Datasets:

---

stellalisy

/

mediQ

like 0

[ "A 22-year-old professional softball player is undergoing an annual check-up.", "Her medical history is significant for hallux valgus and scoliosis.", "She additionally notes that she frequently has bumps and bruises from playing softball, but she has no injuries today.", "Her family history is significant for heart disease.", "The patient's blood pressure is 110/70 mm Hg, heart rate is 78/min, and respiratory rate is 15/min.", "A physical examination is unremarkable except for an indurated palpable mass on her left breast.", "A biopsy of the mass is performed." ]

[ "1. A 22-year-old professional softball player is undergoing an annual check-up.", "2. Her medical history is significant for hallux valgus and scoliosis.", "3. She additionally notes that she frequently has bumps and bruises from playing softball.", "4. She has no injuries today.", "5. Her family history is significant for heart disease.", "6. The patient's blood pressure is 110/70 mm Hg.", "7. The patient's heart rate is 78/min.", "8. The patient's respiratory rate is 15/min.", "9. A physical examination is unremarkable except for an indurated palpable mass on her left breast.", "10. A biopsy of the mass is performed." ]

[ "1. Her medical history includes hallux valgus and scoliosis.", "2. She frequently has bumps and bruises from playing softball.", "3. She has no injuries today.", "4. Her family history includes heart disease.", "5. Her blood pressure is 110/70 mm Hg.", "6. Her heart rate is 78/min.", "7. Her respiratory rate is 15/min.", "8. A physical examination is unremarkable except for an indurated palpable mass on her left breast.", "9. A biopsy of the mass is performed." ]

[ "A 5-month-old male infant is brought to the physician by his parents for the evaluation of a progressive enlargement of his head circumference.", "His parents report that he has been healthy except for an episode of tonsillitis 3 months ago treated with penicillin.", "The patient was born at term by a lower segment transverse cesarean section because of a transverse lie.", "He has met all developmental milestones.", "His immunizations are up-to-date.", "The patient is at the 50th percentile for length, 50th percentile for weight, and 95th percentile for head circumference.", "He appears well-nourished.", "His temperature is 37°C (98.6°F), pulse is 120/min, and blood pressure is 90/60 mm Hg.", "Physical examination shows a tense anterior fontanelle.", "The eyes deviate inferiorly and the eyelids are retracted." ]

[ "1. Patient is a 5-month-old male infant.", "2. Parents brought him to the physician for evaluation of progressive enlargement of head circumference.", "3. Patient had an episode of tonsillitis 3 months ago, treated with penicillin.", "4. Patient was born at term by lower segment transverse cesarean section because of transverse lie.", "5. Patient has met all developmental milestones.", "6. Patient's immunizations are up-to-date.", "7. Patient is at 50th percentile for length.", "8. Patient is at 50th percentile for weight.", "9. Patient is at 95th percentile for head circumference.", "10. Patient appears well-nourished.", "11. Patient's temperature is 37°C (98.6°F).", "12. Patient's pulse is 120/min.", "13. Patient's blood pressure is 90/60 mm Hg.", "14. Physical examination shows a tense anterior fontanelle.", "15. Patient's eyes deviate inferiorly.", "16. Patient's eyelids are retracted." ]

[ "1. The patient had an episode of tonsillitis 3 months ago.", "2. The tonsillitis was treated with penicillin.", "3. The patient was born at term.", "4. The patient was born by a lower segment transverse cesarean section.", "5. The cesarean section was due to a transverse lie.", "6. The patient has met all developmental milestones.", "7. The patient's immunizations are up-to-date.", "8. The patient is at the 50th percentile for length.", "9. The patient is at the 50th percentile for weight.", "10. The patient is at the 95th percentile for head circumference.", "11. The patient appears well-nourished.", "12. The patient's temperature is 37°C (98.6°F).", "13. The patient's pulse is 120/min.", "14. The patient's blood pressure is 90/60 mm Hg.", "15. Physical examination shows a tense anterior fontanelle.", "16. The patient's eyes deviate inferiorly.", "17. The patient's eyelids are retracted." ]

[ "A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features.", "The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit.", "Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin.", "At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL.", "In addition, her routine third trimester culture for group B Streptococcus was positive.", "At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit.", "She denied rupture of membranes or vaginal bleeding.", "Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication.", "Fetal heart rate tracing had been reassuring throughout her admission.", "Apgar scores at 1 and 5 minutes were 7 and 10.", "After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min.", "When the first feeding is attempted, he does not latch and begins to shake his arms and legs.", "After 20 seconds, the episode ends and the infant becomes lethargic." ]

[ "1. Patient is a 37-year-old G1P1001.", "2. Patient delivers a male infant at 9 pounds 6 ounces.", "3. Delivery is via C-section for preeclampsia with severe features.", "4. Patient has a history of type II diabetes.", "5. Patient's hemoglobin A1c at first obstetric visit is 12.8%.", "6. Patient was taking metformin before this pregnancy.", "7. Patient was started on insulin during this pregnancy.", "8. Patient's glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL.", "9. Patient's routine third trimester culture for group B Streptococcus was positive.", "10. Patient's blood pressure at 38 weeks and 4 days gestation is 176/103 mmHg.", "11. Patient reported a severe headache during a routine obstetric visit.", "12. Patient denied rupture of membranes or vaginal bleeding.", "13. Patient's physician sent her to the obstetric triage unit.", "14. After failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication.", "15. Fetal heart rate tracing had been reassuring throughout her admission.", "16. Apgar scores at 1 and 5 minutes were 7 and 10.", "17. After one hour, the infant is found to be jittery.", "18. Infant's temperature is 96.1°F (35.6°C).", "19. Infant's blood pressure is 80/50 mmHg.", "20. Infant's pulse is 110/min.", "21. Infant's respirations are 60/min.", "22. When the first feeding is attempted, he does not latch and begins to shake his arms and legs.", "23. After 20 seconds, the episode ends and the infant becomes lethargic." ]

[ "1. The mother has a history of type II diabetes.", "2. The mother's hemoglobin A1c was 12.8% at her first obstetric visit.", "3. Before this pregnancy, the mother was taking metformin.", "4. During this pregnancy, the mother was started on insulin.", "5. The mother's glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL.", "6. The routine third trimester culture for group B Streptococcus was positive.", "7. At 38 weeks and 4 days gestation, the mother had a blood pressure of 176/103 mmHg.", "8. The mother reported a severe headache during a routine obstetric visit.", "9. The mother denied rupture of membranes or vaginal bleeding.", "10. The physician sent the mother to the obstetric triage unit.", "11. Several intravenous doses of labetalol failed to lower the mother's blood pressure and relieve her headache.", "12. A C-section was performed without complication.", "13. The fetal heart rate tracing had been reassuring throughout the mother's admission.", "14. The infant's Apgar scores at 1 and 5 minutes were 7 and 10.", "15. After one hour, the infant was found to be jittery.", "16. The infant's temperature was 96.1°F (35.6°C).", "17. The infant's blood pressure was 80/50 mmHg.", "18. The infant's pulse was 110/min.", "19. The infant's respirations were 60/min.", "20. When the first feeding was attempted, the infant did not latch and began to shake his arms and legs.", "21. After 20 seconds, the episode ended and the infant became lethargic." ]

[ "A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs.", "He also now needs three pillows at night to sleep.", "Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses.", "The cardiologist is very concerned and immediately refers the patient for a surgical workup." ]

[ "1. A 65-year-old male presents to his cardiologist.", "2. The patient has increasing episodes of dyspnea after climbing stairs.", "3. The patient now needs three pillows at night to sleep.", "4. Physical examination reveals an early diastolic murmur.", "5. The murmur is best appreciated at the left sternal border.", "6. The patient has bounding peripheral pulses.", "7. The cardiologist is very concerned.", "8. The cardiologist immediately refers the patient for a surgical workup." ]

[ "1. The patient now needs three pillows at night to sleep.", "2. Physical examination reveals an early diastolic murmur.", "3. The murmur is best appreciated at the left sternal border.", "4. The patient has bounding peripheral pulses.", "5. The cardiologist is very concerned.", "6. The cardiologist immediately refers the patient for a surgical workup." ]

[ "A 42-year-old overweight restaurant waiter develops excruciating pain in the heel of his right foot.", "Symptoms are most intense after getting out of bed but get better after walking.", "On physical examination, both feet have a flat medial arch.", "There is tenderness to palpation along the inner aspect of the right heel bone, minimal active dorsiflexion, and pain at passive dorsiflexion.", "X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia.", "The spur is also present in the comparison film of the left foot.", "He is diagnosed with plantar fasciitis and is told to lose weight, rest, use ice, and take anti-inflammatory medications." ]

[ "1. A 42-year-old restaurant waiter is overweight.", "2. He has excruciating pain in the heel of his right foot.", "3. Symptoms are most intense after getting out of bed but get better after walking.", "4. On physical examination, both feet have a flat medial arch.", "5. There is tenderness to palpation along the inner aspect of the right heel bone.", "6. There is minimal active dorsiflexion and pain at passive dorsiflexion.", "7. X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia.", "8. The spur is also present in the comparison film of the left foot.", "9. He is diagnosed with plantar fasciitis.", "10. He is told to lose weight, rest, use ice, and take anti-inflammatory medications." ]

[ "1. Symptoms are most intense after getting out of bed but get better after walking.", "2. On physical examination, both feet have a flat medial arch.", "3. There is tenderness to palpation along the inner aspect of the right heel bone.", "4. Minimal active dorsiflexion is observed.", "5. Pain at passive dorsiflexion is present.", "6. X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia.", "7. The spur is also present in the comparison film of the left foot.", "8. The patient is diagnosed with plantar fasciitis.", "9. The patient is advised to lose weight.", "10. The patient is advised to rest.", "11. The patient is advised to use ice.", "12. The patient is advised to take anti-inflammatory medications." ]

[ "A 7-year-old boy is brought to the physician because of decreased vision, hearing, and speaking over the past 3 months.", "During this time, he has also had difficulty walking, concentrating, drawing, and feeding himself.", "His maternal male cousin had similar complaints and died at the age of 5 years.", "Examination shows hyperpigmented skin and nails.", "His speech is dysarthric.", "Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities.", "Fundoscopy shows optic atrophy." ]

