria during this period.", "4. Patient is sexually active with 2 male partners.", "5. Patient uses condoms inconsistently.", "6. Patient's immunizations are up-to-date.", "7. Patient completed the vaccination course for human papilloma virus 2 months ago.", "8. Patient's temperature is 38.1°C (100.6°F).", "9. Patient's pulse is 100/min.", "10. Patient's respirations are 12/min.", "11. Patient's blood pressure is 110/70 mm Hg.", "12. Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora.", "13. Patient has bilateral, tender inguinal lymphadenopathy." ]

[ "1. She has dysuria.", "2. She is sexually active with 2 male partners.", "3. She uses condoms inconsistently.", "4. Her immunizations are up-to-date.", "5. She completed the vaccination course for human papilloma virus 2 months ago.", "6. Her temperature is 38.1°C (100.6°F).", "7. Her pulse is 100/min.", "8. Her respirations are 12/min.", "9. Her blood pressure is 110/70 mm Hg.", "10. Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora.", "11. There is bilateral, tender inguinal lymphadenopathy." ]

[ "A 57-year-old man comes to the physician because of progressively worsening epigastric pain and 6.8-kg (15-lb) weight loss for the past 2 months.", "Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf.", "He has smoked one pack of cigarettes daily for the last 35 years.", "He appears thin.", "Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa.", "Endoscopy shows a large mass in the antrum of the stomach.", "A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis." ]

[ "1. A 57-year-old man comes to the physician.", "2. He has experienced progressively worsening epigastric pain for the past 2 months.", "3. He has lost 6.8 kg (15 lb) in the past 2 months.", "4. Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf.", "5. He has smoked one pack of cigarettes daily for the last 35 years.", "6. He appears thin.", "7. Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa.", "8. Endoscopy shows a large mass in the antrum of the stomach.", "9. A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis." ]

[ "1. Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf.", "2. He has smoked one pack of cigarettes daily for the last 35 years.", "3. He appears thin.", "4. Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa.", "5. Endoscopy shows a large mass in the antrum of the stomach.", "6. A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis." ]

[ "A 62-year-old woman comes to the emergency department because of painful and difficult swallowing.", "Her voice has also become muffled.", "She has been well until last night and reports having intermittent fevers at home.", "The patient has smoked a pack of cigarettes a day since age 19 but is otherwise healthy.", "Her temperature is 39°C (102.2°F), blood pressure is 142/93 Hg/mm, heart rate is 109/min, and respiratory rate is 18/min.", "On examination, the patient's head is extended and she appears anxious.", "Her voice is muffled and there is inspiratory stridor.", "There is tender bilateral cervical lymphadenopathy and pain upon palpation of the hyoid.", "The remainder of the examination shows no abnormalities.", "Laboratory studies show a leukocyte count of 18,000/mm3 with 83% neutrophils." ]

[ "1. A 62-year-old woman comes to the emergency department.", "2. She has painful and difficult swallowing.", "3. Her voice has become muffled.", "4. She has been well until last night.", "5. She reports having intermittent fevers at home.", "6. She has smoked a pack of cigarettes a day since age 19.", "7. She is otherwise healthy.", "8. Her temperature is 39°C (102.2°F).", "9. Her blood pressure is 142/93 Hg/mm.", "10. Her heart rate is 109/min.", "11. Her respiratory rate is 18/min.", "12. On examination, her head is extended.", "13. She appears anxious.", "14. Her voice is muffled.", "15. There is inspiratory stridor.", "16. There is tender bilateral cervical lymphadenopathy.", "17. There is pain upon palpation of the hyoid.", "18. The remainder of the examination shows no abnormalities.", "19. Laboratory studies show a leukocyte count of 18,000/mm3.", "20. 83% of the leukocytes are neutrophils." ]

[ "1. The patient's voice has become muffled.", "2. The patient has been well until last night.", "3. The patient reports having intermittent fevers at home.", "4. The patient has smoked a pack of cigarettes a day since age 19.", "5. The patient's temperature is 39°C (102.2°F).", "6. The patient's blood pressure is 142/93 Hg/mm.", "7. The patient's heart rate is 109/min.", "8. The patient's respiratory rate is 18/min.", "9. On examination, the patient's head is extended and she appears anxious.", "10. The patient's voice is muffled.", "11. The patient has inspiratory stridor.", "12. The patient has tender bilateral cervical lymphadenopathy.", "13. The patient has pain upon palpation of the hyoid.", "14. The remainder of the examination shows no abnormalities.", "15. Laboratory studies show a leukocyte count of 18,000/mm3 with 83% neutrophils." ]

[ "A 56-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure.", "Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.", "She has no personal or family history of a seizure disorder.", "An MRI of the brain shows a central mass; surgical resection is planned.", "One day before the surgery, the patient has another generalized seizure and, despite resuscitative efforts, she dies.", "Gross examination of the brain at autopsy is shown." ]

[ "1. A 56-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure.", "2. Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.", "3. She has no personal or family history of a seizure disorder.", "4. An MRI of the brain shows a central mass.", "5. Surgical resection is planned.", "6. One day before the surgery, the patient has another generalized seizure.", "7. Despite resuscitative efforts, she dies.", "8. Gross examination of the brain at autopsy is shown." ]

[ "1. Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.", "2. She has no personal or family history of a seizure disorder.", "3. An MRI of the brain shows a central mass; surgical resection is planned.", "4. One day before the surgery, the patient has another generalized seizure and, despite resuscitative efforts, she dies.", "5. Gross examination of the brain at autopsy is shown." ]

[ "A 29-year-old woman (gravida 2, para 1) presents at 32 weeks gestation for routine follow-up care.", "Her previous pregnancy was complicated with preeclampsia, and she delivered at 35 weeks via cesarean delivery.", "Four years ago, she was diagnosed with arterial hypertension.", "Prior to pregnancy, she took amlodipine and hydrochlorothiazide; after she found out she was pregnant, she switched to methyldopa.", "The course of her current pregnancy has been unremarkable with normal laboratory values at each checkup.", "According to her blood pressure diary, her systolic blood pressure varies between 120 and 130 mm Hg, and her diastolic blood pressure is usually normal.", "At presentation, the blood pressure is 140/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.9°C (98.4°F).", "The fetal heart rate is 143/min.", "Examination shows a 1+ pitting lower leg edema.", "Dipstick test shows 2+ protein.", "24-hour urine assessment demonstrates urinary protein excretion of 1 g/L." ]

[ "1. Patient is a 29-year-old woman.", "2. Patient is gravida 2, para 1.", "3. Patient is 32 weeks gestation.", "4. Patient's previous pregnancy was complicated with preeclampsia.", "5. Patient delivered at 35 weeks via cesarean delivery.", "6. Patient was diagnosed with arterial hypertension four years ago.", "7. Patient took amlodipine and hydrochlorothiazide prior to pregnancy.", "8. Patient switched to methyldopa after finding out she was pregnant.", "9. Course of current pregnancy has been unremarkable.", "10. Normal laboratory values at each checkup.", "11. Systolic blood pressure varies between 120 and 130 mm Hg.", "12. Diastolic blood pressure is usually normal.", "13. Blood pressure at presentation is 140/80 mm Hg.", "14. Heart rate at presentation is 76/min.", "15. Respiratory rate at presentation is 15/min.", "16. Temperature at presentation is 36.9°C (98.4°F).", "17. Fetal heart rate is 143/min.", "18. Examination shows 1+ pitting lower leg edema.", "19. Dipstick test shows 2+ protein.", "20. 24-hour urine assessment demonstrates urinary protein excretion of 1 g/L." ]

[ "1. Her previous pregnancy was complicated with preeclampsia.", "2. She delivered at 35 weeks via cesarean delivery.", "3. Four years ago, she was diagnosed with arterial hypertension.", "4. Prior to pregnancy, she took amlodipine and hydrochlorothiazide.", "5. After she found out she was pregnant, she switched to methyldopa.", "6. The course of her current pregnancy has been unremarkable with normal laboratory values at each checkup.", "7. According to her blood pressure diary, her systolic blood pressure varies between 120 and 130 mm Hg.", "8. Her diastolic blood pressure is usually normal.", "9. At presentation, the blood pressure is 140/80 mm Hg.", "10. Heart rate is 76/min.", "11. Respiratory rate is 15/min.", "12. Temperature is 36.9°C (98.4°F).", "13. The fetal heart rate is 143/min.", "14. Examination shows a 1+ pitting lower leg edema.", "15. Dipstick test shows 2+ protein.", "16. 24-hour urine assessment demonstrates urinary protein excretion of 1 g/L." ]

[ "Following a colonoscopy performed on a 63-year-old man, the gastroenterologist identifies a firm tumor approx.", "80 cm (31.4 in) from the entry site.", "He also performs an endoscopic polypectomy and tattooing at 50 cm (19.6 in) from the entry site.", "A pathologic report shows a benign polyp.", "One week later, the surgeon in the operating room is erroneously preparing to perform partial colectomy of the tattooed site.", "After confirming the patient’s name and before surgery, the surgical team reviews the patient’s history and medical documents orally based on institutional protocols.", "The surgery resident points out that the resected polyp is benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area.", "The attending surgeon performs a partial colectomy on the correct site." ]

[ "1. A colonoscopy was performed on a 63-year-old man.", "2. An endoscopic polypectomy and tattooing was performed at 50 cm (19.6 in) from the entry site.", "3. A pathologic report showed a benign polyp.", "4. One week later, the surgeon was erroneously preparing to perform partial colectomy of the tattooed site.", "5. The surgical team reviewed the patient’s history and medical documents orally based on institutional protocols.", "6. The surgery resident pointed out that the resected polyp was benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area.", "7. The attending surgeon performed a partial colectomy on the correct site." ]

[ "1. The distance from the entry site for endoscopic polypectomy and tattooing is 80 cm (31.4 in).", "2. A pathologic report shows a benign polyp.", "3. The surgeon erroneously prepares to perform partial colectomy of the tattooed site.", "4. The surgical team reviews the patient’s history and medical documents orally before surgery.", "5. The resected polyp is benign.", "6. The tumor lies 30 cm (11.8 in) distal to the tattooed area.", "7. The attending surgeon performs a partial colectomy on the correct site." ]

[ "A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy.", "She has a history of type I diabetes controlled by insulin and delivered 1 child by normal spontaneous vaginal delivery 2 years ago.", "Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination.", "Urinalysis each time confirmed a urinary tract infection, and both urine cultures isolated organisms sensitive to nitrofurantoin.", "Her symptoms resolved with 10-day courses of nitrofurantoin.", "She has no complaints today.", "Urinalysis is positive for leukocyte esterase and nitrites." ]

[ "1. A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy.", "2. She has a history of type I diabetes controlled by insulin.", "3. She delivered 1 child by normal spontaneous vaginal delivery 2 years ago.", "4. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination.", "5. Urinalysis each time confirmed a urinary tract infection.", "6. Both urine cultures isolated organisms sensitive to nitrofurantoin.", "7. Her symptoms resolved with 10-day courses of nitrofurantoin.", "8. She has no complaints today.", "9. Urinalysis is positive for leukocyte esterase and nitrites." ]

[ "1. She has a history of type I diabetes controlled by insulin.", "2. She delivered 1 child by normal spontaneous vaginal delivery 2 years ago.", "3. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination.", "4. Urinalysis each time confirmed a urinary tract infection.", "5. Both urine cultures isolated organisms sensitive to nitrofurantoin.", "6. Her symptoms resolved with 10-day courses of nitrofurantoin.", "7. She has no complaints today.", "8. Urinalysis is positive for leukocyte esterase and nitrites." ]

[ "A 3-year-old boy is brought to the physician by his parents because of clumsiness and multiple falls over the past 4 months.", "He started walking at the age of 18 months and could walk up steps by the time he was 27 months old but now struggles to walk at all without assistance.", "When standing up from a lying position, he crawls onto his knees and slowly walks himself up with his hands.", "There is bilateral calf enlargement." ]

[ "1. A 3-year-old boy is brought to the physician by his parents.", "2. The boy has experienced clumsiness and multiple falls over the past 4 months.", "3. The boy started walking at the age of 18 months.", "4. The boy could walk up steps by the time he was 27 months old.", "5. The boy now struggles to walk at all without assistance.", "6. When standing up from a lying position, he crawls onto his knees and slowly walks himself up with his hands.", "7. There is bilateral calf enlargement." ]

[ "1. He started walking at the age of 18 months.", "2. He could walk up steps by the time he was 27 months old.", "3. He now struggles to walk at all without assistance.", "4. When standing up from a lying position, he crawls onto his knees.", "5. He slowly walks himself up with his hands.", "6. There is bilateral calf enlargement." ]

[ "A 60-year-old man presented to the hospital with right upper quadrant abdominal pain.", "He has a history of hepatitis B.", "He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node.", "He was diagnosed with hepatocellular carcinoma and initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.", "3 months after radiotherapy, the patient experienced hematemesis and melena.", "He was admitted to the emergency department for evaluation.", "His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min.", "Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3.", "He received a blood transfusion.", "An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum." ]

[ "1. A 60-year-old man presented to the hospital with right upper quadrant abdominal pain.", "2. He has a history of hepatitis B.", "3. He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node.", "4. He was diagnosed with hepatocellular carcinoma.", "5. He initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.", "6. 3 months after radiotherapy, the patient experienced hematemesis and melena.", "7. He was admitted to the emergency department for evaluation.", "8. His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min.", "9. Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3.", "10. He received a blood transfusion.", "11. An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum." ]

[ "1. He has a history of hepatitis B.", "2. He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node.", "3. He was diagnosed with hepatocellular carcinoma.", "4. He initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.", "5. 3 months after radiotherapy, the patient experienced hematemesis and melena.", "6. He was admitted to the emergency department for evaluation.", "7. His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min.", "8. Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3.", "9. He received a blood transfusion.", "10. An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum." ]

[ "A 49-year-old Caucasian woman presents to your office for elevated blood pressure.", "She is a nurse and checks her blood pressure regularly while working in the wards.", "She presents with readings ranging between 163/101 and 156/94 mm Hg.", "After some research she conducted on her own, she has been exercising and following a low-fat, low-salt diet for the past 3 months.", "Her past medical history includes laparoscopic cholecystectomy for acute cholecystitis 2 years previously.", "Her mother and father have hypertension and her father had myocardial infarction at the age of 68 years.", "She takes no medications and denies smoking.", "She drinks 3 glasses of wine a week.", "Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm.", "A review of her medical record reveals that her blood pressure was 142/92 mm Hg at her visit 1 year ago." ]

[ "1. A 49-year-old Caucasian woman presents to your office for elevated blood pressure.", "2. She is a nurse and checks her blood pressure regularly while working in the wards.", "3. She presents with readings ranging between 163/101 and 156/94 mm Hg.", "4. After some research she conducted on her own, she has been exercising and following a low-fat, low-salt diet for the past 3 months.", "5. Her past medical history includes laparoscopic cholecystectomy for acute cholecystitis 2 years previously.", "6. Her mother and father have hypertension.", "7. Her father had myocardial infarction at the age of 68 years.", "8. She takes no medications and denies smoking.", "9. She drinks 3 glasses of wine a week.", "10. Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm.", "11. A review of her medical record reveals that her blood pressure was 142/92 mm Hg at her visit 1 year ago." ]