[ "1. A 7-year-old boy is brought to the physician.", "2. The boy has had decreased vision, hearing, and speaking over the past 3 months.", "3. The boy has also had difficulty walking, concentrating, drawing, and feeding himself.", "4. His maternal male cousin had similar complaints and died at the age of 5 years.", "5. Examination shows hyperpigmented skin and nails.", "6. His speech is dysarthric.", "7. Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities.", "8. Fundoscopy shows optic atrophy." ]

[ "1. Patient has difficulty walking, concentrating, drawing, and feeding himself.", "2. Maternal male cousin had similar complaints and died at the age of 5 years.", "3. Examination shows hyperpigmented skin and nails.", "4. Patient's speech is dysarthric.", "5. Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities.", "6. Fundoscopy shows optic atrophy." ]

[ "A 55-year-old man comes to the physician because of a 4-month history of nocturia.", "He wakes up twice each night to urinate.", "He has no history of serious illness.", "He takes no medication.", "His younger brother was diagnosed with testicular cancer at the age of 35 years.", "Rectal examination shows a smooth, symmetrical prostate without nodules.", "The physician offers to discuss the advantages and limitations of the prostate specific antigen (PSA) test in diagnosing prostate cancer.", "He mentions that a a serum PSA of 4 ng/mL is generally used as a cutoff value.", "At this cutoff, the test has a sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-risk prostate cancer, with a specificity of 91%.", "In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30% and the negative predictive value for PSA ≤ 4 ng/mL at 85%." ]

[ "1. A 55-year-old man comes to the physician because of a 4-month history of nocturia.", "2. He wakes up twice each night to urinate.", "3. He has no history of serious illness.", "4. He takes no medication.", "5. His younger brother was diagnosed with testicular cancer at the age of 35 years.", "6. Rectal examination shows a smooth, symmetrical prostate without nodules.", "7. The physician offers to discuss the advantages and limitations of the prostate specific antigen (PSA) test in diagnosing prostate cancer.", "8. He mentions that a a serum PSA of 4 ng/mL is generally used as a cutoff value.", "9. At this cutoff, the test has a sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-risk prostate cancer, with a specificity of 91%.", "10. In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30%.", "11. The negative predictive value for PSA ≤ 4 ng/mL at 85%." ]

[ "1. He wakes up twice each night to urinate.", "2. He has no history of serious illness.", "3. He takes no medication.", "4. His younger brother was diagnosed with testicular cancer at the age of 35 years.", "5. Rectal examination shows a smooth, symmetrical prostate without nodules.", "6. The physician offers to discuss the advantages and limitations of the prostate specific antigen (PSA) test in diagnosing prostate cancer.", "7. He mentions that a serum PSA of 4 ng/mL is generally used as a cutoff value.", "8. At this cutoff, the test has a sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-risk prostate cancer, with a specificity of 91%.", "9. In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30% and the negative predictive value for PSA ≤ 4 ng/mL at 85%." ]

[ "A 23-year-old woman presents to the emergency department for vomiting and abdominal pain.", "The patient states that she has been unable to eat or drink for the past 24 hours without vomiting.", "She also complains of worsening abdominal pain that started 3 days ago.", "The patient has a past medical history of IV drug abuse and alcohol abuse.", "She is not on any current medications.", "Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, tenderness is elicited when the right lower quadrant of her abdomen is palpated.", "Deep palpation and release of the left lower quadrant of her abdomen also causes severe pain.", "Rectal exam reveals normal tone and stool is Guiac negative.", "Laboratory studies are ordered as seen below. | | Hemoglobin: 12 g/dL | Hematocrit: 36% | Leukocyte count: 11,500/mm^3 with normal differential | Platelet count: 197,000/mm^3 | | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 27 mEq/L | BUN: 20 mg/dL | Glucose: 67 mg/dL | Creatinine: 1.1 mg/dL | Ca2+: 10.2 mg/dL | AST: 12 U/L | ALT: 15 U/L | | Urine: | Cocaine: positive | Amphetamines: positive | ß-hCG: positive | Marijuana: positive | Heroin: negative | PCP: negative | MDMA: positive | Glucose: negative | Ketones: negative | | ." ]

[ "1. Patient is a 23-year-old woman.", "2. Patient presents to the emergency department for vomiting and abdominal pain.", "3. Patient states she has been unable to eat or drink for the past 24 hours without vomiting.", "4. Patient complains of worsening abdominal pain that started 3 days ago.", "5. Patient has a past medical history of IV drug abuse and alcohol abuse.", "6. Patient is not on any current medications.", "7. Patient's temperature is 99.5°F (37.5°C).", "8. Patient's blood pressure is 127/68 mmHg.", "9. Patient's pulse is 120/min.", "10. Patient's respirations are 17/min.", "11. Patient's oxygen saturation is 98% on room air.", "12. Tenderness is elicited when the right lower quadrant of her abdomen is palpated.", "13. Deep palpation and release of the left lower quadrant of her abdomen also causes severe pain.", "14. Rectal exam reveals normal tone and stool is Guiac negative.", "15. Laboratory studies show hemoglobin of 12 g/dL, hematocrit of 36%, leukocyte count of 11,500/mm^3 with normal differential, and platelet count of 197,000/mm^3.", "16. Serum Na+ is 139 mEq/L, Cl- is 100 mEq/L, K+ is 4.3 mEq/L, HCO3- is 27 mEq/L, BUN is 20 mg/dL, glucose is 67 mg/dL, creatinine is 1.1 mg/dL, and Ca2+ is 10.2 mg/dL.", "17. Serum AST is 12 U/L and ALT is 15 U/L.", "18. Urine cocaine is positive, amphetamines is positive, ß-hCG is positive, marijuana is positive, heroin is negative, PCP is negative, MDMA is positive, glucose is negative, and ketones are negative." ]

[ "1. The patient has been unable to eat or drink for the past 24 hours without vomiting.", "2. The patient complains of worsening abdominal pain that started 3 days ago.", "3. The patient has a past medical history of IV drug abuse and alcohol abuse.", "4. The patient is not on any current medications.", "5. The patient's temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "6. Tenderness is elicited when the right lower quadrant of her abdomen is palpated.", "7. Deep palpation and release of the left lower quadrant of her abdomen also causes severe pain.", "8. Rectal exam reveals normal tone and stool is Guiac negative.", "9. Laboratory studies show: Hemoglobin: 12 g/dL, Hematocrit: 36%, Leukocyte count: 11,500/mm^3 with normal differential, Platelet count: 197,000/mm^3, Serum: Na+: 139 mEq/L, Cl-: 100 mEq/L, K+: 4.3 mEq/L, HCO3-: 27 mEq/L, BUN: 20 mg/dL, Glucose: 67 mg/dL, Creatinine: 1.1 mg/dL, Ca2+: 10.2 mg/dL, AST: 12 U/L, ALT: 15 U/L, Urine: Cocaine: positive, Amphetamines: positive, ß-hCG: positive, Marijuana: positive, Heroin: negative, PCP: negative, MDMA: positive, Glucose: negative, Ketones: negative." ]

[ "A 75-year-old man was brought in by his daughter since he was having increased incidences of forgetting things.", "His daughter said that he becomes increasingly frustrated searching for his glasses and keys most of the time.", "He was helped out a couple of times in the supermarket for forgetting the way out.", "He recently lost his driving license when he was spotted by the cops driving in the wrong direction on the interstate." ]

[ "1. A 75-year-old man was brought in by his daughter.", "2. He was having increased incidences of forgetting things.", "3. His daughter said he becomes increasingly frustrated searching for his glasses and keys most of the time.", "4. He was helped out a couple of times in the supermarket for forgetting the way out.", "5. He recently lost his driving license.", "6. He was spotted by the cops driving in the wrong direction on the interstate." ]

[ "1. His daughter said he becomes increasingly frustrated searching for his glasses and keys most of the time.", "2. He was helped out a couple of times in the supermarket for forgetting the way out.", "3. He recently lost his driving license when he was spotted by the cops driving in the wrong direction on the interstate." ]

[ "A 7-month-old male child is brought into your office for recent rhinorrhea and cough.", "The mother states that the child has had mild fevers of up to 100.7 F over the last three days along with clear nasal discharge, and a nonproductive cough, but the child has been working harder to breathe over the last day.", "The mother states the child was vaccinated for the flu one month ago.", "His vitals are significant for a temperature of 100.9F and his physical exam is significant for intercostal retractions along with expiratory wheezing." ]

[ "1. A 7-month-old male child is brought into your office.", "2. The mother states the child has had mild fevers of up to 100.7 F over the last three days.", "3. The child has clear nasal discharge and a nonproductive cough.", "4. The child has been working harder to breathe over the last day.", "5. The mother states the child was vaccinated for the flu one month ago.", "6. The child's vitals are significant for a temperature of 100.9F.", "7. The child's physical exam is significant for intercostal retractions.", "8. The child's physical exam is significant for expiratory wheezing." ]

[ "1. The child has had mild fevers of up to 100.7 F over the last three days.", "2. The child has clear nasal discharge.", "3. The child has a nonproductive cough.", "4. The child has been working harder to breathe over the last day.", "5. The child was vaccinated for the flu one month ago.", "6. The child's temperature is 100.9F.", "7. The child's physical exam shows intercostal retractions.", "8. The child's physical exam shows expiratory wheezing." ]

[ "A 56-year-old man comes to the physician because of increasing generalized fatigue for 1 month.", "He also has had a 5.4 kg (12 lb) weight loss over the past 6 months.", "He has hypertension and type 1 diabetes mellitus.", "His father died of colon cancer at the age of 65 years.", "He has smoked one pack of cigarettes daily for 32 years and drinks one alcoholic beverage per week.", "He has numerous tattoos, several of which were acquired when he went backpacking through Southeast Asia as a young man.", "Current medications include enalapril and insulin.", "He is 180 cm (5 ft 11 in) tall and weighs 78 kg (172 lb); BMI is 24.1 kg/m2.", "His temperature is 37.0°C (98.6°F), pulse is 86/min, and blood pressure is 140/90 mm Hg.", "The abdomen is soft and nontender.", "The liver is palpated 3 cm below the right costal margin.", "Laboratory studies show: | Hemoglobin 12.6 g/dL | Mean corpuscular volume 86 μm3 | Leukocyte count 8800/mm3 | Platelet count 282,000/mm3 | Hemoglobin A1C 6.3 % | Serum | Glucose 113 mg/dL | Creatinine 1.1 mg/dL | Albumin 4.1 mg/dL | Total bilirubin 1.1 mg/dL | Alkaline phosphatase 66 U/L | AST 100 U/L | ALT 69 U/L | Ferritin 180 ng/mL | α-fetoprotein | 410 ng/mL (N < 10 ng/mL) | CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver." ]

[ "1. A 56-year-old man comes to the physician because of increasing generalized fatigue for 1 month.", "2. He has had a 5.4 kg (12 lb) weight loss over the past 6 months.", "3. He has hypertension and type 1 diabetes mellitus.", "4. His father died of colon cancer at the age of 65 years.", "5. He has smoked one pack of cigarettes daily for 32 years.", "6. He drinks one alcoholic beverage per week.", "7. He has numerous tattoos, several of which were acquired when he went backpacking through Southeast Asia as a young man.", "8. Current medications include enalapril and insulin.", "9. He is 180 cm (5 ft 11 in) tall and weighs 78 kg (172 lb); BMI is 24.1 kg/m2.", "10. His temperature is 37.0°C (98.6°F), pulse is 86/min, and blood pressure is 140/90 mm Hg.", "11. The abdomen is soft and nontender.", "12. The liver is palpated 3 cm below the right costal margin.", "13. Laboratory studies show: Hemoglobin 12.6 g/dL, Mean corpuscular volume 86 μm3, Leukocyte count 8800/mm3, Platelet count 282,000/mm3, Hemoglobin A1C 6.3 %, Serum Glucose 113 mg/dL, Creatinine 1.1 mg/dL, Albumin 4.1 mg/dL, Total bilirubin 1.1 mg/dL, Alkaline phosphatase 66 U/L, AST 100 U/L, ALT 69 U/L, Ferritin 180 ng/mL, α-fetoprotein 410 ng/mL (N < 10 ng/mL).", "14. CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver." ]

[ "1. 5.4 kg (12 lb) weight loss over the past 6 months", "2. Hypertension and type 1 diabetes mellitus", "3. Father died of colon cancer at the age of 65 years", "4. Smoked one pack of cigarettes daily for 32 years and drinks one alcoholic beverage per week", "5. Numerous tattoos, several acquired when backpacking through Southeast Asia", "6. Current medications include enalapril and insulin", "7. Height: 180 cm (5 ft 11 in), weight: 78 kg (172 lb), BMI: 24.1 kg/m2", "8. Temperature: 37.0°C (98.6°F), pulse: 86/min, blood pressure: 140/90 mm Hg", "9. Abdomen is soft and nontender", "10. Liver is palpated 3 cm below the right costal margin", "11. Laboratory studies show: Hemoglobin 12.6 g/dL, Mean corpuscular volume 86 μm3, Leukocyte count 8800/mm3, Platelet count 282,000/mm3, Hemoglobin A1C 6.3 %, Serum Glucose 113 mg/dL, Creatinine 1.1 mg/dL, Albumin 4.1 mg/dL, Total bilirubin 1.1 mg/dL, Alkaline phosphatase 66 U/L, AST 100 U/L, ALT 69 U/L, Ferritin 180 ng/mL, α-fetoprotein 410 ng/mL (N < 10 ng/mL)", "12. CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver" ]

[ "A 6-year-old girl with polycystic kidney disease is started on a new medication after receiving a kidney transplant from a matched, unrelated donor.", "Two days after starting the medication, laboratory studies show a leukocyte count of 17,500/mm3 (90% segmented neutrophils, 4% bands, 1% eosinophils, 3% lymphocytes, and 1% monocytes)." ]

[ "1. A 6-year-old girl has polycystic kidney disease.", "2. She received a kidney transplant from a matched, unrelated donor.", "3. She was started on a new medication.", "4. Two days after starting the medication, laboratory studies showed a leukocyte count of 17,500/mm3.", "5. 90% of the leukocytes were segmented neutrophils.", "6. 4% of the leukocytes were bands.", "7. 1% of the leukocytes were eosinophils.", "8. 3% of the leukocytes were lymphocytes.", "9. 1% of the leukocytes were monocytes." ]

[ "1. The medication was started two days ago.", "2. The leukocyte count is 17,500/mm3.", "3. 90% of the leukocytes are segmented neutrophils.", "4. 4% of the leukocytes are bands.", "5. 1% of the leukocytes are eosinophils.", "6. 3% of the leukocytes are lymphocytes.", "7. 1% of the leukocytes are monocytes." ]

[ "A clinical trial is conducted to investigate the efficiency of a new glucagon receptor antagonist in the treatment of type 2 diabetes mellitus.", "After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in fasting and postprandial serum glucose.", "Three individuals reported symptoms of hypoglycemia while exercising." ]

[ "1. A clinical trial is conducted to investigate the efficiency of a new glucagon receptor antagonist in the treatment of type 2 diabetes mellitus.", "2. After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in fasting and postprandial serum glucose.", "3. Three individuals reported symptoms of hypoglycemia while exercising." ]

[ "1. After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in fasting serum glucose.", "2. After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in postprandial serum glucose.", "3. Three individuals reported symptoms of hypoglycemia while exercising." ]

[ "A 19-year-old man is admitted to the medical intensive care unit with suspected sepsis.", "Blood cultures grow Gram-negative cocci containing lipooligosaccharide in their cell wall." ]

[ "1. A 19-year-old man is admitted to the medical intensive care unit.", "2. The man is suspected of having sepsis.", "3. Blood cultures grow Gram-negative cocci.", "4. The Gram-negative cocci contain lipooligosaccharide in their cell wall." ]

[ "1. Blood cultures grow Gram-negative cocci.", "2. The cocci contain lipooligosaccharide in their cell wall." ]

[ "A 25-year-old male rugby player presents to the emergency room complaining of a severe headache.", "He is accompanied by his teammate who reports that he had a head-to-head collision with another player and briefly passed out before regaining consciousness.", "His past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery.", "His family history is notable for stroke in his father.", "His temperature is 98.9°F (37.2°C), blood pressure is 160/90 mmHg, pulse is 60/min, and respirations are 20/min.", "On examination, he is lethargic but oriented to person, place, and time." ]

[ "1. Patient is a 25-year-old male rugby player.", "2. Patient presents to the emergency room complaining of a severe headache.", "3. Patient is accompanied by his teammate.", "4. Patient had a head-to-head collision with another player and briefly passed out before regaining consciousness.", "5. Patient's past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery.", "6. Patient's family history is notable for stroke in his father.", "7. Patient's temperature is 98.9°F (37.2°C).", "8. Patient's blood pressure is 160/90 mmHg.", "9. Patient's pulse is 60/min.", "10. Patient's respirations are 20/min.", "11. On examination, patient is lethargic but oriented to person, place, and time." ]

[ "1. He is accompanied by his teammate.", "2. His teammate reports a head-to-head collision with another player.", "3. He briefly passed out before regaining consciousness.", "4. His past medical history includes a pilocytic astrocytoma as a child.", "5. The pilocytic astrocytoma was successfully treated with surgery.", "6. His family history includes a stroke in his father.", "7. His temperature is 98.9°F (37.2°C).", "8. His blood pressure is 160/90 mmHg.", "9. His pulse is 60/min.", "10. His respirations are 20/min.", "11. On examination, he is lethargic.", "12. He is oriented to person, place, and time." ]

[ "A 4-year-old boy presents with 3 days of fever, crampy abdominal pain, vomiting, and loose, bloody bowel movements containing mucus.", "The patient’s mother says that other children from his daycare class have also developed similar symptoms.", "The patient’s temperature is 39.0°C (102.2°F).", "On physical examination, the patient is irritable and inconsolable, and his abdomen is distended.", "Intravenous fluid resuscitation is initiated.", "Histopathologic analysis of his stool reveals numerous red and white blood cells." ]

[ "1. A 4-year-old boy presents with 3 days of fever, crampy abdominal pain, vomiting, and loose, bloody bowel movements containing mucus.", "2. The patient's mother says that other children from his daycare class have also developed similar symptoms.", "3. The patient's temperature is 39.0°C (102.2°F).", "4. On physical examination, the patient is irritable and inconsolable, and his abdomen is distended.", "5. Intravenous fluid resuscitation is initiated.", "6. Histopathologic analysis of his stool reveals numerous red and white blood cells." ]

[ "1. The patient's mother reports other children from his daycare class have similar symptoms.", "2. The patient's temperature is 39.0°C (102.2°F).", "3. On physical examination, the patient is irritable and inconsolable.", "4. On physical examination, the patient's abdomen is distended.", "5. Intravenous fluid resuscitation is initiated.", "6. Histopathologic analysis of the patient's stool reveals numerous red and white blood cells." ]

[ "A 23-year-old man develops a seizure on the medical floor.", "He was admitted 2 days ago with high-grade fever and severe headache.", "At the time of admission, he had photophobia, neck rigidity, and the following vital signs: temperature 39.5°C (103.1°F), blood pressure 130/70 mm Hg, and heart rate 120/min.", "A cerebral spinal fluid analysis was ordered, and he was started on intravenous antibiotics.", "The patient’s seizure terminates without any medication or intervention.", "An MRI is performed which reveals dilation of all the ventricles of the brain." ]

[ "1. A 23-year-old man develops a seizure on the medical floor.", "2. He was admitted 2 days ago with high-grade fever and severe headache.", "3. At the time of admission, he had photophobia, neck rigidity.", "4. Temperature at admission was 39.5°C (103.1°F).", "5. Blood pressure at admission was 130/70 mm Hg.", "6. Heart rate at admission was 120/min.", "7. A cerebral spinal fluid analysis was ordered.", "8. He was started on intravenous antibiotics.", "9. The patient’s seizure terminates without any medication or intervention.", "10. An MRI is performed.", "11. MRI reveals dilation of all the ventricles of the brain." ]

[ "1. He was admitted 2 days ago with high-grade fever and severe headache.", "2. At the time of admission, he had photophobia, neck rigidity, and the following vital signs: temperature 39.5°C (103.1°F), blood pressure 130/70 mm Hg, and heart rate 120/min.", "3. A cerebral spinal fluid analysis was ordered, and he was started on intravenous antibiotics.", "4. The patient’s seizure terminates without any medication or intervention.", "5. An MRI is performed which reveals dilation of all the ventricles of the brain." ]