[ "1. She is a nurse.", "2. She checks her blood pressure regularly while working in the wards.", "3. Her blood pressure readings range between 163/101 and 156/94 mm Hg.", "4. She has been exercising and following a low-fat, low-salt diet for the past 3 months.", "5. Her past medical history includes laparoscopic cholecystectomy for acute cholecystitis 2 years previously.", "6. Her mother and father have hypertension.", "7. Her father had a myocardial infarction at the age of 68 years.", "8. She takes no medications.", "9. She denies smoking.", "10. She drinks 3 glasses of wine a week.", "11. Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm.", "12. Her blood pressure was 142/92 mm Hg at her visit 1 year ago." ]

[ "A 55-year-old man presents to his primary care physician for back pain.", "The patient states that his back pain is worse in the morning and improves with certain activities.", "He does not experience pain when cycling but notices the pain when standing or walking.", "2 months prior to presentation he was lifting heavy boxes and furniture into his daughter's new home.", "He is requesting pain medication and a doctor's note to take off work for the week as his symptoms are disrupting his life." ]

[ "1. A 55-year-old man presents to his primary care physician for back pain.", "2. The patient states that his back pain is worse in the morning and improves with certain activities.", "3. He does not experience pain when cycling.", "4. He notices the pain when standing or walking.", "5. 2 months prior to presentation he was lifting heavy boxes and furniture into his daughter's new home.", "6. He is requesting pain medication.", "7. He is requesting a doctor's note to take off work for the week.", "8. His symptoms are disrupting his life." ]

[ "1. The patient's back pain is worse in the morning.", "2. The patient's back pain improves with certain activities.", "3. The patient does not experience pain when cycling.", "4. The patient notices the pain when standing or walking.", "5. Two months prior to presentation, the patient was lifting heavy boxes and furniture.", "6. The patient is requesting pain medication.", "7. The patient is requesting a doctor's note to take off work for the week." ]

[ "A 75-year-old man presents to the emergency department from his doctor’s office with a 2-day history of urinary hesitancy, fever, and chills.", "He additionally notes that he has been getting up frequently during the night to urinate.", "For the last 2 years, it has taken him longer than usual to initiate urination and his stream has gotten weaker.", "He has a history of hypertension for which he takes losartan.", "His blood pressure is 128/84 mm Hg, heart rate is 84/min, respiratory rate is 14/min, and temperature is 38.2°C (100.8°F).", "No costovertebral angle tenderness is present on physical examination.", "The patient declines rectal examination.", "Significant laboratory results are as follows: | ." ]

[ "1. Patient is 75 years old.", "2. Patient has a 2-day history of urinary hesitancy, fever, and chills.", "3. Patient has been getting up frequently during the night to urinate.", "4. Patient has a history of hypertension for which he takes losartan.", "5. Patient's blood pressure is 128/84 mm Hg.", "6. Patient's heart rate is 84/min.", "7. Patient's respiratory rate is 14/min.", "8. Patient's temperature is 38.2°C (100.8°F).", "9. No costovertebral angle tenderness is present on physical examination.", "10. Patient declines rectal examination.", "11. Significant laboratory results are present." ]

[ "1. He has been getting up frequently during the night to urinate.", "2. For the last 2 years, it has taken him longer than usual to initiate urination.", "3. His stream has gotten weaker.", "4. He has a history of hypertension.", "5. He takes losartan for hypertension.", "6. His blood pressure is 128/84 mm Hg.", "7. His heart rate is 84/min.", "8. His respiratory rate is 14/min.", "9. His temperature is 38.2°C (100.8°F).", "10. No costovertebral angle tenderness is present on physical examination.", "11. The patient declines rectal examination.", "12. Significant laboratory results are present." ]

[ "A 6-year-old boy is brought to the physician for evaluation of bilateral erythematous skin lesions on the flexures of the elbows and knees.", "He has been scratching the areas frequently.", "He has had similar lesions intermittently for the last 2 years.", "A photograph of the lesions on the back of the knees is shown." ]

[ "1. A 6-year-old boy is brought to the physician for evaluation.", "2. The evaluation is for bilateral erythematous skin lesions on the flexures of the elbows and knees.", "3. The boy has been scratching the areas frequently.", "4. The boy has had similar lesions intermittently for the last 2 years.", "5. A photograph of the lesions on the back of the knees is shown." ]

[ "1. The patient has been scratching the areas frequently.", "2. The patient has had similar lesions intermittently for the last 2 years.", "3. A photograph of the lesions on the back of the knees is shown." ]

[ "An important step in the formation of thyroid hormones is the formation of I2 via oxidation of I-." ]

[ "1. An important step in the formation of thyroid hormones.", "2. Formation of I2.", "3. Oxidation of I-." ]

[ "1. An important step in the formation of thyroid hormones is the formation of I2.", "2. The formation of I2 occurs via oxidation of I-." ]

[ "A 29-year-old woman presents to her primary care provider for a normal check-up at the prompting of her mother.", "When asked how she is doing, she replies that she feels depressed.", "Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago.", "She has been sitting in his bed all day trying to call him but he is not answering her calls.", "She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him.", "She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed.", "She denies having any other friends and has some social anxiety, particularly in large groups of people.", "A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships which she suggested “were all her fault.” She has had 4 prior serious relationships and reports that she has not been single for more than a few days in the last 10 years.", "On exam, she is unkempt with poor self-care." ]

[ "1. A 29-year-old woman presents to her primary care provider for a normal check-up. ", "2. Her mother prompted her to go for the check-up. ", "3. When asked how she is doing, she replies that she feels depressed. ", "4. Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago. ", "5. She has been sitting in his bed all day trying to call him but he is not answering her calls. ", "6. She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him. ", "7. She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed. ", "8. She denies having any other friends and has some social anxiety, particularly in large groups of people. ", "9. A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships. ", "10. She suggested that the abuse was “all her fault.” ", "11. She has had 4 prior serious relationships. ", "12. She reports that she has not been single for more than a few days in the last 10 years. ", "13. On exam, she is unkempt with poor self-care." ]

[ "1. She feels depressed.", "2. She feels \"worthless\" after her ex-boyfriend left her 2 days ago.", "3. She has been sitting in his bed all day trying to call him but he is not answering her calls.", "4. She feels like she should just \"disappear\" rather than continue living without him.", "5. She can hear his voice when he's not around, especially at night before she goes to bed.", "6. She denies having any other friends and has social anxiety, particularly in large groups of people.", "7. She has endured several episodes of verbal and physical abuse from her prior relationships.", "8. She suggested that the abuse \"were all her fault.\"", "9. She has had 4 prior serious relationships.", "10. She has not been single for more than a few days in the last 10 years.", "11. On exam, she is unkempt with poor self-care." ]

[ "A 65-year-old man presents to the emergency department with confusion and chest pain.", "He states his symptoms started after he landed on a return flight from Brazil.", "Since then, the patient states that he feels anxious, short of breath, and has pleuritic chest pain.", "The patient has a past medical history of diabetes and chronic kidney disease.", "His medications include insulin, lisinopril, aspirin, and atorvastatin.", "His temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air.", "Physical exam is notable for a confused man.", "The patient’s laboratory studies are ordered as seen below. | | Serum: | Na+: 140 mEq/L | Cl-: 103 mEq/L | K+: 5.3 mEq/L | HCO3-: 25 mEq/L | BUN: 33 mg/dL | Glucose: 168 mg/dL | Creatinine: 1.8 mg/dL | Ca2+: 10.0 mg/dL | Troponin: < 0.05 mcg/L | | A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable.", "The patient’s chest pain resolves with diazepam.", "A lumbar puncture is performed and based on the results the patient is subsequently started on acyclovir." ]

[ "1. A 65-year-old man presents to the emergency department with confusion and chest pain.", "2. He states his symptoms started after he landed on a return flight from Brazil.", "3. Since then, the patient states that he feels anxious, short of breath, and has pleuritic chest pain.", "4. The patient has a past medical history of diabetes and chronic kidney disease.", "5. His medications include insulin, lisinopril, aspirin, and atorvastatin.", "6. His temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air.", "7. Physical exam is notable for a confused man.", "8. Serum Na+: 140 mEq/L", "9. Serum Cl-: 103 mEq/L", "10. Serum K+: 5.3 mEq/L", "11. Serum HCO3-: 25 mEq/L", "12. Serum BUN: 33 mg/dL", "13. Serum Glucose: 168 mg/dL", "14. Serum Creatinine: 1.8 mg/dL", "15. Serum Ca2+: 10.0 mg/dL", "16. Serum Troponin: < 0.05 mcg/L", "17. A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable.", "18. The patient’s chest pain resolves with diazepam.", "19. A lumbar puncture is performed.", "20. Based on the results of the lumbar puncture, the patient is subsequently started on acyclovir." ]

[ "1. Symptoms started after returning from Brazil", "2. Feels anxious, short of breath, and has pleuritic chest pain", "3. Past medical history of diabetes and chronic kidney disease", "4. Medications include insulin, lisinopril, aspirin, and atorvastatin", "5. Temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air", "6. Physical exam is notable for a confused man", "7. Laboratory studies show: Na+: 140 mEq/L, Cl-: 103 mEq/L, K+: 5.3 mEq/L, HCO3-: 25 mEq/L, BUN: 33 mg/dL, Glucose: 168 mg/dL, Creatinine: 1.8 mg/dL, Ca2+: 10.0 mg/dL, Troponin: < 0.05 mcg/L", "8. Chest CT angiogram, echocardiogram (ECG), and second troponin are all unremarkable", "9. Chest pain resolves with diazepam", "10. Lumbar puncture is performed and patient is subsequently started on acyclovir" ]

[ "A 52-year-old homosexual man presents to the emergency department because of sudden right loin pain accompanied by nausea and vomiting.", "He has essential hypertension for 3 years for which he takes bisoprolol.", "He has a remote history of intravenous drug use.", "His temperature is 36.9°C (98.4°F), the blood pressure is 137/92 mm Hg, and the pulse is 95/min.", "Physical examination reveals right flank tenderness and 2+ edema of both legs up to the knees.", "Doppler ultrasonography shows an enlarged, echogenic right kidney with the absent venous signal.", "Laboratory results are shown: | Serum creatinine 2.2 mg/dL | Urine dipstick 4+ protein | Urine analysis 20–25 red cells/high power field | ." ]

[ "1. A 52-year-old homosexual man presents to the emergency department.", "2. He has sudden right loin pain accompanied by nausea and vomiting.", "3. He has essential hypertension for 3 years for which he takes bisoprolol.", "4. He has a remote history of intravenous drug use.", "5. His temperature is 36.9°C (98.4°F).", "6. His blood pressure is 137/92 mm Hg.", "7. His pulse is 95/min.", "8. Physical examination reveals right flank tenderness.", "9. Physical examination reveals 2+ edema of both legs up to the knees.", "10. Doppler ultrasonography shows an enlarged, echogenic right kidney with the absent venous signal.", "11. Serum creatinine is 2.2 mg/dL.", "12. Urine dipstick is 4+ protein.", "13. Urine analysis shows 20–25 red cells/high power field." ]

[ "1. He has essential hypertension for 3 years.", "2. He takes bisoprolol for his essential hypertension.", "3. He has a remote history of intravenous drug use.", "4. His temperature is 36.9°C (98.4°F).", "5. His blood pressure is 137/92 mm Hg.", "6. His pulse is 95/min.", "7. Physical examination reveals right flank tenderness.", "8. Physical examination reveals 2+ edema of both legs up to the knees.", "9. Doppler ultrasonography shows an enlarged, echogenic right kidney.", "10. Doppler ultrasonography shows the absent venous signal in the right kidney.", "11. Laboratory results show serum creatinine 2.2 mg/dL.", "12. Laboratory results show urine dipstick 4+ protein.", "13. Laboratory results show urine analysis 20–25 red cells/high power field." ]

[ "A 53-year-old woman is brought to the emergency department for a 2-hour history of balance problems.", "She was gardening when she suddenly felt very dizzy and she quickly called for her husband.", "When he arrived, she was sitting on the ground, swaying back and forth but overall leaning to the right.", "When she tried to stand up they found she was very unsteady and unbalanced, so her husband carried her to the car.", "In the emergency department, while lying in bed, she complains of a room-spinning sensation; when she sits up, she sways to the right.", "She is unable to walk more than 3 steps without falling.", "Finger-nose-finger and heel-knee-shin testing are abnormal.", "She has a past medical history of hypertension, polycystic ovarian syndrome, and type 2 diabetes mellitus.", "All of her vital signs are all within normal limits." ]

[ "1. A 53-year-old woman is brought to the emergency department.", "2. She has a 2-hour history of balance problems.", "3. She was gardening when she suddenly felt very dizzy.", "4. She quickly called for her husband.", "5. When he arrived, she was sitting on the ground, swaying back and forth but overall leaning to the right.", "6. When she tried to stand up they found she was very unsteady and unbalanced.", "7. Her husband carried her to the car.", "8. In the emergency department, while lying in bed, she complains of a room-spinning sensation.", "9. When she sits up, she sways to the right.", "10. She is unable to walk more than 3 steps without falling.", "11. Finger-nose-finger and heel-knee-shin testing are abnormal.", "12. She has a past medical history of hypertension.", "13. She has a past medical history of polycystic ovarian syndrome.", "14. She has a past medical history of type 2 diabetes mellitus.", "15. All of her vital signs are all within normal limits." ]

[ "1. She was gardening when she suddenly felt very dizzy.", "2. She quickly called for her husband.", "3. When he arrived, she was sitting on the ground, swaying back and forth.", "4. She was overall leaning to the right.", "5. When she tried to stand up, they found she was very unsteady and unbalanced.", "6. Her husband carried her to the car.", "7. In the emergency department, while lying in bed, she complains of a room-spinning sensation.", "8. When she sits up, she sways to the right.", "9. She is unable to walk more than 3 steps without falling.", "10. Finger-nose-finger testing is abnormal.", "11. Heel-knee-shin testing is abnormal.", "12. She has a past medical history of hypertension.", "13. She has a past medical history of polycystic ovarian syndrome.", "14. She has a past medical history of type 2 diabetes mellitus.", "15. All of her vital signs are within normal limits." ]

[ "A 65-year-old man with squamous cell carcinoma of the lung presents with a sodium of 118 and an altered mental status.", "He is started on 3% normal saline over the next several hours.", "The patient’s mental status improves and and a repeat sodium six hours later is 129.", "Three days after treatment he demonstrates quadriparesis and dysarthria." ]

[ "1. A 65-year-old man has squamous cell carcinoma of the lung.", "2. His sodium level is 118.", "3. His mental status is altered.", "4. He is started on 3% normal saline.", "5. His mental status improves.", "6. His sodium level is 129 six hours later.", "7. Three days after treatment he has quadriparesis and dysarthria." ]

[ "1. The patient is started on 3% normal saline over the next several hours.", "2. The patient's mental status improves.", "3. A repeat sodium six hours later is 129.", "4. Three days after treatment, the patient demonstrates quadriparesis and dysarthria." ]