[ "A 27-year-old unconscious man is brought to the ED by EMS.", "He was found face down in the middle of the sidewalk at 2AM.", "The patient is disheveled and smells of alcohol.", "Physical exam reveals bruising and ecchymosis at the right temple and 1-mm pupils bilaterally.", "His temperature 97.1°F (36.3°C), blood pressure is 84/58 mmHg, pulse is 71/min, respirations are 8/min." ]

[ "1. A 27-year-old man was brought to the ED by EMS.", "2. He was found face down in the middle of the sidewalk at 2AM.", "3. The patient is disheveled and smells of alcohol.", "4. Physical exam reveals bruising and ecchymosis at the right temple.", "5. Pupils are 1-mm bilaterally.", "6. His temperature is 97.1°F (36.3°C).", "7. Blood pressure is 84/58 mmHg.", "8. Pulse is 71/min.", "9. Respirations are 8/min." ]

[ "1. The patient was found face down in the middle of the sidewalk at 2AM.", "2. The patient is disheveled and smells of alcohol.", "3. Physical exam reveals bruising and ecchymosis at the right temple.", "4. Physical exam reveals 1-mm pupils bilaterally.", "5. The patient's temperature is 97.1°F (36.3°C).", "6. The patient's blood pressure is 84/58 mmHg.", "7. The patient's pulse is 71/min.", "8. The patient's respirations are 8/min." ]

[ "A 43-year-old man presents to the clinic for pain with swallowing for a month.", "He says that the pain has gotten worse over the past few weeks.", "His past medical history is significant for AIDS.", "He states that he has not been able to afford his highly active antiretroviral therapy, so he is not currently taking any medications.", "His temperature is 98.6°F (37°C), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg.", "Physical examination reveals no mucosal lesions.", "Evaluation of the blood reveals: | Hb%: 11 gm/dL | Total count (." ]

[ "1. Patient is 43 years old.", "2. Patient presents to clinic with pain with swallowing for one month.", "3. Pain has gotten worse over past few weeks.", "4. Patient has past medical history of AIDS.", "5. Patient is not currently taking any medications due to inability to afford highly active antiretroviral therapy.", "6. Patient's temperature is 98.6°F (37°C).", "7. Patient's respirations are 15/min.", "8. Patient's pulse is 70/min.", "9. Patient's blood pressure is 100/84 mm Hg.", "10. Physical examination reveals no mucosal lesions.", "11. Evaluation of blood reveals Hb%: 11 gm/dL.", "12. Evaluation of blood reveals total count." ]

[ "1. The patient reports worsening pain over the past few weeks.", "2. The patient has a past medical history significant for AIDS.", "3. The patient cannot afford highly active antiretroviral therapy and is not currently taking any medications.", "4. The patient's temperature is 98.6°F (37°C), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg.", "5. Physical examination reveals no mucosal lesions.", "6. Evaluation of the blood reveals: Hb%: 11 gm/dL, Total count (unspecified)." ]

[ "A 25-year-old man is brought by his roommate to the emergency department with chest pain, which began 90 minutes ago.", "His roommate says that he has not slept within the past 24 hours and has been taking pills to help him study longer for his upcoming national dental board exam.", "On examination, he is diaphoretic, extremely agitated, and attempts to remove his IV lines and ECG leads.", "His temperature is 38.9°C (102.2°F), pulse is 115/min, and blood pressure is 160/102 mmHg.", "His pupil size is 7 mm bilaterally.", "The lungs are clear to auscultation." ]

[ "1. A 25-year-old man is brought to the emergency department with chest pain.", "2. The chest pain began 90 minutes ago.", "3. His roommate says he has not slept within the past 24 hours.", "4. He has been taking pills to help him study longer for his upcoming national dental board exam.", "5. On examination, he is diaphoretic, extremely agitated, and attempts to remove his IV lines and ECG leads.", "6. His temperature is 38.9°C (102.2°F).", "7. His pulse is 115/min.", "8. His blood pressure is 160/102 mmHg.", "9. His pupil size is 7 mm bilaterally.", "10. The lungs are clear to auscultation." ]

[ "1. His roommate reports that he has not slept within the past 24 hours.", "2. He has been taking pills to help him study longer for his upcoming national dental board exam.", "3. On examination, he is diaphoretic.", "4. On examination, he is extremely agitated.", "5. On examination, he attempts to remove his IV lines and ECG leads.", "6. His temperature is 38.9°C (102.2°F).", "7. His pulse is 115/min.", "8. His blood pressure is 160/102 mmHg.", "9. His pupil size is 7 mm bilaterally.", "10. The lungs are clear to auscultation." ]

[ "A 65-year-old female presents to her primary care physician for a routine check-up.", "She reports feeling well but has noticed occasional weakness and constipation over the past few months.", "A complete blood count is within normal limits.", "Serum calcium is 11.9 mg/dL and serum phosphate is 2.4 mg/dL.", "Urine calcium output is 400 mg/24 h.", "A sestamibi scan demonstrates increased uptake near the inferior left pole of the thyroid gland." ]

[ "1. A 65-year-old female presents to her primary care physician for a routine check-up.", "2. She reports feeling well but has noticed occasional weakness and constipation over the past few months.", "3. A complete blood count is within normal limits.", "4. Serum calcium is 11.9 mg/dL.", "5. Serum phosphate is 2.4 mg/dL.", "6. Urine calcium output is 400 mg/24 h.", "7. A sestamibi scan demonstrates increased uptake near the inferior left pole of the thyroid gland." ]

[ "1. The patient reports feeling well.", "2. The patient has noticed occasional weakness and constipation over the past few months.", "3. The complete blood count is within normal limits.", "4. Serum calcium level is 11.9 mg/dL.", "5. Serum phosphate level is 2.4 mg/dL.", "6. Urine calcium output is 400 mg/24 h.", "7. A sestamibi scan demonstrates increased uptake near the inferior left pole of the thyroid gland." ]

[ "A 35-year-old male presents to his physician with a small mass that he found in the anterior of his neck a few days ago.", "The mass is not painful and does not affect his swallowing.", "He noticed no change in his weight.", "His history is significant for radiation exposure for treating his neuroblastoma at the age of 15.", "On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule; the nodule is firm and non-tender.", "There is cervical lymphadenopathy.", "His blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 67/min, and temperature is 37.5°C (99.5°F).", "Laboratory findings include serum Na+ of 136 mmol/L, K+ of 4.2 mmol/L, Cl– of 90 mmol/L, and bicarbonate of 24 mmol/L." ]

[ "1. Patient is a 35-year-old male.", "2. Patient found a small mass in the anterior of his neck a few days ago.", "3. Mass is not painful and does not affect his swallowing.", "4. Patient noticed no change in his weight.", "5. Patient has a history of radiation exposure for treating his neuroblastoma at the age of 15.", "6. On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule.", "7. Nodule is firm and non-tender.", "8. Cervical lymphadenopathy is present.", "9. Blood pressure is 118/75 mm Hg.", "10. Respirations are 17/min.", "11. Pulse is 67/min.", "12. Temperature is 37.5°C (99.5°F).", "13. Serum Na+ is 136 mmol/L.", "14. Serum K+ is 4.2 mmol/L.", "15. Serum Cl– is 90 mmol/L.", "16. Serum bicarbonate is 24 mmol/L." ]

[ "1. The mass is not painful and does not affect his swallowing.", "2. He noticed no change in his weight.", "3. His history is significant for radiation exposure for treating his neuroblastoma at the age of 15.", "4. On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule; the nodule is firm and non-tender.", "5. There is cervical lymphadenopathy.", "6. His blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 67/min, and temperature is 37.5°C (99.5°F).", "7. Laboratory findings include serum Na+ of 136 mmol/L, K+ of 4.2 mmol/L, Cl– of 90 mmol/L, and bicarbonate of 24 mmol/L." ]

[ "An 18-year-old man is referred to a psychiatrist for evaluation after a recent suicide attempt.", "On questioning him, he says that he did it because he got fed up with life and feels that he is worthless.", "The patient’s father informs the doctor that his son has been gloomy most of the time over the last 2 months, and his academic performance has declined significantly.", "His father further adds that his son’s appetite has decreased significantly over the last 3 months, leading to a 5.0 kg (11.0 lb) weight loss.", " The patient denies any history of manic or hypomanic episodes.", "Physical examination is unremarkable.", "Routine laboratory tests, including thyroid hormone and cortisol levels, are within normal limits." ]

[ "1. An 18-year-old man is referred to a psychiatrist for evaluation after a recent suicide attempt. ", "2. On questioning him, he says that he did it because he got fed up with life and feels that he is worthless. ", "3. The patient's father informs the doctor that his son has been gloomy most of the time over the last 2 months. ", "4. The patient's father further adds that his son's academic performance has declined significantly. ", "5. The patient's father further adds that his son's appetite has decreased significantly over the last 3 months. ", "6. The patient's father further adds that his son has experienced a 5.0 kg (11.0 lb) weight loss. ", "7. The patient denies any history of manic or hypomanic episodes. ", "8. Physical examination is unremarkable. ", "9. Routine laboratory tests, including thyroid hormone and cortisol levels, are within normal limits." ]

[ "1. The patient states that he did it because he got fed up with life and feels worthless.", "2. The patient has been gloomy most of the time over the last 2 months.", "3. The patient's academic performance has declined significantly.", "4. The patient's appetite has decreased significantly over the last 3 months.", "5. The patient has experienced a 5.0 kg (11.0 lb) weight loss.", "6. The patient denies any history of manic or hypomanic episodes.", "7. Physical examination is unremarkable.", "8. Routine laboratory tests, including thyroid hormone and cortisol levels, are within normal limits." ]

[ "A 10-year-old girl is evaluated for a suspected primary deficiency.", "She is the first child in a consanguineous marriage.", "She was born vaginally at full term after an uncomplicated pregnancy and was breastfed for 9 months.", "The patient has had an episode of meningococcal meningitis, recurrent bronchiolitis, and multiple bouts of pneumococcal pneumonia over the past 5 years.", "She has also suffered from chronic otitis media since the age of 5.", "After a thorough examination, the child is found to have a partial CD19 deficiency." ]