[ "A 27-year-old woman presents to the emergency department with severe wheezing, which started an hour ago.", "She informs the doctor that she has had mild persistent asthma for the last 2 years and is on inhaled corticosteroids, and uses them regularly.", "She has not experienced asthma symptoms for the last 2 months and there is no history of non-compliance.", "She mentions that her present symptoms came on about 20 minutes after her last meal.", "When the doctor makes specific inquiries, she recollects items in her lunch, which included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.", "She also mentions that she took a tablet of acetaminophen immediately after the meal because her legs were aching since morning, which she attributes to her morning walk at 6 am the same day.", "She has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.", "Skin prick testing for food allergens, performed a month back, was negative for all the common food allergens, including milk and peanuts." ]

[ "1. Patient is 27 years old.", "2. Patient presents to the emergency department with severe wheezing.", "3. Wheezing started an hour ago.", "4. Patient has had mild persistent asthma for the last 2 years.", "5. Patient is on inhaled corticosteroids.", "6. Patient uses inhaled corticosteroids regularly.", "7. Patient has not experienced asthma symptoms for the last 2 months.", "8. No history of non-compliance.", "9. Symptoms came on about 20 minutes after last meal.", "10. Last meal included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.", "11. Patient took a tablet of acetaminophen immediately after the meal.", "12. Patient's legs were aching since morning.", "13. Patient attributes aching legs to morning walk at 6 am the same day.", "14. Patient has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.", "15. Skin prick testing for food allergens, performed a month back, was negative for all the common food allergens, including milk and peanuts." ]

[ "1. She has had mild persistent asthma for the last 2 years.", "2. She is on inhaled corticosteroids and uses them regularly.", "3. She has not experienced asthma symptoms for the last 2 months.", "4. There is no history of non-compliance with her medication.", "5. Her present symptoms came on about 20 minutes after her last meal.", "6. Her lunch included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.", "7. She took a tablet of acetaminophen immediately after the meal.", "8. She attributes her leg ache to her morning walk at 6 am the same day.", "9. She has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.", "10. Skin prick testing for food allergens performed a month back was negative for all common food allergens, including milk and peanuts." ]

[ "A 30-year old African-American woman comes into your office for pregnancy counseling with her husband.", "She states that both she and her husband have family histories of sickle cell disease.", "Based on previous genetic testing, they both also have a copy of the sickle cell gene from their parents, but neither of them has ever manifested symptoms associated with the disease.", "They want to conceive and are concerned about the chances that their child might have the disease." ]

[ "1. A 30-year old African-American woman comes into your office for pregnancy counseling with her husband.", "2. She has a family history of sickle cell disease.", "3. Her husband has a family history of sickle cell disease.", "4. She has a copy of the sickle cell gene from her parents.", "5. Her husband has a copy of the sickle cell gene from his parents.", "6. Neither of them has ever manifested symptoms associated with the disease.", "7. They want to conceive.", "8. They are concerned about the chances that their child might have the disease." ]

[ "1. The patient and her husband have family histories of sickle cell disease.", "2. Both the patient and her husband have a copy of the sickle cell gene from their parents.", "3. Neither the patient nor her husband has ever manifested symptoms associated with sickle cell disease.", "4. The patient and her husband want to conceive.", "5. They are concerned about the chances that their child might have sickle cell disease." ]

[ "A 52-year-old man presents to the clinic complaining of blood in his urine.", "He had a mild respiratory illness 3 weeks ago.", "Urinalysis reveals a high red blood cell count and casts in the urine.", "A diagnosis of post-streptococcal glomerulonephritis is made.", "The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks.", "Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue.", "On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min.", "He has a mildly distended abdomen.", "Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month.", "He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL.", "The patient is advised to undergo renal transplantation.", "His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3.", "The first allele in each locus is the maternal form; the second is paternal.", "Several potential donors are available for the renal graft." ]

[ "1. A 52-year-old man presents to the clinic complaining of blood in his urine.", "2. He had a mild respiratory illness 3 weeks ago.", "3. Urinalysis reveals a high red blood cell count and casts in the urine.", "4. A diagnosis of post-streptococcal glomerulonephritis is made.", "5. The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks.", "6. Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue.", "7. On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min.", "8. He has a mildly distended abdomen.", "9. Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month.", "10. He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL.", "11. The patient is advised to undergo renal transplantation.", "12. His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3.", "13. The first allele in each locus is the maternal form; the second is paternal.", "14. Several potential donors are available for the renal graft." ]

[ "1. He had a mild respiratory illness 3 weeks ago.", "2. Urinalysis reveals a high red blood cell count and casts in the urine.", "3. A diagnosis of post-streptococcal glomerulonephritis is made.", "4. The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks.", "5. Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue.", "6. On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min.", "7. He has a mildly distended abdomen.", "8. Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month.", "9. He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL.", "10. The patient is advised to undergo renal transplantation.", "11. His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3.", "12. The first allele in each locus is the maternal form; the second is paternal.", "13. Several potential donors are available for the renal graft." ]

[ "An investigator is studying determinants of childhood obesity by observing a cohort of pregnant women with obesity.", "After delivery, he regularly records the height and weight of the cohort's children.", "The results of the correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy are shown." ]

[ "1. An investigator is studying determinants of childhood obesity.", "2. The investigator is observing a cohort of pregnant women with obesity.", "3. The investigator regularly records the height and weight of the cohort's children after delivery.", "4. The investigator is conducting a correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy.", "5. The results of the correlation analysis are shown." ]

[ "1. After delivery, he records the height and weight of the cohort's children.", "2. The results of the correlation analysis are between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy." ]

[ "A 25-year-old woman comes to the physician for a routine examination.", "She is a recreational runner and for the past 3 months she has been training for a marathon.", "Yesterday she ran 17 km (10.5 mile).", "Menses occur at regular 28-day intervals and last 6 days.", "She drinks three to five beers when going out with friends.", "She follows a vegan diet.", "She appears well.", "Her temperature is 36.6°C (98.0°F), blood pressure is 110/72 mm Hg, pulse is 70/min, and respirations are 14/min.", "Physical examination shows no abnormalities.", "Laboratory studies show: | Hemoglobin 9.8 g/dL | Mean corpuscular volume 91 fL | Lactate dehydrogenase 400 U/L | Platelet count 250,000/mm3 | Reticulocyte count 3% | Haptoglobin 23 mg/dL (N=41–165 mg/dL) | Serum | Iron 90 μg/dL | Ferritin 170 ng/mL | Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL) | Urinalysis shows trace blood but no RBCs." ]

[ "1. A 25-year-old woman comes to the physician for a routine examination.", "2. She is a recreational runner and for the past 3 months she has been training for a marathon.", "3. Yesterday she ran 17 km (10.5 mile).", "4. Menses occur at regular 28-day intervals and last 6 days.", "5. She drinks three to five beers when going out with friends.", "6. She follows a vegan diet.", "7. She appears well.", "8. Her temperature is 36.6°C (98.0°F).", "9. Blood pressure is 110/72 mm Hg.", "10. Pulse is 70/min.", "11. Respirations are 14/min.", "12. Physical examination shows no abnormalities.", "13. Laboratory studies show hemoglobin 9.8 g/dL.", "14. Mean corpuscular volume 91 fL.", "15. Lactate dehydrogenase 400 U/L.", "16. Platelet count 250,000/mm3.", "17. Reticulocyte count 3%.", "18. Haptoglobin 23 mg/dL (N=41–165 mg/dL).", "19. Serum iron 90 μg/dL.", "20. Ferritin 170 ng/mL.", "21. Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL).", "22. Urinalysis shows trace blood but no RBCs." ]

[ "1. She is a recreational runner.", "2. She has been training for a marathon for the past 3 months.", "3. Yesterday she ran 17 km (10.5 miles).", "4. Her menses occur at regular 28-day intervals and last 6 days.", "5. She drinks three to five beers when going out with friends.", "6. She follows a vegan diet.", "7. She appears well.", "8. Her temperature is 36.6°C (98.0°F).", "9. Her blood pressure is 110/72 mm Hg.", "10. Her pulse is 70/min.", "11. Her respirations are 14/min.", "12. Physical examination shows no abnormalities.", "13. Laboratory studies show: Hemoglobin 9.8 g/dL.", "14. Laboratory studies show: Mean corpuscular volume 91 fL.", "15. Laboratory studies show: Lactate dehydrogenase 400 U/L.", "16. Laboratory studies show: Platelet count 250,000/mm3.", "17. Laboratory studies show: Reticulocyte count 3%.", "18. Laboratory studies show: Haptoglobin 23 mg/dL (N=41–165 mg/dL).", "19. Laboratory studies show: Serum Iron 90 μg/dL.", "20. Laboratory studies show: Ferritin 170 ng/mL.", "21. Laboratory studies show: Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL).", "22. Urinalysis shows trace blood but no RBCs." ]

[ "A 45-year-old man comes into the ED after a car accident.", "After waiting an hour in the waiting room, he begins to berate the receptionist and demands to be seen by a doctor.", "During the exam, the patient brags that he recently had to quit his job because they did not appreciate his talent and drive.", "After a medical student declines his invitation for a date, he becomes very angry and throws supplies across the room.", "The physician manages the patient's physical injuries and begins to suspect the patient has a personality disorder." ]

[ "1. A 45-year-old man comes into the ED after a car accident.", "2. He waits an hour in the waiting room.", "3. He berates the receptionist and demands to be seen by a doctor.", "4. He brags that he recently had to quit his job because they did not appreciate his talent and drive.", "5. A medical student declines his invitation for a date.", "6. He becomes very angry and throws supplies across the room.", "7. The physician manages the patient's physical injuries.", "8. The physician begins to suspect the patient has a personality disorder." ]

[ "1. The patient waits for an hour in the waiting room.", "2. The patient berates the receptionist.", "3. The patient demands to be seen by a doctor.", "4. The patient brags about recently quitting his job.", "5. The patient claims his job did not appreciate his talent and drive.", "6. The patient becomes angry after a medical student declines his date invitation.", "7. The patient throws supplies across the room.", "8. The physician manages the patient's physical injuries.", "9. The physician suspects the patient has a personality disorder." ]

[ "A 61-year-old man comes to the physician because of weight loss and a non-productive cough for 4 months.", "He has smoked 2 packs of cigarettes daily for 42 years.", "A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy.", "A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer.", "Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7.", "The physician recommends chemotherapy with erlotinib." ]

[ "1. A 61-year-old man comes to the physician.", "2. He has a non-productive cough for 4 months.", "3. He has smoked 2 packs of cigarettes daily for 42 years.", "4. A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy.", "5. A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer.", "6. Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7.", "7. The physician recommends chemotherapy with erlotinib." ]

[ "1. He has smoked 2 packs of cigarettes daily for 42 years.", "2. A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy.", "3. A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer.", "4. Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7.", "5. The physician recommends chemotherapy with erlotinib." ]

[ "A 52-year-old woman comes to the physician because of a 4-day history of painful swallowing and retrosternal pain.", "She was diagnosed with HIV infection 2 months ago; her medications include tenofovir, emtricitabine, and raltegravir.", "Vital signs are within normal limits.", "Physical examination of the oral cavity shows no abnormalities.", "The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).", "Empiric treatment is started.", "Two weeks later, she reports no improvement in symptoms.", "Esophagogastroduodenoscopy is performed and shows multiple round superficial ulcers in the distal esophagus." ]

[ "1. A 52-year-old woman comes to the physician.", "2. She has a 4-day history of painful swallowing and retrosternal pain.", "3. She was diagnosed with HIV infection 2 months ago.", "4. Her medications include tenofovir, emtricitabine, and raltegravir.", "5. Vital signs are within normal limits.", "6. Physical examination of the oral cavity shows no abnormalities.", "7. The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).", "8. Empiric treatment is started.", "9. Two weeks later, she reports no improvement in symptoms.", "10. Esophagogastroduodenoscopy is performed.", "11. Esophagogastroduodenoscopy shows multiple round superficial ulcers in the distal esophagus." ]

[ "1. The patient was diagnosed with HIV infection 2 months ago.", "2. The patient's medications include tenofovir, emtricitabine, and raltegravir.", "3. Vital signs are within normal limits.", "4. Physical examination of the oral cavity shows no abnormalities.", "5. The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).", "6. Empiric treatment is started.", "7. Two weeks later, the patient reports no improvement in symptoms.", "8. Esophagogastroduodenoscopy is performed.", "9. The esophagogastroduodenoscopy shows multiple round superficial ulcers in the distal esophagus." ]

[ "An 18-year-old girl comes to the emergency room with abdominal pain.", "She states that the pain started 6 hours ago, is 8/10, and localizes to the right lower abdomen.", "She recalls a similar episode last month.", "Her older brother was hospitalized 2 years ago for perforated appendicitis.", "Her mother has diverticulitis.", "The patient got her first menstrual period at age 14.", "Her periods occur regularly every 28 days.", "Her last menstrual period was 2 weeks ago.", "She is sexually active with multiple partners and uses condoms inconsistently.", "The patient’s temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air.", "On physical exam, the patient is in moderate distress.", "There is lower abdominal tenderness with guarding.", "A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa.", "Labs are obtained, as shown below: | | Leukocyte count: 10,000/mm^3 with normal differential | Hemoglobin: 13.5 g/dL | Platelet count: 200,000/mm^3 | Beta-human chorionic gonadotropin: Pending | | A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus." ]

[ "1. An 18-year-old girl comes to the emergency room with abdominal pain.", "2. She states that the pain started 6 hours ago, is 8/10, and localizes to the right lower abdomen.", "3. She recalls a similar episode last month.", "4. Her older brother was hospitalized 2 years ago for perforated appendicitis.", "5. Her mother has diverticulitis.", "6. The patient got her first menstrual period at age 14.", "7. Her periods occur regularly every 28 days.", "8. Her last menstrual period was 2 weeks ago.", "9. She is sexually active with multiple partners and uses condoms inconsistently.", "10. The patient’s temperature is 99°F (37.2°C).", "11. The patient’s blood pressure is 110/74 mmHg.", "12. The patient’s pulse is 89/min.", "13. The patient’s respirations are 14/min with an oxygen saturation of 98% on room air.", "14. On physical exam, the patient is in moderate distress.", "15. There is lower abdominal tenderness with guarding.", "16. A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa.", "17. Labs are obtained, as shown below: Leukocyte count: 10,000/mm^3 with normal differential.", "18. Labs are obtained, as shown below: Hemoglobin: 13.5 g/dL.", "19. Labs are obtained, as shown below: Platelet count: 200,000/mm^3.", "20. Labs are obtained, as shown below: Beta-human chorionic gonadotropin: Pending.", "21. A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus." ]

[ "1. The patient's pain started 6 hours ago and is 8/10.", "2. The pain localizes to the right lower abdomen.", "3. The patient had a similar episode last month.", "4. The patient's older brother was hospitalized 2 years ago for perforated appendicitis.", "5. The patient's mother has diverticulitis.", "6. The patient got her first menstrual period at age 14.", "7. Her periods occur regularly every 28 days.", "8. Her last menstrual period was 2 weeks ago.", "9. The patient is sexually active with multiple partners and uses condoms inconsistently.", "10. The patient's temperature is 99°F (37.2°C).", "11. Her blood pressure is 110/74 mmHg.", "12. Her pulse is 89/min.", "13. Her respirations are 14/min with an oxygen saturation of 98% on room air.", "14. On physical exam, the patient is in moderate distress.", "15. There is lower abdominal tenderness with guarding.", "16. A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa.", "17. Labs: Leukocyte count is 10,000/mm^3 with normal differential.", "18. Hemoglobin is 13.5 g/dL.", "19. Platelet count is 200,000/mm^3.", "20. Beta-human chorionic gonadotropin is pending.", "21. A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus." ]

[ "In a suburban town in Virginia, epidemiologists are alarmed by the increasing number of squamous cell lung cancer cases.", "Further investigation reveals that most people in the area work in a glass factory, the region’s main source of employment.", "A researcher is interested in studying the role of immunosurveillance in the pathogenesis of this lung cancer.", "He postulates that tumor infiltration by natural killer (NK) cells has a better prognosis since they play a major role in immunosurveillance.", "NK cells also kill tumor cells by the perforin-mediated destruction of cancerous cells.", "The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort who have been diagnosed with stage 1 lung cancer." ]

[ "1. In a suburban town in Virginia, epidemiologists are alarmed by the increasing number of squamous cell lung cancer cases.", "2. Most people in the area work in a glass factory, the region’s main source of employment.", "3. A researcher is interested in studying the role of immunosurveillance in the pathogenesis of this lung cancer.", "4. He postulates that tumor infiltration by natural killer (NK) cells has a better prognosis since they play a major role in immunosurveillance.", "5. NK cells also kill tumor cells by the perforin-mediated destruction of cancerous cells.", "6. The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort who have been diagnosed with stage 1 lung cancer." ]

[ "1. Most people in the area work in a glass factory, the region’s main source of employment.", "2. A researcher is interested in studying the role of immunosurveillance in the pathogenesis of lung cancer.", "3. The researcher postulates that tumor infiltration by natural killer (NK) cells has a better prognosis.", "4. NK cells play a major role in immunosurveillance.", "5. NK cells kill tumor cells by the perforin-mediated destruction of cancerous cells.", "6. The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort diagnosed with stage 1 lung cancer." ]

[ "A 26-year-old man presents to the office complaining of persistent back pain for the past 3 months.", "You saw the patient previously and prescribed NSAIDs and rest, but he has not improved.", "The patient states that his maternal grandfather had ‘back problems his whole life’, and he worries that he might have the same issues.", "An X-ray is performed and shows squaring of the vertebrae with longitudinal fibrous bands." ]

[ "1. A 26-year-old man presents to the office.", "2. He has been complaining of persistent back pain for the past 3 months.", "3. The patient was previously prescribed NSAIDs and rest, but has not improved.", "4. The patient's maternal grandfather had \"back problems his whole life\".", "5. The patient worries that he might have the same issues.", "6. An X-ray is performed.", "7. The X-ray shows squaring of the vertebrae with longitudinal fibrous bands." ]

[ "1. The patient was previously prescribed NSAIDs and rest.", "2. The patient has not improved.", "3. The patient's maternal grandfather had back problems his whole life.", "4. The patient worries that he might have the same issues.", "5. An X-ray was performed.", "6. The X-ray shows squaring of the vertebrae.", "7. The X-ray shows longitudinal fibrous bands." ]

[ "A regional hospital system has decided to institute a new task group for quality improvement and patient safety.", "The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department to at most 7 days instead of the hospital average of 21 days per prescription." ]

[ "1. A regional hospital system has decided to institute a new task group for quality improvement and patient safety.", "2. The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department.", "3. The number of days given for narcotic pain medication prescriptions in the emergency department should be at most 7 days.", "4. The hospital average for narcotic pain medication prescriptions is 21 days per prescription." ]

[ "1. The task group wants to decrease the number of days for narcotic pain medication prescriptions in the emergency department.", "2. The current hospital average for narcotic pain medication prescriptions is 21 days.", "3. The task group aims to limit narcotic pain medication prescriptions to a maximum of 7 days in the emergency department." ]

[ "A 57-year-old man comes to the clinic complaining of nausea and 1 episode of vomiting during the past day.", "He denies any precipitating event except for a headache for which he took some acetaminophen yesterday.", "The headache is described as bilateral, dull, and 8/10 in severity.", "He has never had such symptoms before.", "His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens when he “tried to quit alcohol cold turkey.” When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.” The patient reports mild abdominal pain that began this morning but denies vision changes, bowel changes, fever, or weight loss.", "Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsens with inhalation." ]

[ "1. A 57-year-old man comes to the clinic.", "2. He complains of nausea and 1 episode of vomiting during the past day.", "3. He denies any precipitating event except for a headache.", "4. The headache is described as bilateral, dull, and 8/10 in severity.", "5. He has never had such symptoms before.", "6. His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens.", "7. He \"tried to quit alcohol cold turkey\" in the past.", "8. When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.”", "9. The patient reports mild abdominal pain that began this morning.", "10. He denies vision changes, bowel changes, fever, or weight loss.", "11. Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsens with inhalation." ]

[ "1. Patient denies any precipitating event except for a headache for which he took acetaminophen yesterday.", "2. The headache is described as bilateral, dull, and 8/10 in severity.", "3. Patient has never had such symptoms before.", "4. Past medical history includes hypertension, biliary colic, and a past hospitalization for delirium tremens.", "5. Patient \"tried to quit alcohol cold turkey.\"", "6. Patient looks away and mutters \"just a couple of drinks here and there\" when asked about current alcohol intake.", "7. Patient reports mild abdominal pain that began this morning.", "8. Patient denies vision changes, bowel changes, fever, or weight loss.", "9. Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsen with inhalation." ]

[ "A 48-year-old patient comes to the physician because of a 4-day history fever, headaches, loss of appetite, and myalgia.", "Two weeks ago, the patient went on a camping trip to Wisconsin.", "His temperature is 39.5°C (103.1°F).", "Physical examination shows no rash or joint swelling.", "Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 3,800/mm3 | Platelet count 85,000/mm3 | Serum | AST 48 U/L | ALT 52 U/L | Treatment with doxycycline is begun and the patient recovers.", "A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis." ]

[ "1. A 48-year-old patient comes to the physician.", "2. The patient has a 4-day history of fever, headaches, loss of appetite, and myalgia.", "3. Two weeks ago, the patient went on a camping trip to Wisconsin.", "4. The patient's temperature is 39.5°C (103.1°F).", "5. Physical examination shows no rash or joint swelling.", "6. Laboratory studies show a hemoglobin level of 14.1 g/dL.", "7. Laboratory studies show a leukocyte count of 3,800/mm3.", "8. Laboratory studies show a platelet count of 85,000/mm3.", "9. Laboratory studies show an AST level of 48 U/L.", "10. Laboratory studies show an ALT level of 52 U/L.", "11. Treatment with doxycycline is begun.", "12. The patient recovers.", "13. A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis." ]

[ "1. Two weeks ago, the patient went on a camping trip to Wisconsin.", "2. His temperature is 39.5°C (103.1°F).", "3. Physical examination shows no rash or joint swelling.", "4. Laboratory studies show: Hemoglobin 14.1 g/dL.", "5. Laboratory studies show: Leukocyte count 3,800/mm3.", "6. Laboratory studies show: Platelet count 85,000/mm3.", "7. Laboratory studies show: Serum AST 48 U/L.", "8. Laboratory studies show: Serum ALT 52 U/L.", "9. Treatment with doxycycline is begun and the patient recovers.", "10. A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis." ]

[ "A 42-year-old woman comes to the clinic complaining of upper abdominal pain.", "Her symptoms started 1 month ago with vague abdominal discomfort following a meal at a steakhouse.", "Since then the pain has progressed to the point that she has more than 5 episodes a week.", "The pain is worse with eating but has not affected her appetite.", "She also reports a burning sensation in her chest when she lies down at night after dinner.", "She denies weight loss or dysphagia.", "She takes no medications except daily calcium supplements.", "She drinks 2 glasses of wine per week and denies tobacco use.", "Her blood pressure is 110/78, pulse is 72/min, and respirations are 13/min.", "On physical examination, the patient’s abdomen is soft and non-distended.", "Normal bowel sounds are appreciation.", "There is mild epigastric tenderness but no guarding and no rebound.", "Fecal occult blood is negative." ]

[ "1. A 42-year-old woman comes to the clinic complaining of upper abdominal pain.", "2. Her symptoms started 1 month ago with vague abdominal discomfort following a meal at a steakhouse.", "3. Since then the pain has progressed to the point that she has more than 5 episodes a week.", "4. The pain is worse with eating but has not affected her appetite.", "5. She also reports a burning sensation in her chest when she lies down at night after dinner.", "6. She denies weight loss or dysphagia.", "7. She takes no medications except daily calcium supplements.", "8. She drinks 2 glasses of wine per week and denies tobacco use.", "9. Her blood pressure is 110/78, pulse is 72/min, and respirations are 13/min.", "10. On physical examination, the patient’s abdomen is soft and non-distended.", "11. Normal bowel sounds are appreciation.", "12. There is mild epigastric tenderness but no guarding and no rebound.", "13. Fecal occult blood is negative." ]

[ "1. Symptoms started 1 month ago with vague abdominal discomfort after a meal at a steakhouse.", "2. Experiences more than 5 episodes of pain per week.", "3. Pain worsens with eating but does not affect appetite.", "4. Reports a burning sensation in the chest when lying down at night after dinner.", "5. Denies weight loss or dysphagia.", "6. Takes daily calcium supplements.", "7. Drinks 2 glasses of wine per week and denies tobacco use.", "8. Blood pressure is 110/78, pulse is 72/min, and respirations are 13/min.", "9. On physical examination, the abdomen is soft and non-distended.", "10. Normal bowel sounds are appreciated.", "11. Mild epigastric tenderness but no guarding and no rebound.", "12. Fecal occult blood is negative." ]

[ "A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature has been 101°F (38.3°C) for several days.", "His mother states that other children at his daycare center have been having similar symptoms.", "She further describes that he was fed formula and was not breastfed.", "The mother admits that she smokes cigarettes daily.", "On exam, the boy is irritable and crying, and frequently tugs on his left ear.", "Both tympanic membranes appear erythematous, and the left appears opaque and bulging with decreased mobility on pneumatic otoscopy." ]

[ "1. Patient is a 3-year-old boy.", "2. Patient has been crying with ear pain.", "3. Patient's temperature has been 101°F (38.3°C) for several days.", "4. Patient's mother states other children at his daycare center have been having similar symptoms.", "5. Patient was fed formula and was not breastfed.", "6. Patient's mother smokes cigarettes daily.", "7. On exam, patient is irritable and crying.", "8. Patient frequently tugs on his left ear.", "9. Both tympanic membranes appear erythematous.", "10. Left tympanic membrane appears opaque and bulging.", "11. Left tympanic membrane has decreased mobility on pneumatic otoscopy." ]

[ "1. His mother states that other children at his daycare center have been having similar symptoms.", "2. She further describes that he was fed formula and was not breastfed.", "3. The mother admits that she smokes cigarettes daily.", "4. On exam, the boy is irritable and crying, and frequently tugs on his left ear.", "5. Both tympanic membranes appear erythematous.", "6. The left tympanic membrane appears opaque and bulging.", "7. Decreased mobility is observed on pneumatic otoscopy." ]

[ "A 47-year-old G3P2 woman presents to her endocrinologist for a follow-up appointment.", "Her last menstrual period was at the age of 35 years.", "She now feels fatigued and cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.", "Her symptoms are taking a toll on her quality of life.", "The patient’s blood pressure is 124/83 mm Hg, pulse is 91/min, respirations are 17/min, and temperature is 36.7°C (98.1°F).", "On physical examination, there is a mild enlargement of the thyroid; the gland is minimally firm in texture and is nontender." ]

[ "1. A 47-year-old G3P2 woman presents to her endocrinologist for a follow-up appointment.", "2. Her last menstrual period was at the age of 35 years.", "3. She now feels fatigued.", "4. She cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.", "5. Her symptoms are taking a toll on her quality of life.", "6. The patient’s blood pressure is 124/83 mm Hg.", "7. The patient’s pulse is 91/min.", "8. The patient’s respirations are 17/min.", "9. The patient’s temperature is 36.7°C (98.1°F).", "10. On physical examination, there is a mild enlargement of the thyroid.", "11. The gland is minimally firm in texture.", "12. The gland is nontender." ]

[ "1. Her last menstrual period was at the age of 35 years.", "2. She now feels fatigued and cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.", "3. Her symptoms are taking a toll on her quality of life.", "4. The patient’s blood pressure is 124/83 mm Hg, pulse is 91/min, respirations are 17/min, and temperature is 36.7°C (98.1°F).", "5. On physical examination, there is a mild enlargement of the thyroid; the gland is minimally firm in texture and is nontender." ]

[ "A 44-year-old woman is brought to the emergency department after she was found lying in the park mumbling to herself.", "She is lethargic and disoriented.", "She has a 2-week history of increasing weakness, nausea, and vomiting.", "She denies any recent alcohol or drug use.", "She has a history of systemic lupus erythematosus but stopped taking methotrexate many years ago.", "Her temperature is 37.3°C (99.1°F), pulse is 89/min, and blood pressure is 154/91 mm Hg.", "On mental status examination, she is confused and only oriented to person, but not to place or time.", "She is unable to name the days of the week backwards.", "She exhibits moderate generalized weakness.", "Physical exam shows jugular venous distention and pitting edema in the lower extremities.", "Laboratory studies show: | Serum | Na+ 137 mEq/L | K+ 5.5 mEq/L | Cl- 120 mEq/L | Bicarbonate 15 mEq/L | Urea nitrogen 94 mg/dL | Creatinine 5.5 mg/dL | Glucose 92 mg/dL | ." ]

[ "1. A 44-year-old woman is brought to the emergency department.", "2. She was found lying in the park mumbling to herself.", "3. She is lethargic and disoriented.", "4. She has a 2-week history of increasing weakness, nausea, and vomiting.", "5. She denies any recent alcohol or drug use.", "6. She has a history of systemic lupus erythematosus.", "7. She stopped taking methotrexate many years ago.", "8. Her temperature is 37.3°C (99.1°F).", "9. Her pulse is 89/min.", "10. Her blood pressure is 154/91 mm Hg.", "11. On mental status examination, she is confused and only oriented to person.", "12. She is not oriented to place or time.", "13. She is unable to name the days of the week backwards.", "14. She exhibits moderate generalized weakness.", "15. Physical exam shows jugular venous distention.", "16. Physical exam shows pitting edema in the lower extremities.", "17. Laboratory studies show serum Na+ 137 mEq/L.", "18. Laboratory studies show serum K+ 5.5 mEq/L.", "19. Laboratory studies show serum Cl- 120 mEq/L.", "20. Laboratory studies show serum bicarbonate 15 mEq/L.", "21. Laboratory studies show serum urea nitrogen 94 mg/dL.", "22. Laboratory studies show serum creatinine 5.5 mg/dL.", "23. Laboratory studies show serum glucose 92 mg/dL." ]