[ "1. A 10-year-old girl is evaluated for a suspected primary deficiency.", "2. She is the first child in a consanguineous marriage.", "3. She was born vaginally at full term after an uncomplicated pregnancy.", "4. She was breastfed for 9 months.", "5. The patient has had an episode of meningococcal meningitis.", "6. The patient has had recurrent bronchiolitis.", "7. The patient has had multiple bouts of pneumococcal pneumonia over the past 5 years.", "8. The patient has suffered from chronic otitis media since the age of 5.", "9. After a thorough examination, the child is found to have a partial CD19 deficiency." ]

[ "1. She is the first child in a consanguineous marriage.", "2. She was born vaginally at full term after an uncomplicated pregnancy.", "3. She was breastfed for 9 months.", "4. The patient has had an episode of meningococcal meningitis.", "5. The patient has had recurrent bronchiolitis.", "6. The patient has had multiple bouts of pneumococcal pneumonia over the past 5 years.", "7. She has suffered from chronic otitis media since the age of 5.", "8. After a thorough examination, the child is found to have a partial CD19 deficiency." ]

[ "A 24-year old woman is brought to the emergency department after a motor vehicle collision.", "She was a restrained passenger at the time of impact.", "On examination, the patient is pale and in moderate distress.", "She complains of a sharp pain in the posterior aspect of the left shoulder.", "Vitals include temperature is 37.0°C (98.6°F), right arm blood pressure is 94/63 mm Hg, left arm blood pressure is 90/61 mm Hg, pulse is 122/min, and respirations are 24/min.", "Cardiopulmonary auscultation reveals normal heart sounds and clear lungs.", "Neck veins are not distended.", "Several, large ecchymoses are visible over the chest and abdomen in a seatbelt pattern.", "Her abdomen is tender on superficial palpation with mild rebound tenderness and rigidity.", "Her range of motion is normal with 5/5 motor strength in all extremities.", "Wrist drop is absent.", "A FAST scan is pending." ]

[ "1. A 24-year old woman is brought to the emergency department after a motor vehicle collision. ", "2. She was a restrained passenger at the time of impact. ", "3. On examination, the patient is pale and in moderate distress. ", "4. She complains of a sharp pain in the posterior aspect of the left shoulder. ", "5. Temperature is 37.0°C (98.6°F). ", "6. Right arm blood pressure is 94/63 mm Hg. ", "7. Left arm blood pressure is 90/61 mm Hg. ", "8. Pulse is 122/min. ", "9. Respirations are 24/min. ", "10. Cardiopulmonary auscultation reveals normal heart sounds and clear lungs. ", "11. Neck veins are not distended. ", "12. Several, large ecchymoses are visible over the chest and abdomen in a seatbelt pattern. ", "13. Abdomen is tender on superficial palpation with mild rebound tenderness and rigidity. ", "14. Range of motion is normal with 5/5 motor strength in all extremities. ", "15. Wrist drop is absent. ", "16. A FAST scan is pending." ]

[ "1. She was a restrained passenger at the time of impact.", "2. On examination, the patient is pale and in moderate distress.", "3. She complains of a sharp pain in the posterior aspect of the left shoulder.", "4. Vitals include temperature is 37.0°C (98.6°F), right arm blood pressure is 94/63 mm Hg, left arm blood pressure is 90/61 mm Hg, pulse is 122/min, and respirations are 24/min.", "5. Cardiopulmonary auscultation reveals normal heart sounds and clear lungs.", "6. Neck veins are not distended.", "7. Several, large ecchymoses are visible over the chest and abdomen in a seatbelt pattern.", "8. Her abdomen is tender on superficial palpation with mild rebound tenderness and rigidity.", "9. Her range of motion is normal with 5/5 motor strength in all extremities.", "10. Wrist drop is absent.", "11. A FAST scan is pending." ]

[ "A 68-year-old woman presents to her primary care physician with complaints of fatigue, difficulty breathing upon exertion, and crampy lower abdominal pain.", "She also notices that her stools are dark.", "She has had essential hypertension for 20 years for which she takes bisoprolol.", "Her family history is positive for type 2 diabetes mellitus.", "On physical examination, she looks pale.", "Complete blood count shows the following: | Hemoglobin 10 g/dL | Mean corpuscular volume (MCV) 70 fL | Mean corpuscular hemoglobin (MCH) 25 pg/cell | Mean corpuscular hemoglobin concentration (MCHC) 27 g/dL | Red cell distribution width 16% | Platelet count 350,000/mm3 | Serum ferritin is 9 ng/mL.", "The patient is referred to a gastroenterologist and conventional colonoscopy reveals a polypoid mass in the ascending colon.", "Biopsy shows poorly differentiated adenocarcinoma.", "A preoperative staging is performed and a laparoscopic cancer resection with postoperative chemotherapy are planned." ]

[ "1. A 68-year-old woman presents to her primary care physician with complaints of fatigue, difficulty breathing upon exertion, and crampy lower abdominal pain.", "2. She also notices that her stools are dark.", "3. She has had essential hypertension for 20 years for which she takes bisoprolol.", "4. Her family history is positive for type 2 diabetes mellitus.", "5. On physical examination, she looks pale.", "6. Complete blood count shows a hemoglobin of 10 g/dL.", "7. Complete blood count shows a mean corpuscular volume (MCV) of 70 fL.", "8. Complete blood count shows a mean corpuscular hemoglobin (MCH) of 25 pg/cell.", "9. Complete blood count shows a mean corpuscular hemoglobin concentration (MCHC) of 27 g/dL.", "10. Complete blood count shows a red cell distribution width of 16%.", "11. Complete blood count shows a platelet count of 350,000/mm3.", "12. Serum ferritin is 9 ng/mL.", "13. The patient is referred to a gastroenterologist.", "14. Conventional colonoscopy reveals a polypoid mass in the ascending colon.", "15. Biopsy shows poorly differentiated adenocarcinoma.", "16. A preoperative staging is performed.", "17. A laparoscopic cancer resection with postoperative chemotherapy are planned." ]

[ "1. The patient has had essential hypertension for 20 years.", "2. The patient takes bisoprolol for essential hypertension.", "3. The patient's family history is positive for type 2 diabetes mellitus.", "4. On physical examination, the patient looks pale.", "5. Hemoglobin level is 10 g/dL.", "6. Mean corpuscular volume (MCV) is 70 fL.", "7. Mean corpuscular hemoglobin (MCH) is 25 pg/cell.", "8. Mean corpuscular hemoglobin concentration (MCHC) is 27 g/dL.", "9. Red cell distribution width is 16%.", "10. Platelet count is 350,000/mm3.", "11. Serum ferritin level is 9 ng/mL.", "12. Conventional colonoscopy reveals a polypoid mass in the ascending colon.", "13. Biopsy shows poorly differentiated adenocarcinoma.", "14. A preoperative staging is performed.", "15. A laparoscopic cancer resection with postoperative chemotherapy is planned." ]

[ "A 34-year-old man comes to the physician because of a 2-day history of progressively blurred vision.", "He also reports seeing flashing lights in his visual field.", "He does not have any pain.", "The patient has not been examined by a physician in several years.", "He appears emaciated.", "Examination shows right conjunctival injection.", "Visual acuity is 20/20 in the left eye and 20/100 in the right eye.", "Fundoscopic examination of the right eye is shown.", "His CD4+ T-lymphocyte count is 46/mm3." ]

[ "1. A 34-year-old man comes to the physician.", "2. He has a 2-day history of progressively blurred vision.", "3. He reports seeing flashing lights in his visual field.", "4. He does not have any pain.", "5. He has not been examined by a physician in several years.", "6. He appears emaciated.", "7. Examination shows right conjunctival injection.", "8. Visual acuity is 20/20 in the left eye and 20/100 in the right eye.", "9. Fundoscopic examination of the right eye is shown.", "10. His CD4+ T-lymphocyte count is 46/mm3." ]

[ "1. He reports seeing flashing lights in his visual field.", "2. He does not have any pain.", "3. The patient has not been examined by a physician in several years.", "4. He appears emaciated.", "5. Examination shows right conjunctival injection.", "6. Visual acuity is 20/20 in the left eye and 20/100 in the right eye.", "7. Fundoscopic examination of the right eye is shown.", "8. His CD4+ T-lymphocyte count is 46/mm3." ]

[ "A 42-year-old man comes to the physician because of several episodes of rectal bleeding over 2 weeks.", "He has had pain around the anal area for the past month.", "Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole.", "He is HIV-positive.", "He has had 9 male sexual partners over his lifetime and uses condoms inconsistently.", "The patient's current medications include dolutegravir, tenofovir, and emtricitabine.", "He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2.", "Vital signs are within normal limits.", "Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact.", "There is no inguinal lymphadenopathy.", "The abdomen is soft and nontender.", "The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3).", "A biopsy confirms the diagnosis." ]

[ "1. A 42-year-old man comes to the physician because of several episodes of rectal bleeding over 2 weeks.", "2. He has had pain around the anal area for the past month.", "3. Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole.", "4. He is HIV-positive.", "5. He has had 9 male sexual partners over his lifetime and uses condoms inconsistently.", "6. The patient's current medications include dolutegravir, tenofovir, and emtricitabine.", "7. He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2.", "8. Vital signs are within normal limits.", "9. Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact.", "10. There is no inguinal lymphadenopathy.", "11. The abdomen is soft and nontender.", "12. The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3).", "13. A biopsy confirms the diagnosis." ]

[ "1. He has had pain around the anal area for the past month.", "2. Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole.", "3. He is HIV-positive.", "4. He has had 9 male sexual partners over his lifetime and uses condoms inconsistently.", "5. The patient's current medications include dolutegravir, tenofovir, and emtricitabine.", "6. He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2.", "7. Vital signs are within normal limits.", "8. Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact.", "9. There is no inguinal lymphadenopathy.", "10. The abdomen is soft and nontender.", "11. The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3).", "12. A biopsy confirms the diagnosis." ]

[ "A 19-month-old boy comes into the emergency department with his parents.", "He has burns on his buttocks and perineal area.", "The patient’s mother says she was at home with the patient when she heard him screaming from the kitchen.", "She says she ran to the room to find that the patient had pulled down a container of hot water on himself." ]