[ "1. She is lethargic and disoriented.", "2. She has a 2-week history of increasing weakness, nausea, and vomiting.", "3. She denies any recent alcohol or drug use.", "4. She has a history of systemic lupus erythematosus but stopped taking methotrexate many years ago.", "5. Her temperature is 37.3°C (99.1°F), pulse is 89/min, and blood pressure is 154/91 mm Hg.", "6. On mental status examination, she is confused and only oriented to person, but not to place or time.", "7. She is unable to name the days of the week backwards.", "8. She exhibits moderate generalized weakness.", "9. Physical exam shows jugular venous distention and pitting edema in the lower extremities.", "10. Laboratory studies show: Serum Na+ 137 mEq/L, K+ 5.5 mEq/L, Cl- 120 mEq/L, Bicarbonate 15 mEq/L, Urea nitrogen 94 mg/dL, Creatinine 5.5 mg/dL, Glucose 92 mg/dL." ]

[ "An investigator is studying the secretion of gastrointestinal hormones before and after food intake.", "She isolates a hormone that accelerates the emptying of gastric contents into the duodenal bulb." ]

[ "1. An investigator is studying the secretion of gastrointestinal hormones.", "2. The study is conducted before and after food intake.", "3. The investigator isolates a hormone.", "4. The hormone accelerates the emptying of gastric contents.", "5. The gastric contents are emptied into the duodenal bulb." ]

[ "1. She isolates a hormone.", "2. The hormone accelerates the emptying of gastric contents.", "3. The acceleration occurs into the duodenal bulb." ]

[ "A 45-year-old woman presents to the office with a chief complaint of a cough that has persisted for a month and a half.", "She also has night fevers and has lost 5 kg (11 lb) in the last 2 months.", "She recently returned from a 6-month trip to Peru.", "Her vitals include: heart rate 82/min, respiratory rate 17/min, temperature 38.0°C (100.4°F), and blood pressure 107/80 mm Hg.", "On auscultation, she has diminished respiratory sounds at the base of the right lung.", "Chest radiography shows an opacity in the right apex." ]

[ "1. A 45-year-old woman presents to the office.", "2. Her chief complaint is a cough that has persisted for a month and a half.", "3. She also has night fevers.", "4. She has lost 5 kg (11 lb) in the last 2 months.", "5. She recently returned from a 6-month trip to Peru.", "6. Her heart rate is 82/min.", "7. Her respiratory rate is 17/min.", "8. Her temperature is 38.0°C (100.4°F).", "9. Her blood pressure is 107/80 mm Hg.", "10. On auscultation, she has diminished respiratory sounds at the base of the right lung.", "11. Chest radiography shows an opacity in the right apex." ]

[ "1. She has night fevers.", "2. She has lost 5 kg (11 lb) in the last 2 months.", "3. She recently returned from a 6-month trip to Peru.", "4. Her heart rate is 82/min.", "5. Her respiratory rate is 17/min.", "6. Her temperature is 38.0°C (100.4°F).", "7. Her blood pressure is 107/80 mm Hg.", "8. On auscultation, she has diminished respiratory sounds at the base of the right lung.", "9. Chest radiography shows an opacity in the right apex." ]

[ "A 52-year-old homeless man is brought to the urgent care clinic with altered mental status and disorientation for the last day.", "Past medical records are unavailable.", "His temperature is 37°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 92/67 mm Hg.", "He has a flapping tremor of the wrists during attempted extension.", "He is started on intravenous D5 1/2NS and blood is drawn for further testing.", "His condition deteriorates overnight.", "On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait.", "His blood tests show: | Serum | Albumin 3.2 gm/dL | Alkaline phosphatase 150 U/L | Alanine aminotransferase 76 U/L | Aspartate aminotransferase 155 U/L | Gamma-glutamyl transpeptidase 202 U/L | ." ]

[ "1. A 52-year-old homeless man is brought to the urgent care clinic with altered mental status and disorientation for the last day.", "2. Past medical records are unavailable.", "3. His temperature is 37°C (98.6°F).", "4. The respiratory rate is 15/min.", "5. The pulse is 107/min.", "6. The blood pressure is 92/67 mm Hg.", "7. He has a flapping tremor of the wrists during attempted extension.", "8. He is started on intravenous D5 1/2NS and blood is drawn for further testing.", "9. His condition deteriorates overnight.", "10. On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait.", "11. His blood tests show: Serum Albumin 3.2 gm/dL.", "12. His blood tests show: Alkaline phosphatase 150 U/L.", "13. His blood tests show: Alanine aminotransferase 76 U/L.", "14. His blood tests show: Aspartate aminotransferase 155 U/L.", "15. His blood tests show: Gamma-glutamyl transpeptidase 202 U/L." ]

[ "1. Past medical records are unavailable.", "2. His temperature is 37°C (98.6°F).", "3. The respiratory rate is 15/min.", "4. The pulse is 107/min.", "5. The blood pressure is 92/67 mm Hg.", "6. He has a flapping tremor of the wrists during attempted extension.", "7. He is started on intravenous D5 1/2NS.", "8. Blood is drawn for further testing.", "9. His condition deteriorates overnight.", "10. On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait.", "11. His blood tests show: Serum Albumin 3.2 gm/dL.", "12. Alkaline phosphatase 150 U/L.", "13. Alanine aminotransferase 76 U/L.", "14. Aspartate aminotransferase 155 U/L.", "15. Gamma-glutamyl transpeptidase 202 U/L." ]

[ "A 27-year-old woman comes to the emergency department at 14 weeks gestation with abdominal pain.", "She states she has passed a large amount of blood from her vagina in the past 2 hours.", "Her vitals are within normal limits and she describes her abdominal pain as a 4/10.", "Physical exam is notable for a dilated cervix.", "The patient states she does not want any invasive procedures in her workup but is accepting to necessary medical interventions." ]

[ "1. A 27-year-old woman comes to the emergency department.", "2. She is 14 weeks gestation.", "3. She has passed a large amount of blood from her vagina in the past 2 hours.", "4. Her vitals are within normal limits.", "5. She describes her abdominal pain as a 4/10.", "6. Physical exam is notable for a dilated cervix.", "7. The patient states she does not want any invasive procedures in her workup.", "8. She is accepting to necessary medical interventions." ]

[ "1. The patient has passed a large amount of blood from her vagina in the past 2 hours.", "2. Her vitals are within normal limits.", "3. She describes her abdominal pain as a 4/10.", "4. Physical exam is notable for a dilated cervix.", "5. The patient does not want any invasive procedures in her workup.", "6. The patient is accepting to necessary medical interventions." ]

[ "A 25-year-old female is admitted to the hospital for an intrauterine fetal demise (IUFD) during her 30th gestational week.", "The patient did not receive any prenatal care or screenings.", "The baby is delivered via C-section and the family wishes to conduct an autopsy to understand the reason for the IUFD and to better prepare for future pregnancies.", "On autopsy, the fetus is discovered to have severe facial abnormalities as well as a brain lacking the normal sagittal fissure." ]

[ "1. A 25-year-old female is admitted to the hospital.", "2. The patient is admitted for an intrauterine fetal demise (IUFD).", "3. The patient is in her 30th gestational week.", "4. The patient did not receive any prenatal care or screenings.", "5. The baby is delivered via C-section.", "6. The family wishes to conduct an autopsy.", "7. The purpose of the autopsy is to understand the reason for the IUFD and to better prepare for future pregnancies.", "8. On autopsy, the fetus is discovered to have severe facial abnormalities.", "9. On autopsy, the fetus is discovered to have a brain lacking the normal sagittal fissure." ]

[ "1. The patient did not receive any prenatal care.", "2. The patient did not receive any prenatal screenings.", "3. The baby was delivered via C-section.", "4. The family wishes to conduct an autopsy.", "5. The reason for the IUFD is to be understood.", "6. The autopsy is to better prepare for future pregnancies.", "7. On autopsy, the fetus is discovered to have severe facial abnormalities.", "8. On autopsy, the fetus is discovered to have a brain lacking the normal sagittal fissure." ]

[ "A healthy 32-year-old woman enrolls in a study investigating kidney function.", "Her renal plasma flow (RPF) is 600 mL/min.", "She is administered an intravenous substance that does not undergo tubular reabsorption." ]

[ "1. A healthy 32-year-old woman enrolls in a study investigating kidney function.", "2. Her renal plasma flow (RPF) is 600 mL/min.", "3. She is administered an intravenous substance.", "4. The intravenous substance does not undergo tubular reabsorption." ]

[ "1. Renal plasma flow (RPF) is 600 mL/min.", "2. She is administered an intravenous substance.", "3. The substance does not undergo tubular reabsorption." ]

[ "A 6-year-old girl is brought to the physician for a well-child examination.", "She has no history of serious illness.", "Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 96/52 mm Hg.", "Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border that radiates towards the neck.", "The murmur disappears when she flexes her neck.", "The remainder of the examination shows no abnormalities." ]

[ "1. A 6-year-old girl is brought to the physician for a well-child examination.", "2. She has no history of serious illness.", "3. Her temperature is 37°C (98.6°F).", "4. Her pulse is 95/min.", "5. Her blood pressure is 96/52 mm Hg.", "6. Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border.", "7. The murmur radiates towards the neck.", "8. The murmur disappears when she flexes her neck.", "9. The remainder of the examination shows no abnormalities." ]

[ "1. She has no history of serious illness.", "2. Her temperature is 37°C (98.6°F).", "3. Her pulse is 95/min.", "4. Her blood pressure is 96/52 mm Hg.", "5. Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border.", "6. The murmur radiates towards the neck.", "7. The murmur disappears when she flexes her neck.", "8. The remainder of the examination shows no abnormalities." ]

[ "A 72-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department with three-days of fever, cough, and shortness of breath.", "On physical exam, temperature is 101.3 deg F (38.5 deg C), pulse is 106/min, blood pressure is 148/92 mmHg, and respiratory rate is 24/min.", "Crackles are auscultated on the right lower lobe.", "Chest radiograph demonstrates right lower lobe opacities concerning for consolidation.", "Sodium level is 118 mEq/L.", "He is admitted to the hospital on empiric antibiotics." ]

[ "1. A 72-year-old man presents to the emergency department.", "2. He has a history of hypertension and hyperlipidemia.", "3. He has three days of fever, cough, and shortness of breath.", "4. His temperature is 101.3 deg F (38.5 deg C).", "5. His pulse is 106/min.", "6. His blood pressure is 148/92 mmHg.", "7. His respiratory rate is 24/min.", "8. Crackles are auscultated on the right lower lobe.", "9. Chest radiograph demonstrates right lower lobe opacities concerning for consolidation.", "10. His sodium level is 118 mEq/L.", "11. He is admitted to the hospital on empiric antibiotics." ]

[ "1. Temperature is 101.3 deg F (38.5 deg C)", "2. Pulse is 106/min", "3. Blood pressure is 148/92 mmHg", "4. Respiratory rate is 24/min", "5. Crackles are auscultated on the right lower lobe", "6. Chest radiograph demonstrates right lower lobe opacities concerning for consolidation", "7. Sodium level is 118 mEq/L", "8. Admitted to the hospital on empiric antibiotics" ]

[ "A 75-year-old man presents to the physician for a follow-up examination.", "Over the last several months, he reports dyspnea when walking during his daily exercise routine.", "He feels tired most of the time.", "He has no fever or weight loss.", "He has no history of severe illness and takes no medications.", "He does not smoke, drinks alcohol, or follow a particular diet.", "The vital signs are within normal limits.", "The physical examination reveals pale conjunctiva.", "The examination of the heart, lungs, abdomen, and extremities shows no abnormalities.", "No lymphadenopathy is palpated.", "The laboratory studies show the following: | Hemoglobin 8.5 g/dL | Mean corpuscular volume 105 μm3 | Leukocyte count 4,500/mm3 | Platelet 160,000/mm3 | Abdominal ultrasonography shows no organomegaly or other pathologic findings.", "The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei.", "No blasts are seen.", "Bone marrow aspiration shows hypercellularity.", "In addition, ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present.", "Marrow myeloblasts are 4% in volume." ]

[ "1. A 75-year-old man presents to the physician for a follow-up examination.", "2. Over the last several months, he reports dyspnea when walking during his daily exercise routine.", "3. He feels tired most of the time.", "4. He has no fever or weight loss.", "5. He has no history of severe illness and takes no medications.", "6. He does not smoke, drinks alcohol, or follow a particular diet.", "7. The vital signs are within normal limits.", "8. The physical examination reveals pale conjunctiva.", "9. The examination of the heart, lungs, abdomen, and extremities shows no abnormalities.", "10. No lymphadenopathy is palpated.", "11. The laboratory studies show the following: Hemoglobin 8.5 g/dL, Mean corpuscular volume 105 μm3, Leukocyte count 4,500/mm3, Platelet 160,000/mm3.", "12. Abdominal ultrasonography shows no organomegaly or other pathologic findings.", "13. The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei.", "14. No blasts are seen.", "15. Bone marrow aspiration shows hypercellularity.", "16. In addition, ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present.", "17. Marrow myeloblasts are 4% in volume." ]

[ "1. He reports dyspnea when walking during his daily exercise routine.", "2. He feels tired most of the time.", "3. He has no fever.", "4. He has no weight loss.", "5. He has no history of severe illness.", "6. He takes no medications.", "7. He does not smoke.", "8. He does not drink alcohol.", "9. He does not follow a particular diet.", "10. The vital signs are within normal limits.", "11. The physical examination reveals pale conjunctiva.", "12. The examination of the heart, lungs, abdomen, and extremities shows no abnormalities.", "13. No lymphadenopathy is palpated.", "14. Hemoglobin is 8.5 g/dL.", "15. Mean corpuscular volume is 105 μm3.", "16. Leukocyte count is 4,500/mm3.", "17. Platelet count is 160,000/mm3.", "18. Abdominal ultrasonography shows no organomegaly or other pathologic findings.", "19. The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei.", "20. No blasts are seen.", "21. Bone marrow aspiration shows hypercellularity.", "22. Ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present.", "23. Marrow myeloblasts are 4% in volume." ]

[ "A 37-year-old man comes to the physician because of a 1-month history of a burning sensation in his chest.", "The sensation is most prominent when he is lying in bed, but it is also present after eating heavy meals.", "He also states his breath has an unpleasant odor in the morning.", "He has not lost any weight during this period.", "He has hypothyroidism.", "His father died of colon cancer and his mother has hypertension.", "He has smoked one pack of cigarettes daily for 15 years and drinks 2–3 beers on weekends.", "His medications include levothyroxine and an over-the-counter multivitamin.", "He is 170 cm (5 ft 7 in) tall and weighs 95 kg (210 lb); BMI is 32.9 kg/m2.", "Vital signs are within normal limits.", "Physical examination shows no abnormalities." ]