[ "1. A 19-month-old boy comes into the emergency department with his parents.", "2. He has burns on his buttocks and perineal area.", "3. The patient's mother was at home with the patient when she heard him screaming from the kitchen.", "4. She ran to the room to find that the patient had pulled down a container of hot water on himself." ]

[ "1. The patient has burns on his buttocks.", "2. The patient has burns on his perineal area.", "3. The patient's mother was at home with the patient.", "4. The mother heard the patient screaming from the kitchen.", "5. The mother ran to the room.", "6. The patient had pulled down a container of hot water on himself." ]

[ "A 44-year-old woman presents to the physician for evaluation of recurrent episodes of pounding headache, palpitations, excessive sweating, anxiety, tremors, and pallor, with occasional vomiting for the last 2 weeks.", "She has presented to the same physician with similar complaints in the past; however, she is frustrated with the lack of proper diagnosis and now insists on a detailed workup.", "She does not take any medications.", "She has a history of progressively increasing thyroid swelling as well as multiple bone pain for the past 2 months.", "On physical examination, she is very lean and appears anxious and apprehensive.", "She has clammy and moist hands.", "Her temperature is 37.1°C (98.9°F), the pulse is 110/min, the blood pressure is 176/94 mm Hg, and the respiratory rate is 27/min.", "Her weight is 43 kg (94.8 lb), height is 145 cm (4 ft 7 in), and body mass index (BMI) is 20.4 kg/m2.", "A firm thyroid nodule is palpable in the right lobe.", "Physical examination is otherwise normal." ]

[ "1. Patient is 44 years old.", "2. Patient has recurrent episodes of pounding headache, palpitations, excessive sweating, anxiety, tremors, and pallor, with occasional vomiting for the last 2 weeks.", "3. Patient has presented to the same physician with similar complaints in the past.", "4. Patient is frustrated with the lack of proper diagnosis and now insists on a detailed workup.", "5. Patient does not take any medications.", "6. Patient has a history of progressively increasing thyroid swelling for the past 2 months.", "7. Patient has multiple bone pain for the past 2 months.", "8. Patient appears anxious and apprehensive.", "9. Patient has clammy and moist hands.", "10. Patient's temperature is 37.1°C (98.9°F).", "11. Patient's pulse is 110/min.", "12. Patient's blood pressure is 176/94 mm Hg.", "13. Patient's respiratory rate is 27/min.", "14. Patient's weight is 43 kg (94.8 lb).", "15. Patient's height is 145 cm (4 ft 7 in).", "16. Patient's body mass index (BMI) is 20.4 kg/m2.", "17. A firm thyroid nodule is palpable in the right lobe.", "18. Physical examination is otherwise normal." ]

[ "1. She has presented to the same physician with similar complaints in the past.", "2. She is frustrated with the lack of proper diagnosis and now insists on a detailed workup.", "3. She does not take any medications.", "4. She has a history of progressively increasing thyroid swelling.", "5. She has a history of multiple bone pain for the past 2 months.", "6. On physical examination, she is very lean.", "7. On physical examination, she appears anxious and apprehensive.", "8. She has clammy and moist hands.", "9. Her temperature is 37.1°C (98.9°F).", "10. Her pulse is 110/min.", "11. Her blood pressure is 176/94 mm Hg.", "12. Her respiratory rate is 27/min.", "13. Her weight is 43 kg (94.8 lb).", "14. Her height is 145 cm (4 ft 7 in).", "15. Her body mass index (BMI) is 20.4 kg/m2.", "16. A firm thyroid nodule is palpable in the right lobe.", "17. Physical examination is otherwise normal." ]

[ "A 54-year-old male is involved in a high speed motor vehicle collision and is brought to the emergency department.", "On arrival, his vitals are temperature 98.6 °F (37 °C), blood pressure 110/70 mmHg, pulse 100/min, and respirations are 20/min.", "His Glasgow Coma Score (GCS) is 13 (eye opening 3, verbal response 5, and motor response 5).", "Physical exam is notable for a rapid and thready pulse, and a rigid and distended abdomen with positive rebound tenderness.", "FAST exam reveals a large hypoechoic stripe in the hepatorenal recess.", "Two large bore IV's are started and the patient is given a 1L bolus of normal saline.", "The patient’s mental status rapidly deteriorates and he becomes unresponsive.", "His pulse is 149/min and blood pressure is 70/40 mmHg.", "The patient is started on a medication while additional fluids are administered.", "Subsequently his vitals, his pulse is 80/minute and blood pressure is 120/80 mmHg.", "While the patient is being taken to the operating room, he develops pain in all four distal extremities.", "His digits appear blue and are cool to the touch." ]

[ "1. A 54-year-old male is involved in a high speed motor vehicle collision.", "2. He is brought to the emergency department.", "3. On arrival, his temperature is 98.6 °F (37 °C).", "4. His blood pressure is 110/70 mmHg.", "5. His pulse is 100/min.", "6. His respirations are 20/min.", "7. His Glasgow Coma Score (GCS) is 13 (eye opening 3, verbal response 5, and motor response 5).", "8. Physical exam is notable for a rapid and thready pulse.", "9. His abdomen is rigid and distended with positive rebound tenderness.", "10. FAST exam reveals a large hypoechoic stripe in the hepatorenal recess.", "11. Two large bore IV's are started.", "12. He is given a 1L bolus of normal saline.", "13. His mental status rapidly deteriorates and he becomes unresponsive.", "14. His pulse is 149/min and blood pressure is 70/40 mmHg.", "15. He is started on a medication.", "16. Additional fluids are administered.", "17. His pulse is 80/minute and blood pressure is 120/80 mmHg.", "18. While being taken to the operating room, he develops pain in all four distal extremities.", "19. His digits appear blue and are cool to the touch." ]

[ "1. On arrival, temperature is 98.6 °F (37 °C)", "2. On arrival, blood pressure is 110/70 mmHg", "3. On arrival, pulse is 100/min", "4. On arrival, respirations are 20/min", "5. Glasgow Coma Score (GCS) is 13", "6. Glasgow Coma Score (GCS) components: eye opening 3, verbal response 5, motor response 5", "7. Physical exam shows rapid and thready pulse", "8. Physical exam shows rigid and distended abdomen with positive rebound tenderness", "9. FAST exam reveals a large hypoechoic stripe in the hepatorenal recess", "10. Two large bore IV's are started", "11. Patient is given a 1L bolus of normal saline", "12. Patient’s mental status rapidly deteriorates and becomes unresponsive", "13. Pulse is 149/min", "14. Blood pressure is 70/40 mmHg", "15. Patient is started on a medication", "16. Additional fluids are administered", "17. Subsequently, pulse is 80/minute", "18. Blood pressure is 120/80 mmHg", "19. Patient develops pain in all four distal extremities while being taken to the operating room", "20. Patient's digits appear blue and are cool to the touch" ]

[ "A 20-year-old man with a history of cystic fibrosis presents to his pulmonologist for a regular checkup.", "He generally feels well but noticed that he has had an increase in stool frequency.", "He describes his stools as loose and “greasy”, often staining the toilet bowl.", "He regularly uses albuterol and budesonide inhalers and has chest physical therapy several times a month.", "Physical exam is unremarkable." ]

[ "1. A 20-year-old man presents to his pulmonologist for a regular checkup.", "2. He has a history of cystic fibrosis.", "3. He generally feels well.", "4. He has had an increase in stool frequency.", "5. He describes his stools as loose and “greasy”.", "6. His stools often stain the toilet bowl.", "7. He regularly uses albuterol and budesonide inhalers.", "8. He has chest physical therapy several times a month.", "9. Physical exam is unremarkable." ]

[ "1. The patient generally feels well.", "2. The patient has noticed an increase in stool frequency.", "3. The patient describes his stools as loose and \"greasy\".", "4. The patient's stools often stain the toilet bowl.", "5. The patient regularly uses albuterol and budesonide inhalers.", "6. The patient has chest physical therapy several times a month.", "7. The patient's physical exam is unremarkable." ]

[ "A 6-year-old boy is brought to the physician by his father for an annual health maintenance examination.", "His father notes that he has several pigmented areas on his skin and a few fleshy bumps.", "He has also had some blurred vision in his left eye.", "He has no history of serious medical illness.", "He lives at home with both parents and is up-to-date on all his immunizations.", "His father has similar skin findings.", "His mother has epilepsy and glaucoma.", "Vital signs are within normal limits.", "Visual acuity testing shows 20/50 in the left eye and 20/20 in the right eye.", "Slit-lamp examination shows pigmented iris nodules.", "Examination of his skin shows eight brownish macules and numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen." ]

[ "1. A 6-year-old boy is brought to the physician by his father for an annual health maintenance examination.", "2. His father notes that he has several pigmented areas on his skin and a few fleshy bumps.", "3. He has also had some blurred vision in his left eye.", "4. He has no history of serious medical illness.", "5. He lives at home with both parents and is up-to-date on all his immunizations.", "6. His father has similar skin findings.", "7. His mother has epilepsy and glaucoma.", "8. Vital signs are within normal limits.", "9. Visual acuity testing shows 20/50 in the left eye and 20/20 in the right eye.", "10. Slit-lamp examination shows pigmented iris nodules.", "11. Examination of his skin shows eight brownish macules.", "12. Examination of his skin shows numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen." ]

[ "1. His father notes pigmented areas on his skin.", "2. His father notes fleshy bumps on his skin.", "3. He has blurred vision in his left eye.", "4. He has no history of serious medical illness.", "5. He lives at home with both parents.", "6. He is up-to-date on all his immunizations.", "7. His father has similar skin findings.", "8. His mother has epilepsy.", "9. His mother has glaucoma.", "10. Vital signs are within normal limits.", "11. Visual acuity testing shows 20/50 in the left eye.", "12. Visual acuity testing shows 20/20 in the right eye.", "13. Slit-lamp examination shows pigmented iris nodules.", "14. Examination of his skin shows eight brownish macules.", "15. Examination of his skin shows numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen." ]

[ "A 43-year-old man is brought to the emergency department because of a fever, cough, pleuritic chest pain, and dyspnea.", "Two days ago, he returned from a construction site along the Mississippi River.", "Abdominal examination shows a palpable spleen.", "An x-ray of the chest shows diffuse reticulonodular infiltrates.", "Therapy with a drug that binds ergosterol is initiated." ]