[ "1. A 37-year-old man comes to the physician.", "2. He has a 1-month history of a burning sensation in his chest.", "3. The sensation is most prominent when he is lying in bed.", "4. The sensation is also present after eating heavy meals.", "5. He states his breath has an unpleasant odor in the morning.", "6. He has not lost any weight during this period.", "7. He has hypothyroidism.", "8. His father died of colon cancer.", "9. His mother has hypertension.", "10. He has smoked one pack of cigarettes daily for 15 years.", "11. He drinks 2–3 beers on weekends.", "12. His medications include levothyroxine and an over-the-counter multivitamin.", "13. He is 170 cm (5 ft 7 in) tall.", "14. He weighs 95 kg (210 lb).", "15. His BMI is 32.9 kg/m2.", "16. Vital signs are within normal limits.", "17. Physical examination shows no abnormalities." ]

[ "1. The sensation is most prominent when he is lying in bed.", "2. The sensation is also present after eating heavy meals.", "3. He states his breath has an unpleasant odor in the morning.", "4. He has not lost any weight during this period.", "5. He has hypothyroidism.", "6. His father died of colon cancer.", "7. His mother has hypertension.", "8. He has smoked one pack of cigarettes daily for 15 years.", "9. He drinks 2–3 beers on weekends.", "10. His medications include levothyroxine and an over-the-counter multivitamin.", "11. He is 170 cm (5 ft 7 in) tall.", "12. He weighs 95 kg (210 lb).", "13. His BMI is 32.9 kg/m2.", "14. Vital signs are within normal limits.", "15. Physical examination shows no abnormalities." ]

[ "A 36-year-old man presents with right upper quadrant pain, fatigue, and pruritus.", "His past medical history is significant for ulcerative colitis diagnosed 5 years ago, which is well-managed medically.", "He is vaccinated against hepatitis A and B and denies any recent travel abroad.", "On physical examination, mild jaundice of the skin is present.", "An abdominal examination reveals significant hepatosplenomegaly.", "A percutaneous liver biopsy is performed." ]

[ "1. A 36-year-old man presents with right upper quadrant pain, fatigue, and pruritus.", "2. His past medical history is significant for ulcerative colitis diagnosed 5 years ago, which is well-managed medically.", "3. He is vaccinated against hepatitis A and B.", "4. He denies any recent travel abroad.", "5. On physical examination, mild jaundice of the skin is present.", "6. An abdominal examination reveals significant hepatosplenomegaly.", "7. A percutaneous liver biopsy is performed." ]

[ "1. Past medical history includes ulcerative colitis diagnosed 5 years ago.", "2. Ulcerative colitis is well-managed medically.", "3. Vaccinated against hepatitis A and B.", "4. Denies recent travel abroad.", "5. Mild jaundice of the skin is present on physical examination.", "6. Significant hepatosplenomegaly is revealed on abdominal examination.", "7. A percutaneous liver biopsy is performed." ]

[ "A 26-year-old man is brought to the emergency department because he has had abdominal pain, nausea, and vomiting for the past 2 hours.", "He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began.", "He has no history of serious illness and takes no medications.", "His temperature is 99.6°F (37.6°C), pulse is 80/min, respirations are 18/min, and blood pressure is 122/68 mm Hg.", "The lungs are clear to auscultation.", "Cardiac examination shows no abnormalities.", "Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding.", "The remainder of the examination shows no abnormalities." ]

[ "1. A 26-year-old man is brought to the emergency department.", "2. He has had abdominal pain, nausea, and vomiting for the past 2 hours.", "3. He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began.", "4. He has no history of serious illness and takes no medications.", "5. His temperature is 99.6°F (37.6°C).", "6. His pulse is 80/min.", "7. His respirations are 18/min.", "8. His blood pressure is 122/68 mm Hg.", "9. The lungs are clear to auscultation.", "10. Cardiac examination shows no abnormalities.", "11. Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding.", "12. The remainder of the examination shows no abnormalities." ]

[ "1. He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began.", "2. He has no history of serious illness and takes no medications.", "3. His temperature is 99.6°F (37.6°C).", "4. His pulse is 80/min.", "5. His respirations are 18/min.", "6. His blood pressure is 122/68 mm Hg.", "7. The lungs are clear to auscultation.", "8. Cardiac examination shows no abnormalities.", "9. Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding.", "10. The remainder of the examination shows no abnormalities." ]

[ "A 12-year-old girl is brought to the emergency department because of severe pain and swelling of her right eye for 3 days.", "Over the past two weeks, she had nasal congestion and a constant, mild headache.", "She did not visit a doctor and instead took over-the-counter naproxen and phenylephrine.", "Her nasal congestion has since improved, but the headache persists.", "She underwent a dental procedure for caries about ten days ago.", "She does not recollect any recent insect bites or trauma.", "Her immunizations are up-to-date.", "She appears ill and reports occasional chills.", "Her temperature is 38.3°C (101°F), pulse is 89/min, and blood pressure is 110/70 mm Hg.", "Examination shows proptosis of the right eye.", "Vision is impaired in the affected eye.", "Her right upper and lower eyelid are erythematous, swollen, and tender to touch.", "Ocular movements cause severe pain.", "Her headache is worsened by leaning forward and improves when the patient is lying on her back." ]

[ "1. Patient is a 12-year-old girl.", "2. Patient has had severe pain and swelling of her right eye for 3 days.", "3. Patient had nasal congestion and a constant, mild headache for two weeks.", "4. Patient took over-the-counter naproxen and phenylephrine for her symptoms.", "5. Nasal congestion has improved, but headache persists.", "6. Patient underwent a dental procedure for caries about ten days ago.", "7. Patient does not recollect any recent insect bites or trauma.", "8. Patient's immunizations are up-to-date.", "9. Patient appears ill and reports occasional chills.", "10. Patient's temperature is 38.3°C (101°F).", "11. Patient's pulse is 89/min.", "12. Patient's blood pressure is 110/70 mm Hg.", "13. Examination shows proptosis of the right eye.", "14. Vision is impaired in the affected eye.", "15. Right upper and lower eyelid are erythematous, swollen, and tender to touch.", "16. Ocular movements cause severe pain.", "17. Patient's headache is worsened by leaning forward and improves when the patient is lying on her back." ]

[ "1. Over the past two weeks, she had nasal congestion and a constant, mild headache.", "2. She did not visit a doctor and instead took over-the-counter naproxen and phenylephrine.", "3. Her nasal congestion has since improved, but the headache persists.", "4. She underwent a dental procedure for caries about ten days ago.", "5. She does not recollect any recent insect bites or trauma.", "6. Her immunizations are up-to-date.", "7. She appears ill and reports occasional chills.", "8. Her temperature is 38.3°C (101°F), pulse is 89/min, and blood pressure is 110/70 mm Hg.", "9. Examination shows proptosis of the right eye.", "10. Vision is impaired in the affected eye.", "11. Her right upper and lower eyelid are erythematous, swollen, and tender to touch.", "12. Ocular movements cause severe pain.", "13. Her headache is worsened by leaning forward and improves when the patient is lying on her back." ]

[ "A 45-year-old man presents to the emergency room with fever and headache.", "He recently had a middle ear infection.", "On physical examination, when the head is passively flexed towards the chest, then flexion of the knee is observed.", "In addition, he reports that his headache increases after rotating his head horizontally.", "Lumbar puncture and CSF analysis were done." ]

[ "1. A 45-year-old man presents to the emergency room with fever and headache.", "2. He recently had a middle ear infection.", "3. On physical examination, when the head is passively flexed towards the chest, then flexion of the knee is observed.", "4. He reports that his headache increases after rotating his head horizontally.", "5. Lumbar puncture and CSF analysis were done." ]

[ "1. He recently had a middle ear infection.", "2. On physical examination, when the head is passively flexed towards the chest, flexion of the knee is observed.", "3. He reports that his headache increases after rotating his head horizontally.", "4. Lumbar puncture and CSF analysis were done." ]

[ "A 6-day-old female infant is brought to the emergency department because of poor feeding and irritability for two days.", "She was born at 39 weeks' gestation, and the pregnancy and delivery were uncomplicated.", "Her temperature is 39.2°C (102.6°F).", "She appears lethargic and makes occasional twitching movements in both upper extremities.", "The anterior fontanelle is soft and full.", "A lumbar puncture is performed and analysis of the cerebrospinal fluid shows increased protein and decreased glucose.", "Cerebrospinal fluid culture shows gram-positive, intracellular rods with tumbling motility." ]

[ "1. A 6-day-old female infant is brought to the emergency department.", "2. The infant has been poor feeding and irritable for two days.", "3. The infant was born at 39 weeks' gestation.", "4. The pregnancy and delivery were uncomplicated.", "5. The infant's temperature is 39.2°C (102.6°F).", "6. The infant appears lethargic and makes occasional twitching movements in both upper extremities.", "7. The anterior fontanelle is soft and full.", "8. A lumbar puncture is performed.", "9. Analysis of the cerebrospinal fluid shows increased protein and decreased glucose.", "10. Cerebrospinal fluid culture shows gram-positive, intracellular rods with tumbling motility." ]

[ "1. She was born at 39 weeks' gestation", "2. The pregnancy and delivery were uncomplicated", "3. Her temperature is 39.2°C (102.6°F)", "4. She appears lethargic", "5. She makes occasional twitching movements in both upper extremities", "6. The anterior fontanelle is soft and full", "7. A lumbar puncture is performed", "8. Analysis of the cerebrospinal fluid shows increased protein", "9. Analysis of the cerebrospinal fluid shows decreased glucose", "10. Cerebrospinal fluid culture shows gram-positive, intracellular rods", "11. Cerebrospinal fluid culture shows tumbling motility" ]

[ "A 64-year-old man has complaints of scrotal pain and swelling for the past 2 weeks.", "The pain is so severe that he is now unable to even sit comfortably for more than 5 minutes.", "Additionally, he complains of an inability to hold urine when he has an urge to urinate and of mild discomfort during urination.", "His medical history is significant for hypertension that is well-controlled with losartan.", "He smokes 1 pack of cigarettes every day and has been doing so for the past 25 years.", "On physical examination, swelling and erythema of the right hemiscrotal sac are evident, accompanied by intense tenderness with palpation of an indurated epididymis." ]

[ "1. Patient is 64 years old.", "2. Patient has had scrotal pain and swelling for 2 weeks.", "3. Patient has severe pain that prevents him from sitting for more than 5 minutes.", "4. Patient has difficulty holding urine when he has an urge to urinate.", "5. Patient has mild discomfort during urination.", "6. Patient has a history of hypertension, which is well-controlled with losartan.", "7. Patient smokes 1 pack of cigarettes every day for the past 25 years.", "8. On physical examination, swelling and erythema of the right hemiscrotal sac are evident.", "9. On physical examination, intense tenderness is present with palpation of an indurated epididymis." ]

[ "1. The pain is severe", "2. He is unable to sit comfortably for more than 5 minutes", "3. He complains of an inability to hold urine when he has an urge to urinate", "4. He complains of mild discomfort during urination", "5. His medical history includes hypertension", "6. His hypertension is well-controlled with losartan", "7. He smokes 1 pack of cigarettes every day", "8. He has been smoking for the past 25 years", "9. On physical examination, swelling and erythema of the right hemiscrotal sac are evident", "10. Intense tenderness with palpation of an indurated epididymis is present" ]

[ "A 65-year-old female is diagnosed with invasive ductal carcinoma of the breast.", "After a lumpectomy with a negative axillary lymph node dissection and subsequent radiation therapy, the patient is started on adjuvant chemotherapy with anastrozole." ]

[ "1. A 65-year-old female is diagnosed with invasive ductal carcinoma of the breast.", "2. A lumpectomy is performed.", "3. Axillary lymph node dissection is negative.", "4. The patient receives radiation therapy.", "5. The patient is started on adjuvant chemotherapy with anastrozole." ]

[ "1. The patient had a lumpectomy.", "2. The lumpectomy had a negative axillary lymph node dissection.", "3. The patient received subsequent radiation therapy.", "4. The patient is started on adjuvant chemotherapy.", "5. The adjuvant chemotherapy includes anastrozole." ]

[ "An 18-year-old man comes to the physician because of fatigue, back pain, and dark-colored urine for two days.", "He has no history of serious illness.", "He recently sprained his ankle playing basketball and has been taking ibuprofen as needed for pain.", "Physical examination shows scleral icterus.", "Laboratory studies show a hemoglobin concentration of 9.2 g/dL and serum lactate dehydrogenase concentration of 254 U/L.", "A photomicrograph of a peripheral blood smear with Wright's stain is shown." ]

[ "1. An 18-year-old man comes to the physician.", "2. He has fatigue, back pain, and dark-colored urine for two days.", "3. He has no history of serious illness.", "4. He recently sprained his ankle playing basketball.", "5. He has been taking ibuprofen as needed for pain.", "6. Physical examination shows scleral icterus.", "7. Laboratory studies show a hemoglobin concentration of 9.2 g/dL.", "8. Laboratory studies show a serum lactate dehydrogenase concentration of 254 U/L.", "9. A photomicrograph of a peripheral blood smear with Wright's stain is shown." ]

[ "1. No history of serious illness", "2. Recently sprained his ankle playing basketball", "3. Taking ibuprofen as needed for pain", "4. Physical examination shows scleral icterus", "5. Laboratory studies show hemoglobin concentration of 9.2 g/dL", "6. Laboratory studies show serum lactate dehydrogenase concentration of 254 U/L", "7. A photomicrograph of a peripheral blood smear with Wright's stain is shown" ]

[ "A 32-day-old boy is brought to the pediatrician with complaints of purulent discharge from the umbilicus and perianal ulceration for the past few days.", "A detailed developmental history reveals that he was born to a couple who had a non-consanguineous marriage.", "He was born by normal delivery at 39 weeks of gestation and his neonatal period was uneventful.", "His birth weight was 2.9 kg (6.3 lb) and he is exclusively breastfed.", "His parents also report that he has had 25–30 episodes of loose stools per day since his seventh day of life.", "His umbilical cord fell off on the 25th day of life.", "His temperature is 38.6ºC (101.4°F), pulse is 110/min, and respiratory rate is 35/min.", "On physical examination, erythema and induration are noted around the umbilicus and mild hepatosplenomegaly is present.", "His laboratory studies show: | Hemoglobin 12.9 gm/dL | Leukocyte count 73,000/mm3 | Platelet count 170,000/mm3 | Peripheral smear Hypersegmented polymorphs, toxic granules | Stool pH 6 | ." ]

[ "1. A 32-day-old boy is brought to the pediatrician with complaints of purulent discharge from the umbilicus and perianal ulceration for the past few days.", "2. The boy's parents had a non-consanguineous marriage.", "3. He was born by normal delivery at 39 weeks of gestation.", "4. His neonatal period was uneventful.", "5. His birth weight was 2.9 kg (6.3 lb).", "6. He is exclusively breastfed.", "7. His parents report that he has had 25–30 episodes of loose stools per day since his seventh day of life.", "8. His umbilical cord fell off on the 25th day of life.", "9. His temperature is 38.6ºC (101.4°F).", "10. His pulse is 110/min.", "11. His respiratory rate is 35/min.", "12. On physical examination, erythema and induration are noted around the umbilicus.", "13. Mild hepatosplenomegaly is present.", "14. His hemoglobin is 12.9 gm/dL.", "15. His leukocyte count is 73,000/mm3.", "16. His platelet count is 170,000/mm3.", "17. His peripheral smear shows hypersegmented polymorphs and toxic granules.", "18. His stool pH is 6." ]