[ "1. A 43-year-old man is brought to the emergency department.", "2. He has a fever, cough, pleuritic chest pain, and dyspnea.", "3. Two days ago, he returned from a construction site along the Mississippi River.", "4. Abdominal examination shows a palpable spleen.", "5. An x-ray of the chest shows diffuse reticulonodular infiltrates.", "6. Therapy with a drug that binds ergosterol is initiated." ]

[ "1. Two days ago, he returned from a construction site along the Mississippi River.", "2. Abdominal examination shows a palpable spleen.", "3. An x-ray of the chest shows diffuse reticulonodular infiltrates.", "4. Therapy with a drug that binds ergosterol is initiated." ]

[ "A 49-year-old African man presents to the physician with a 3-month history of fatigue, shortness of breath, and abdominal distention.", "He immigrated to the US approximately 6 months ago.", "He has no other medical problems and is currently not on medication.", "He previously worked as a farmer but stopped due to his inability to keep up with the work.", "His blood pressure is 112/58 mm Hg, pulse is 90/min, respiratory rate is 19/min, and temperature is 37.8°C (100.0°F).", "Physical examination reveals bilateral pedal edema up to the knees, jugular venous distention, and abdominal distention with free fluid.", "Chest auscultation reveals the following sound.", "Jugular venous pressure tracing reveals prominent ‘x’ and ‘y’ descents.", "Radial pulse is absent during inspiration bilaterally." ]

[ "1. Patient is a 49-year-old African man.", "2. Patient has a 3-month history of fatigue, shortness of breath, and abdominal distention.", "3. Patient immigrated to the US approximately 6 months ago.", "4. Patient has no other medical problems and is currently not on medication.", "5. Patient previously worked as a farmer but stopped due to his inability to keep up with the work.", "6. Patient's blood pressure is 112/58 mm Hg.", "7. Patient's pulse is 90/min.", "8. Patient's respiratory rate is 19/min.", "9. Patient's temperature is 37.8°C (100.0°F).", "10. Physical examination reveals bilateral pedal edema up to the knees.", "11. Physical examination reveals jugular venous distention.", "12. Physical examination reveals abdominal distention with free fluid.", "13. Chest auscultation reveals a specific sound.", "14. Jugular venous pressure tracing reveals prominent ‘x’ and ‘y’ descents.", "15. Radial pulse is absent during inspiration bilaterally." ]

[ "1. He immigrated to the US approximately 6 months ago.", "2. He has no other medical problems.", "3. He is currently not on medication.", "4. He previously worked as a farmer.", "5. He stopped working as a farmer due to his inability to keep up with the work.", "6. His blood pressure is 112/58 mm Hg.", "7. His pulse is 90/min.", "8. His respiratory rate is 19/min.", "9. His temperature is 37.8°C (100.0°F).", "10. Physical examination reveals bilateral pedal edema up to the knees.", "11. Physical examination reveals jugular venous distention.", "12. Physical examination reveals abdominal distention with free fluid.", "13. Chest auscultation reveals specific sounds.", "14. Jugular venous pressure tracing reveals prominent ‘x’ and ‘y’ descents.", "15. Radial pulse is absent during inspiration bilaterally." ]

[ "A 25-year-old primigravida is admitted to the hospital at 35 weeks gestation with lower leg edema.", "She denies any other symptoms.", "Prior to admission, the antepartum course was unremarkable and she was compliant with recommended prenatal care.", "The vital signs were as follows: blood pressure, 155/90 mm Hg; heart rate, 84/min; respiratory rate, 16/min; and temperature, 36.6℃ (97.9℉).", "The fetal heart rate was 142/min.", "The physical examination shows 2+ pitting edema.", "A 24-hour urine assessment showed proteinuria (1.2 g).", "An ultrasound examination showed a normally developing fetus without structural abnormalities.", "The placental margin was located 3 cm away from the internal os." ]

[ "1. Patient is a 25-year-old primigravida.", "2. Patient is admitted to the hospital at 35 weeks gestation.", "3. Patient has lower leg edema.", "4. Patient denies any other symptoms.", "5. Antepartum course was unremarkable.", "6. Patient was compliant with recommended prenatal care.", "7. Blood pressure is 155/90 mm Hg.", "8. Heart rate is 84/min.", "9. Respiratory rate is 16/min.", "10. Temperature is 36.6℃ (97.9℉).", "11. Fetal heart rate is 142/min.", "12. Physical examination shows 2+ pitting edema.", "13. 24-hour urine assessment showed proteinuria (1.2 g).", "14. Ultrasound examination showed a normally developing fetus without structural abnormalities.", "15. Placental margin is located 3 cm away from the internal os." ]

[ "1. She denies any other symptoms.", "2. Prior to admission, the antepartum course was unremarkable and she was compliant with recommended prenatal care.", "3. The vital signs were as follows: blood pressure, 155/90 mm Hg; heart rate, 84/min; respiratory rate, 16/min; and temperature, 36.6℃ (97.9℉).", "4. The fetal heart rate was 142/min.", "5. The physical examination shows 2+ pitting edema.", "6. A 24-hour urine assessment showed proteinuria (1.2 g).", "7. An ultrasound examination showed a normally developing fetus without structural abnormalities.", "8. The placental margin was located 3 cm away from the internal os." ]

[ "A 12-year-old female presents to the emergency room difficult to arouse and occasionally vomiting.", "On physical exam, her oral mucosa looks dry, her breath has a fruity odor, and her breathing is slow, deep and labored." ]

[ "1. A 12-year-old female presents to the emergency room.", "2. She is difficult to arouse.", "3. She is occasionally vomiting.", "4. On physical exam, her oral mucosa looks dry.", "5. Her breath has a fruity odor.", "6. Her breathing is slow, deep and labored." ]

[ "1. On physical exam, her oral mucosa looks dry.", "2. Her breath has a fruity odor.", "3. Her breathing is slow.", "4. Her breathing is deep.", "5. Her breathing is labored." ]

[ "A 36-year-old man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath with exertion.", "The patient is generally healthy, lifts weights regularly, and does not smoke.", "His temperature is 97.8°F (36.6°C), blood pressure is 122/83 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids.", "An ECG shows left axis deviation and meets criteria for left ventricular hypertrophy.", "An initial troponin is < 0.01 ng/mL." ]

[ "1. A 36-year-old man presents to the emergency room.", "2. Patient has subacute worsening of chronic chest pain and shortness of breath with exertion.", "3. Patient is generally healthy and lifts weights regularly.", "4. Patient does not smoke.", "5. Patient's temperature is 97.8°F (36.6°C).", "6. Patient's blood pressure is 122/83 mm Hg.", "7. Patient's pulse is 80/min.", "8. Patient's respirations are 13/min.", "9. Patient's oxygen saturation is 98% on room air.", "10. Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids.", "11. ECG shows left axis deviation and meets criteria for left ventricular hypertrophy.", "12. Initial troponin is < 0.01 ng/mL." ]

[ "1. The patient is generally healthy.", "2. The patient lifts weights regularly.", "3. The patient does not smoke.", "4. The patient's temperature is 97.8°F (36.6°C).", "5. The patient's blood pressure is 122/83 mm Hg.", "6. The patient's pulse is 80/min.", "7. The patient's respirations are 13/min.", "8. The patient's oxygen saturation is 98% on room air.", "9. Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids.", "10. An ECG shows left axis deviation.", "11. An ECG meets criteria for left ventricular hypertrophy.", "12. An initial troponin is < 0.01 ng/mL." ]

[ "A 66-year-old man is admitted to the intensive care unit for management of laboratory-confirmed septic shock.", "His current plan includes appropriate management of airway and breathing, intravenous antibiotics, fluid resuscitation, and supportive care.", "After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F), the pulse rate is 120/min, the blood pressure is 90/50 mm Hg, and the respiratory rate is 22/min.", "His extremities are warm and capillary refill time is normal.", "The patient is started on vasopressor therapy, and norepinephrine is chosen over epinephrine." ]

[ "1. A 66-year-old man is admitted to the intensive care unit.", "2. He has laboratory-confirmed septic shock.", "3. His current plan includes appropriate management of airway and breathing, intravenous antibiotics, fluid resuscitation, and supportive care.", "4. After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F).", "5. His pulse rate is 120/min.", "6. His blood pressure is 90/50 mm Hg.", "7. His respiratory rate is 22/min.", "8. His extremities are warm.", "9. His capillary refill time is normal.", "10. He is started on vasopressor therapy.", "11. Norepinephrine is chosen over epinephrine." ]

[ "1. His current plan includes appropriate management of airway and breathing, intravenous antibiotics, fluid resuscitation, and supportive care.", "2. After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F), the pulse rate is 120/min, the blood pressure is 90/50 mm Hg, and the respiratory rate is 22/min.", "3. His extremities are warm and capillary refill time is normal.", "4. The patient is started on vasopressor therapy.", "5. Norepinephrine is chosen over epinephrine." ]

[ "A 67-year-old man comes to the physician because of a worsening tremor that began one year ago.", "The tremor affects his left hand and improves when he uses his hand to complete a task.", "He also reports feeling stiffer throughout the day, and he has fallen twice in the past year.", "He has not noticed any changes in his cognition or mood.", "He has not had difficulty sleeping, but his wife says that he would kick and punch while dreaming for almost a decade.", "He drinks two cans of beer daily.", "He takes no medications.", "He appears healthy and well nourished.", "His vital signs are within normal limits.", "He maintains a blank stare throughout the visit." ]

[ "1. Patient is 67 years old.", "2. Patient has worsening tremor that began one year ago.", "3. Tremor affects left hand.", "4. Tremor improves when patient uses hand to complete a task.", "5. Patient reports feeling stiffer throughout the day.", "6. Patient has fallen twice in the past year.", "7. Patient has not noticed any changes in cognition or mood.", "8. Patient has not had difficulty sleeping.", "9. Patient's wife says he has been kicking and punching while dreaming for almost a decade.", "10. Patient drinks two cans of beer daily.", "11. Patient takes no medications.", "12. Patient appears healthy and well nourished.", "13. Patient's vital signs are within normal limits.", "14. Patient maintains a blank stare throughout the visit." ]