[ "1. Detailed developmental history reveals non-consanguineous marriage of parents.", "2. Born by normal delivery at 39 weeks of gestation.", "3. Neonatal period was uneventful.", "4. Birth weight was 2.9 kg (6.3 lb).", "5. Exclusively breastfed.", "6. Experienced 25–30 episodes of loose stools per day since seventh day of life.", "7. Umbilical cord fell off on the 25th day of life.", "8. Temperature is 38.6ºC (101.4°F).", "9. Pulse is 110/min.", "10. Respiratory rate is 35/min.", "11. Physical examination shows erythema and induration around the umbilicus.", "12. Mild hepatosplenomegaly is present.", "13. Laboratory studies show: Hemoglobin 12.9 gm/dL.", "14. Leukocyte count 73,000/mm3.", "15. Platelet count 170,000/mm3.", "16. Peripheral smear shows hypersegmented polymorphs and toxic granules.", "17. Stool pH is 6." ]

[ "A 1-hour-old newborn male is evaluated in the delivery room.", "The infant was born at 37 weeks gestation to a 39-year-old G3.", "The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress.", "The infant was eventually delivered via Caesarean section.", "The mother declined all prenatal screening during this pregnancy.", "Upon delivery, the infant is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of bowel.", "His Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.", "His weight is 3.0 kg (6.6 lb), and his height and head circumference are in the 30th and 40th percentiles, respectively." ]

[ "1. Infant is 1-hour-old.", "2. Infant is male.", "3. Infant was born at 37 weeks gestation.", "4. Mother is 39-years-old.", "5. Mother is G3.", "6. Mother initially labored at home with a midwife.", "7. Mother was transferred to the hospital for failure to progress.", "8. Infant was delivered via Caesarean section.", "9. Mother declined all prenatal screening during this pregnancy.", "10. Infant has a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of bowel.", "11. Infant's Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.", "12. Infant's weight is 3.0 kg (6.6 lb).", "13. Infant's height is in the 30th percentile.", "14. Infant's head circumference is in the 40th percentile." ]

[ "1. The infant was born at 37 weeks gestation.", "2. The mother is 39 years old and has had 3 pregnancies.", "3. The mother initially labored at home with a midwife.", "4. The mother was transferred to the hospital for failure to progress.", "5. The infant was delivered via Caesarean section.", "6. The mother declined all prenatal screening during this pregnancy.", "7. Upon delivery, the infant is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of bowel.", "8. The infant's Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.", "9. The infant's weight is 3.0 kg (6.6 lb).", "10. The infant's height and head circumference are in the 30th and 40th percentiles, respectively." ]

[ "A 17-year-old girl is brought to the physician for a well-child examination.", "She is worried about gaining weight.", "She frequents buffet restaurants but feels guilty soon after.", "She has a history of burning her extremities with cigarettes.", "Her last menstrual period was 3 weeks ago.", "She attends high school and plays field hockey on the school team.", "She is at the 25th percentile for height, 12th percentile for weight, and 17th percentile for BMI.", "Examination shows bilateral parotid gland enlargement.", "Oropharyngeal examination shows perimolysis.", "The remainder of the examination shows no abnormalities." ]

[ "1. A 17-year-old girl is brought to the physician for a well-child examination.", "2. She is worried about gaining weight.", "3. She frequents buffet restaurants but feels guilty soon after.", "4. She has a history of burning her extremities with cigarettes.", "5. Her last menstrual period was 3 weeks ago.", "6. She attends high school.", "7. She plays field hockey on the school team.", "8. She is at the 25th percentile for height.", "9. She is at the 12th percentile for weight.", "10. She is at the 17th percentile for BMI.", "11. Examination shows bilateral parotid gland enlargement.", "12. Oropharyngeal examination shows perimolysis.", "13. The remainder of the examination shows no abnormalities." ]

[ "1. She is worried about gaining weight.", "2. She frequents buffet restaurants.", "3. She feels guilty soon after eating at buffet restaurants.", "4. She has a history of burning her extremities with cigarettes.", "5. Her last menstrual period was 3 weeks ago.", "6. She attends high school.", "7. She plays field hockey on the school team.", "8. She is at the 25th percentile for height.", "9. She is at the 12th percentile for weight.", "10. She is at the 17th percentile for BMI.", "11. Examination shows bilateral parotid gland enlargement.", "12. Oropharyngeal examination shows perimolysis.", "13. The remainder of the examination shows no abnormalities." ]

[ "A 37-year-old man with a history of depression has a two-year history of slowly worsening movement abnormalities characterized by rapid, involuntary, nonrepetitive movements involving his face, trunk, and limbs presents to clinic.", "He has also noted worsening of his depression, along with symptoms of increased anxiety and irritability.", "During the interview, his wife explains that he has suffered cognitive decline, most notably in the realm of executive function.", "On family history, you discover that his father suffered from a similar illness before dying at the age of 44." ]

[ "1. A 37-year-old man has a two-year history of slowly worsening movement abnormalities.", "2. The movement abnormalities involve his face, trunk, and limbs.", "3. The man has a history of depression.", "4. The man has worsening of his depression, along with symptoms of increased anxiety and irritability.", "5. The man's wife explains that he has suffered cognitive decline, most notably in the realm of executive function.", "6. The man's father suffered from a similar illness.", "7. The man's father died at the age of 44." ]

[ "1. The patient has noted worsening of his depression.", "2. The patient has symptoms of increased anxiety.", "3. The patient has symptoms of irritability.", "4. The patient has suffered cognitive decline.", "5. The cognitive decline is most notable in the realm of executive function.", "6. The patient's father suffered from a similar illness.", "7. The patient's father died at the age of 44." ]

[ "A 55-year-old man with a history of diabetes and hypertension presents to the emergency department when he found half of his face paralyzed this morning.", "The patient was last seen normal the night before by his wife and woke up with these symptoms.", "He has a past medical history of diabetes and hypertension and is not currently taking any medications for these conditions.", "His temperature is 98.5°F (36.9°C), blood pressure is 177/118 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for an inability for the patient to move any part of his face on the right side.", "The rest of his neurological exam is within normal limits." ]

[ "1. Patient is 55 years old.", "2. Patient has a history of diabetes and hypertension.", "3. Patient was last seen normal the night before by his wife.", "4. Patient woke up with half of his face paralyzed.", "5. Patient is not currently taking any medications for diabetes or hypertension.", "6. Patient's temperature is 98.5°F (36.9°C).", "7. Patient's blood pressure is 177/118 mmHg.", "8. Patient's pulse is 90/min.", "9. Patient's respirations are 15/min.", "10. Patient's oxygen saturation is 99% on room air.", "11. Patient is unable to move any part of his face on the right side.", "12. Patient's neurological exam is within normal limits." ]

[ "1. The patient was last seen normal the night before by his wife.", "2. The patient woke up with symptoms.", "3. The patient has a past medical history of diabetes and hypertension.", "4. The patient is not currently taking any medications for diabetes and hypertension.", "5. The patient's temperature is 98.5°F (36.9°C).", "6. The patient's blood pressure is 177/118 mmHg.", "7. The patient's pulse is 90/min.", "8. The patient's respirations are 15/min.", "9. The patient's oxygen saturation is 99% on room air.", "10. The patient has an inability to move any part of his face on the right side.", "11. The rest of the patient's neurological exam is within normal limits." ]

[ "A newborn boy develops excessive bilious vomiting 4 hours after delivery.", "The infant was born vaginally to a 29-year-old mother (gravida 2, para 1) at 38 weeks gestation.", "History was significant for polyhydramnios detected at 32 weeks and monitored for the duration of gestation.", "He was put to the breast right after birth and sucked actively.", "He still has not passed meconium.", "The patient’s vital signs include: blood pressure 77/50 mm Hg, heart rate 128/min, respiratory rate 37/min, and temperature 36.4℃ (97.5℉).", "On physical examination, the newborn appears fussy and mildly dehydrated.", "His abdomen appears rounded, soft and nontender on palpation, with no palpable organomegaly or masses." ]

[ "1. A newborn boy was born vaginally.", "2. The mother was 29 years old.", "3. This was her second pregnancy.", "4. She had one prior delivery.", "5. The infant was born at 38 weeks gestation.", "6. Polyhydramnios was detected at 32 weeks gestation.", "7. The infant was put to the breast right after birth.", "8. He sucked actively.", "9. He has not passed meconium.", "10. The infant developed excessive bilious vomiting 4 hours after delivery.", "11. His blood pressure is 77/50 mm Hg.", "12. His heart rate is 128/min.", "13. His respiratory rate is 37/min.", "14. His temperature is 36.4℃ (97.5℉).", "15. On physical examination, the newborn appears fussy and mildly dehydrated.", "16. His abdomen appears rounded, soft and nontender on palpation.", "17. There is no palpable organomegaly or masses." ]

[ "1. The infant was born vaginally.", "2. The mother is 29 years old.", "3. The mother is gravida 2, para 1.", "4. The infant was born at 38 weeks gestation.", "5. History was significant for polyhydramnios detected at 32 weeks.", "6. Polyhydramnios was monitored for the duration of gestation.", "7. The infant was put to the breast right after birth.", "8. The infant sucked actively.", "9. The infant has not passed meconium.", "10. The patient’s blood pressure is 77/50 mm Hg.", "11. The patient’s heart rate is 128/min.", "12. The patient’s respiratory rate is 37/min.", "13. The patient’s temperature is 36.4℃ (97.5℉).", "14. On physical examination, the newborn appears fussy.", "15. On physical examination, the newborn appears mildly dehydrated.", "16. The infant's abdomen appears rounded.", "17. The infant's abdomen is soft and nontender on palpation.", "18. There is no palpable organomegaly or masses in the infant's abdomen." ]

[ "The patient is counselled about her risk of thyroid malignancy.", "Serum studies show: | Na+ 138 mEq/L | K+ 4.1 mEq/L | Cl- 101 mEq/L | TSH 0.03 μU/mL | Calcium 9 mg/dL | ." ]

[ "1. The patient is counselled about her risk of thyroid malignancy.", "2. Serum studies show Na+ 138 mEq/L.", "3. Serum studies show K+ 4.1 mEq/L.", "4. Serum studies show Cl- 101 mEq/L.", "5. Serum studies show TSH 0.03 μU/mL.", "6. Serum studies show Calcium 9 mg/dL." ]

[ "1. Serum Na+ level is 138 mEq/L.", "2. Serum K+ level is 4.1 mEq/L.", "3. Serum Cl- level is 101 mEq/L.", "4. Serum TSH level is 0.03 μU/mL.", "5. Serum calcium level is 9 mg/dL." ]

[ "An 18-month-old girl is brought to her pediatrician because of swelling in her hands and feet.", "Her mother is concerned because she has been inconsolable for the last 8 hours.", "The mother adds that the girl has been getting tired easily recently.", "The vital signs include: temperature 38.0°C (100.4°F), blood pressure 90/55 mm Hg, and pulse 122/min.", "Gentle palpation of the metacarpal and metatarsal bones causes the infant to scream.", "The laboratory evaluation is remarkable for mild anemia, leukocytosis, and increased reticulocyte count.", "Her peripheral blood smear is shown in the picture." ]

[ "1. An 18-month-old girl is brought to her pediatrician.", "2. The girl has swelling in her hands and feet.", "3. The girl has been inconsolable for the last 8 hours.", "4. The girl has been getting tired easily recently.", "5. The girl's temperature is 38.0°C (100.4°F).", "6. The girl's blood pressure is 90/55 mm Hg.", "7. The girl's pulse is 122/min.", "8. Gentle palpation of the metacarpal and metatarsal bones causes the infant to scream.", "9. The laboratory evaluation is remarkable for mild anemia.", "10. The laboratory evaluation is remarkable for leukocytosis.", "11. The laboratory evaluation is remarkable for increased reticulocyte count.", "12. The peripheral blood smear is shown in the picture." ]

[ "1. The girl has been inconsolable for the last 8 hours.", "2. The girl has been getting tired easily recently.", "3. Vital signs: temperature 38.0°C (100.4°F), blood pressure 90/55 mm Hg, and pulse 122/min.", "4. Gentle palpation of the metacarpal and metatarsal bones causes the infant to scream.", "5. Laboratory evaluation shows mild anemia, leukocytosis, and increased reticulocyte count.", "6. Peripheral blood smear is shown in the picture." ]

[ "A 34-year-old gravida-1 at 8 weeks gestation seeks evaluation for a fever and sore throat for 3 days.", "She also reports generalized body pain and fatigue over this period.", "She was diagnosed with Graves’ disease 6 months ago.", "Before conception, methimazole was switched to propylthiouracil.", "She appears ill.", "The vital signs include: axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg.", "A 1 × 1 cm ulcer is seen on the side of the tongue.", "The ulcer is tender with surrounding erythema.", "Examination of the neck, lungs, heart, and abdomen shows no abnormalities.", "The laboratory studies show the following: | Hemoglobin 13.5 g/dL | Mean corpuscular volume 90 μm3 | Leukocyte count 2,500/mm3 | Segmented neutrophils 5% | Lymphocytes 88% | Platelet count 240,000/mm3 | Alanine aminotransferase 18 U/L | Aspartate transaminase 16 U/L | ." ]

[ "1. Patient is a 34-year-old gravida-1 at 8 weeks gestation.", "2. Patient has had a fever and sore throat for 3 days.", "3. Patient also reports generalized body pain and fatigue over this period.", "4. Patient was diagnosed with Graves’ disease 6 months ago.", "5. Before conception, methimazole was switched to propylthiouracil.", "6. Patient appears ill.", "7. Vital signs include axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg.", "8. Examination of the neck, lungs, heart, and abdomen shows no abnormalities.", "9. A 1 × 1 cm ulcer is seen on the side of the tongue.", "10. The ulcer is tender with surrounding erythema.", "11. Laboratory studies show hemoglobin 13.5 g/dL.", "12. Laboratory studies show mean corpuscular volume 90 μm3.", "13. Laboratory studies show leukocyte count 2,500/mm3.", "14. Laboratory studies show segmented neutrophils 5%.", "15. Laboratory studies show lymphocytes 88%.", "16. Laboratory studies show platelet count 240,000/mm3.", "17. Laboratory studies show alanine aminotransferase 18 U/L.", "18. Laboratory studies show aspartate transaminase 16 U/L." ]

[ "1. The patient reports generalized body pain and fatigue over a period of time.", "2. The patient was diagnosed with Graves’ disease 6 months ago.", "3. Methimazole was switched to propylthiouracil before conception.", "4. The patient appears ill.", "5. Vital signs include: axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg.", "6. A 1 × 1 cm ulcer is seen on the side of the tongue.", "7. The ulcer is tender with surrounding erythema.", "8. Examination of the neck, lungs, heart, and abdomen shows no abnormalities.", "9. Laboratory studies show: Hemoglobin 13.5 g/dL, Mean corpuscular volume 90 μm3, Leukocyte count 2,500/mm3, Segmented neutrophils 5%, Lymphocytes 88%, Platelet count 240,000/mm3, Alanine aminotransferase 18 U/L, Aspartate transaminase 16 U/L." ]

[ "A 27-year-old man comes to the physician because of a 1-week history of fever and pain with urination.", "His temperature is 39°C (102.2°F).", "Physical examination shows no abnormalities.", "A photomicrograph of a urine sample is shown." ]

[ "1. A 27-year-old man comes to the physician.", "2. He has a 1-week history of fever and pain with urination.", "3. His temperature is 39°C (102.2°F).", "4. Physical examination shows no abnormalities.", "5. A photomicrograph of a urine sample is shown." ]

[ "1. His temperature is 39°C (102.2°F).", "2. Physical examination shows no abnormalities.", "3. A photomicrograph of a urine sample is shown." ]

[ "Twelve hours after undergoing uncomplicated total knee replacement, a 55-year-old man develops increasing anxiety, agitation, hand tremor, and nausea.", "He told the nurse he saw a bear in his room.", "His pain has been controlled with intravenous morphine.", "He has a history of advanced liver disease.", "He drinks 7 cans of beer daily.", "He is diaphoretic.", "His temperature is 37.6°C (99.7°F), pulse is 118/min, respirations are 18/min, and blood pressure is 146/92 mm Hg." ]

[ "1. A 55-year-old man underwent uncomplicated total knee replacement 12 hours ago.", "2. He has developed increasing anxiety, agitation, hand tremor, and nausea.", "3. He told the nurse he saw a bear in his room.", "4. His pain has been controlled with intravenous morphine.", "5. He has a history of advanced liver disease.", "6. He drinks 7 cans of beer daily.", "7. He is diaphoretic.", "8. His temperature is 37.6°C (99.7°F).", "9. His pulse is 118/min.", "10. His respirations are 18/min.", "11. His blood pressure is 146/92 mm Hg." ]

[ "1. He told the nurse he saw a bear in his room.", "2. His pain has been controlled with intravenous morphine.", "3. He has a history of advanced liver disease.", "4. He drinks 7 cans of beer daily.", "5. He is diaphoretic.", "6. His temperature is 37.6°C (99.7°F).", "7. His pulse is 118/min.", "8. His respirations are 18/min.", "9. His blood pressure is 146/92 mm Hg." ]

[ "A 45-year-old woman comes to the physician’s office with complaints of jaw pain.", "When she eats, yawns, or rubs her jaw, she gets intense, shooting pains down the left side of her jaw, including her lower lip and chin.", "These episodes last about 30 seconds and have recurred about 10 times per day for the last month.", "She finds these episodes extremely distressing and comes to the physician’s office in hope of finding a treatment.", "The patient denies any locking of her jaw.", "Physical exam is not notable for any tenderness to palpation over the jaw.", "She has no crepitus in her temporomandibular joint.", "The patient is able to open and close her jaw without pain." ]

[ "1. A 45-year-old woman comes to the physician's office with complaints of jaw pain.", "2. When she eats, yawns, or rubs her jaw, she gets intense, shooting pains down the left side of her jaw, including her lower lip and chin.", "3. These episodes last about 30 seconds.", "4. These episodes have recurred about 10 times per day for the last month.", "5. She finds these episodes extremely distressing and comes to the physician's office in hope of finding a treatment.", "6. The patient denies any locking of her jaw.", "7. Physical exam is not notable for any tenderness to palpation over the jaw.", "8. She has no crepitus in her temporomandibular joint.", "9. The patient is able to open and close her jaw without pain." ]

[ "1. When she eats, yawns, or rubs her jaw, she gets intense, shooting pains down the left side of her jaw, including her lower lip and chin.", "2. These episodes last about 30 seconds and have recurred about 10 times per day for the last month.", "3. She finds these episodes extremely distressing and comes to the physician’s office in hope of finding a treatment.", "4. The patient denies any locking of her jaw.", "5. Physical exam is not notable for any tenderness to palpation over the jaw.", "6. She has no crepitus in her temporomandibular joint.", "7. The patient is able to open and close her jaw without pain." ]

[ "A 64-year-old woman presents to the hospital for chemotherapy.", "She has newly diagnosed acute myeloid leukemia.", "She is due to receive treatment with bendamustine for 2 days.", "On day 2 of her treatment, the patient complains of intense pain in her right great toe.", "On physical exam, the metatarsophalangeal joint of the 1st toe is warm, erythematous, swollen, and tender to both movement and palpation.", "An arthrocentesis is performed that reveals negatively birefringent needle-shaped crystals under polarized light.", "A Gram stain of the synovial fluid is negative." ]

[ "1. A 64-year-old woman presents to the hospital for chemotherapy.", "2. She has newly diagnosed acute myeloid leukemia.", "3. She is due to receive treatment with bendamustine for 2 days.", "4. On day 2 of her treatment, the patient complains of intense pain in her right great toe.", "5. On physical exam, the metatarsophalangeal joint of the 1st toe is warm, erythematous, swollen, and tender to both movement and palpation.", "6. An arthrocentesis is performed.", "7. Negatively birefringent needle-shaped crystals are seen under polarized light.", "8. A Gram stain of the synovial fluid is negative." ]

[ "1. She has newly diagnosed acute myeloid leukemia.", "2. She is due to receive treatment with bendamustine for 2 days.", "3. On day 2 of her treatment, the patient complains of intense pain in her right great toe.", "4. On physical exam, the metatarsophalangeal joint of the 1st toe is warm, erythematous, swollen, and tender to both movement and palpation.", "5. An arthrocentesis is performed that reveals negatively birefringent needle-shaped crystals under polarized light.", "6. A Gram stain of the synovial fluid is negative." ]

[ "A 29-year-old woman comes to the physician with complaints of fever, headache, and rash, which have gradually worsened over the past 6 days.", "The patient informs the physician that the rash appeared after 2 days of fever.", "The rash started at the wrists and ankles and then gradually spread to the trunk, palms, and soles.", "On examination, the physician notes a maculopapular rash as shown in the image below.", "Vital signs show a temperature of 39.4°C (103.0°F), a blood pressure of 110/70 mm Hg, and a pulse rate of 86/min." ]

[ "1. A 29-year-old woman comes to the physician.", "2. She has complaints of fever, headache, and rash.", "3. The symptoms have gradually worsened over the past 6 days.", "4. The patient informs the physician that the rash appeared after 2 days of fever.", "5. The rash started at the wrists and ankles.", "6. The rash then gradually spread to the trunk, palms, and soles.", "7. On examination, the physician notes a maculopapular rash.", "8. Vital signs show a temperature of 39.4°C (103.0°F).", "9. Vital signs show a blood pressure of 110/70 mm Hg.", "10. Vital signs show a pulse rate of 86/min." ]

[ "1. The patient reports that the rash appeared after 2 days of fever.", "2. The rash began at the wrists and ankles and then spread to the trunk, palms, and soles.", "3. The physician observes a maculopapular rash during the examination.", "4. Vital signs show a temperature of 39.4°C (103.0°F).", "5. The patient's blood pressure is 110/70 mm Hg.", "6. The patient's pulse rate is 86/min." ]

[ "A 25-year-old man presents to the emergency department after paramedics picked him up from an electronic music festival.", "His temperature is 103°F (39.4°C), blood pressure is 167/105 mmHg, and pulse is 122/min.", "On physical exam, the patient is highly alert, agitated, and diaphoretic.", "Laboratory testing is significant for a serum sodium concentration of 130 mEq/L." ]

[ "1. A 25-year-old man presented to the emergency department. ", "2. Paramedics picked him up from an electronic music festival. ", "3. His temperature was 103°F (39.4°C). ", "4. His blood pressure was 167/105 mmHg. ", "5. His pulse was 122/min. ", "6. On physical exam, the patient was highly alert, agitated, and diaphoretic. ", "7. Laboratory testing was significant for a serum sodium concentration of 130 mEq/L." ]

[ "1. Temperature: 103°F (39.4°C)", "2. Blood pressure: 167/105 mmHg", "3. Pulse: 122/min", "4. Patient is highly alert", "5. Patient is agitated", "6. Patient is diaphoretic", "7. Serum sodium concentration: 130 mEq/L" ]

[ "A 1-day-old male is seen in the neonatal intensive care unit for respiratory distress.", "He was born at 37 weeks to a 24-year-old G3P11011 Rh- mother who had no prenatal care.", "On physical examination, temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 120/min, respirations are 26/min, and pulse oximetry is 92% on room air.", "There is abdominal distention with a positive fluid wave.", "Laboratory results are as follows: | | Serum: | Alkaline phosphatase: 80 U/L | ALT: 33 U/L | AST: 32 U/L | Bilirubin (total): 10 mg/dL | Bilirubin (conjugated): 0.2 mg/dL | Amylase: 76 U/L | | Leukocyte count: 5,000/mm^3 with normal differential | Hemoglobin: 8 g/dL | Platelet count: 200,000/mm^3 | Mean corpuscular volume: 80 µm^3 | Reticulocyte count: 3% | | ." ]

[ "1. Patient is a 1-day-old male.", "2. Patient is in the neonatal intensive care unit for respiratory distress.", "3. Patient was born at 37 weeks.", "4. Patient's mother is 24-years-old.", "5. Patient's mother is G3P11011 Rh-.", "6. Patient's mother had no prenatal care.", "7. Patient's temperature is 99°F (37.2°C).", "8. Patient's blood pressure is 120/85 mmHg.", "9. Patient's pulse is 120/min.", "10. Patient's respirations are 26/min.", "11. Patient's pulse oximetry is 92% on room air.", "12. Patient has abdominal distention with a positive fluid wave.", "13. Patient's serum alkaline phosphatase is 80 U/L.", "14. Patient's serum ALT is 33 U/L.", "15. Patient's serum AST is 32 U/L.", "16. Patient's total bilirubin is 10 mg/dL.", "17. Patient's conjugated bilirubin is 0.2 mg/dL.", "18. Patient's amylase is 76 U/L.", "19. Patient's leukocyte count is 5,000/mm^3 with normal differential.", "20. Patient's hemoglobin is 8 g/dL.", "21. Patient's platelet count is 200,000/mm^3.", "22. Patient's mean corpuscular volume is 80 µm^3.", "23. Patient's reticulocyte count is 3%." ]

[ "1. The patient was born at 37 weeks.", "2. The mother is 24 years old.", "3. The mother is G3P11011.", "4. The mother is Rh-.", "5. The mother had no prenatal care.", "6. The patient's temperature is 99°F (37.2°C).", "7. The patient's blood pressure is 120/85 mmHg.", "8. The patient's pulse is 120/min.", "9. The patient's respirations are 26/min.", "10. The patient's pulse oximetry is 92% on room air.", "11. There is abdominal distention with a positive fluid wave.", "12. Serum alkaline phosphatase is 80 U/L.", "13. Serum ALT is 33 U/L.", "14. Serum AST is 32 U/L.", "15. Serum total bilirubin is 10 mg/dL.", "16. Serum conjugated bilirubin is 0.2 mg/dL.", "17. Serum amylase is 76 U/L.", "18. Leukocyte count is 5,000/mm^3 with normal differential.", "19. Hemoglobin is 8 g/dL.", "20. Platelet count is 200,000/mm^3.", "21. Mean corpuscular volume is 80 µm^3.", "22. Reticulocyte count is 3%." ]

[ "Study X examined the relationship between coffee consumption and lung cancer.", "The authors of Study X retrospectively reviewed patients' reported coffee consumption and found that drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer.", "The same study in lab mice; however, did not come to a similar conclusion." ]

[ "1. Study X examined the relationship between coffee consumption and lung cancer.", "2. The authors of Study X retrospectively reviewed patients' reported coffee consumption.", "3. Drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer.", "4. The same study in lab mice did not come to a similar conclusion." ]

[ "1. The authors of Study X retrospectively reviewed patients' reported coffee consumption.", "2. Drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer.", "3. The same study in lab mice did not come to a similar conclusion." ]

[ "A 2-day-old boy was born at 38 weeks gestation to a 37-year-old woman by vaginal delivery.", "Since birth, the boy has had difficulty latching onto the breast but has not vomited or passed meconium.", "Examination reveals a flat facial profile with epicanthal eyelids, low-set earlobes, and a transverse crease on each palm.", "The abdomen is distended with absent breath sounds in the hypogastric region.", "A digital rectal examination shows a patent anal canal and is followed by a projected expulsion of gas and stool." ]

[ "1. A 2-day-old boy was born at 38 weeks gestation.", "2. The mother is 37 years old.", "3. The delivery was vaginal.", "4. The boy has difficulty latching onto the breast.", "5. The boy has not vomited or passed meconium.", "6. Examination reveals a flat facial profile with epicanthal eyelids.", "7. Examination reveals low-set earlobes.", "8. Examination reveals a transverse crease on each palm.", "9. The abdomen is distended.", "10. Breath sounds are absent in the hypogastric region.", "11. A digital rectal examination shows a patent anal canal.", "12. Gas and stool are projected after the digital rectal examination." ]

[ "1. The boy has had difficulty latching onto the breast since birth.", "2. The boy has not vomited or passed meconium.", "3. Examination reveals a flat facial profile.", "4. Examination reveals epicanthal eyelids.", "5. Examination reveals low-set earlobes.", "6. Examination reveals a transverse crease on each palm.", "7. The abdomen is distended.", "8. Absent breath sounds in the hypogastric region.", "9. A digital rectal examination shows a patent anal canal.", "10. A digital rectal examination is followed by a projected expulsion of gas and stool." ]

[ "An otherwise healthy 23-year-old newly-married woman comes to the physician because of a 6-day history of discomfort in her vaginal area during and after sexual intercourse.", "Her last menstrual period was 3 weeks ago.", "Two years ago, she was diagnosed with genital herpes which was treated with acyclovir.", "She has been in a monogamous relationship for the past year and has been using an intrauterine device for contraception for the past month.", "Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus with no signs of inflammation.", "Speculum examination causes her discomfort but shows no abnormalities." ]

[ "1. Patient is a 23-year-old newly-married woman.", "2. Patient has a 6-day history of discomfort in her vaginal area during and after sexual intercourse.", "3. Patient's last menstrual period was 3 weeks ago.", "4. Patient was diagnosed with genital herpes two years ago and was treated with acyclovir.", "5. Patient has been in a monogamous relationship for the past year.", "6. Patient has been using an intrauterine device for contraception for the past month.", "7. Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus with no signs of inflammation.", "8. Speculum examination causes her discomfort but shows no abnormalities." ]

[ "1. Her last menstrual period was 3 weeks ago.", "2. Two years ago, she was diagnosed with genital herpes.", "3. The genital herpes was treated with acyclovir.", "4. She has been in a monogamous relationship for the past year.", "5. She has been using an intrauterine device for contraception for the past month.", "6. Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus.", "7. There are no signs of inflammation in the mass.", "8. Speculum examination causes her discomfort.", "9. The speculum examination shows no abnormalities." ]