[ "1. The tremor affects his left hand.", "2. The tremor improves when he uses his hand to complete a task.", "3. He reports feeling stiffer throughout the day.", "4. He has fallen twice in the past year.", "5. He has not noticed any changes in his cognition or mood.", "6. He has not had difficulty sleeping.", "7. His wife says that he would kick and punch while dreaming for almost a decade.", "8. He drinks two cans of beer daily.", "9. He takes no medications.", "10. He appears healthy and well nourished.", "11. His vital signs are within normal limits.", "12. He maintains a blank stare throughout the visit." ]

[ "A 25-year-old African American man comes to the emergency department for “red urine.” Patient reports that he just returned from a skiing trip in the Rocky Mountains and developed the reddish urine today.", "He denies upper respiratory infection symptoms, chest pain, fever, or chills but does endorse some right flank pain that developed 3 days ago.", "Physical examination was unremarkable except for some tenderness upon palpation at the right flank.", "Laboratory findings are as follows: | | Serum: | Na+: 137 mEq/L | K+: 4.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 25 mEq/L | Osmolality: 275 Osm/kg | | Urine: | Color: Red | Protein: 3+ | RBC: 4 cells/hpf | Osmolality: 214 Osm/kg | Specific gravity: 1.004 | | ." ]

[ "1. A 25-year-old African American man comes to the emergency department for “red urine.”", "2. Patient reports that he just returned from a skiing trip in the Rocky Mountains and developed the reddish urine today.", "3. He denies upper respiratory infection symptoms, chest pain, fever, or chills.", "4. He endorses some right flank pain that developed 3 days ago.", "5. Physical examination was unremarkable except for some tenderness upon palpation at the right flank.", "6. Serum Na+: 137 mEq/L", "7. Serum K+: 4.9 mEq/L", "8. Serum Cl-: 100 mEq/L", "9. Serum HCO3-: 25 mEq/L", "10. Serum Osmolality: 275 Osm/kg", "11. Urine Color: Red", "12. Urine Protein: 3+", "13. Urine RBC: 4 cells/hpf", "14. Urine Osmolality: 214 Osm/kg", "15. Urine Specific gravity: 1.004" ]

[ "1. Patient denies upper respiratory infection symptoms, chest pain, fever, or chills.", "2. Patient endorses right flank pain that developed 3 days ago.", "3. Physical examination was unremarkable except for tenderness upon palpation at the right flank.", "4. Serum sodium level: 137 mEq/L.", "5. Serum potassium level: 4.9 mEq/L.", "6. Serum chloride level: 100 mEq/L.", "7. Serum bicarbonate level: 25 mEq/L.", "8. Serum osmolality: 275 Osm/kg.", "9. Urine color: Red.", "10. Urine protein: 3+.", "11. Urine RBC: 4 cells/hpf.", "12. Urine osmolality: 214 Osm/kg.", "13. Urine specific gravity: 1.004." ]

[ "A 62-year-old man presents to his primary care physician because of lower back pain and radiating leg pain.", "He says that the pain is searing and goes from the buttock into the posterior thigh and lateral leg.", "It is moderate in intensity and he has noticed that it worsens with sitting and improves with standing.", "His past medical history is significant for well controlled hypertension, but he has otherwise been healthy.", "He works as a laborer loading packages in a warehouse and is concerned because the pain does not allow him to work.", "On physical exam, he is found to have pain and paresthesia while performing a straight leg raise.", "Radiographs show loss of disk height and MRI shows significant degeneration and posterolateral herniation of the disk in between the L5 and S1 vertebrae.", "Adjacent disks appear to be relatively normal without notable herniation." ]

[ "1. A 62-year-old man presents to his primary care physician.", "2. He has lower back pain and radiating leg pain.", "3. The pain is searing and goes from the buttock into the posterior thigh and lateral leg.", "4. The pain is moderate in intensity.", "5. The pain worsens with sitting and improves with standing.", "6. His past medical history is significant for well controlled hypertension.", "7. He works as a laborer loading packages in a warehouse.", "8. He is concerned because the pain does not allow him to work.", "9. On physical exam, he has pain and paresthesia while performing a straight leg raise.", "10. Radiographs show loss of disk height.", "11. MRI shows significant degeneration and posterolateral herniation of the disk in between the L5 and S1 vertebrae.", "12. Adjacent disks appear to be relatively normal without notable herniation." ]

[ "1. The patient reports searing pain that goes from the buttock into the posterior thigh and lateral leg.", "2. The pain is moderate in intensity.", "3. The pain worsens with sitting and improves with standing.", "4. The patient has well controlled hypertension.", "5. The patient works as a laborer loading packages in a warehouse.", "6. The pain is preventing the patient from working.", "7. On physical exam, the patient experiences pain and paresthesia while performing a straight leg raise.", "8. Radiographs show loss of disk height.", "9. MRI shows significant degeneration and posterolateral herniation of the disk between the L5 and S1 vertebrae.", "10. Adjacent disks appear to be relatively normal without notable herniation." ]

[ "A 46-year-old woman presents to her primary care provider with pain in both of his hands and wrists.", "She notes that it is hard for her to prepare breakfast or wash dishes in the morning due to stiffness.", "It seems to subsides later in the day.", "She also complains of a constant fatigue and unintentional weight loss during the last few months.", "The past medical history is significant for hypertension.", "She takes captopril and aspirin daily, and occasional ibuprofen for the pain in her hands.", "Her mother developed similar symptoms in her hands resulting in hand deformity.", "The blood pressure is 140/90 mm Hg, heart rate is 67/min, respiratory rate is 13/min, and temperature is 37.0°C (98.6°F).", "Physical examination shows redness, edema, and tenderness on palpation at the metacarpophalangeal and proximal interphalangeal joints of both hands.", "The blood tests show the following findings: | Red blood cell count 3.3 million/mm3 | Hb 12.1 mg/dL | Leukocyte count 10,101/mm3 | ESR 48 mm/h | C-reactive protein 3.9 mg/L | Anti-cyclic citrullinated peptide 45 μ/mL | ." ]

[ "1. A 46-year-old woman presents to her primary care provider with pain in both of his hands and wrists.", "2. She notes that it is hard for her to prepare breakfast or wash dishes in the morning due to stiffness.", "3. It seems to subsides later in the day.", "4. She also complains of a constant fatigue and unintentional weight loss during the last few months.", "5. The past medical history is significant for hypertension.", "6. She takes captopril and aspirin daily, and occasional ibuprofen for the pain in her hands.", "7. Her mother developed similar symptoms in her hands resulting in hand deformity.", "8. The blood pressure is 140/90 mm Hg, heart rate is 67/min, respiratory rate is 13/min, and temperature is 37.0°C (98.6°F).", "9. Physical examination shows redness, edema, and tenderness on palpation at the metacarpophalangeal and proximal interphalangeal joints of both hands.", "10. The blood tests show the following findings:", "11. Red blood cell count 3.3 million/mm3", "12. Hb 12.1 mg/dL", "13. Leukocyte count 10,101/mm3", "14. ESR 48 mm/h", "15. C-reactive protein 3.9 mg/L", "16. Anti-cyclic citrullinated peptide 45 μ/mL." ]

[ "1. The patient has difficulty preparing breakfast and washing dishes in the morning due to stiffness.", "2. The stiffness seems to subside later in the day.", "3. The patient complains of constant fatigue and unintentional weight loss over the last few months.", "4. The patient has a past medical history significant for hypertension.", "5. The patient takes captopril and aspirin daily, and occasional ibuprofen for hand pain.", "6. The patient's mother developed similar symptoms in her hands resulting in hand deformity.", "7. The patient's blood pressure is 140/90 mm Hg, heart rate is 67/min, respiratory rate is 13/min, and temperature is 37.0°C (98.6°F).", "8. Physical examination shows redness, edema, and tenderness on palpation at the metacarpophalangeal and proximal interphalangeal joints of both hands.", "9. Blood tests show the following findings: Red blood cell count 3.3 million/mm3, Hb 12.1 mg/dL, Leukocyte count 10,101/mm3, ESR 48 mm/h, C-reactive protein 3.9 mg/L, Anti-cyclic citrullinated peptide 45 μ/mL." ]

[ "A 27-year-old woman presents to her primary care physician’s office complaining of trouble sleeping.", "She reports that for the past 10 months she has experienced difficulty falling asleep due constant worrying.", "The content of her worry include items such as whether or not her child will feel lonely in day care and the health of her parents.", "These worrying episodes typically begin toward the end of the day and last for several hours.", "She states that she has trouble concentrating at work as well and describes her heart as \"racing\" during these episodes.", "She denies any alcohol or illicit drug use." ]

[ "1. A 27-year-old woman presents to her primary care physician's office.", "2. She is complaining of trouble sleeping.", "3. She has experienced difficulty falling asleep for the past 10 months.", "4. The content of her worry includes items such as whether or not her child will feel lonely in day care and the health of her parents.", "5. These worrying episodes typically begin toward the end of the day and last for several hours.", "6. She has trouble concentrating at work.", "7. She describes her heart as \"racing\" during these episodes.", "8. She denies any alcohol or illicit drug use." ]

[ "1. The patient has experienced difficulty falling asleep for the past 10 months.", "2. The difficulty falling asleep is due to constant worrying.", "3. The content of her worry includes her child feeling lonely in day care and the health of her parents.", "4. The worrying episodes typically begin toward the end of the day and last for several hours.", "5. She has trouble concentrating at work.", "6. She describes her heart as \"racing\" during these episodes.", "7. The patient denies any alcohol or illicit drug use." ]

[ "A 10-year-old boy is brought to the physician because of fever and bloody diarrhea for the past few days.", "His parents report that he has become increasingly lethargic and irritable.", "His temperature is 38.6°C (101.4°F), pulse is 102/min, and respirations are 22/min.", "He has no significant past medical history.", "His parents say that he mostly only eats a diet of chicken, hamburgers, fries, cheese, and milk.", "On physical examination, pallor and edema in both legs are present.", "His laboratory studies show: | Hemoglobin 8.9 gm/dL | Leukocyte count 9,300/mm3 | Platelet count 67,000/mm3 | Blood urea nitrogen 43 mg/dL | Serum creatinine 2.46 mg/dL | Coombs test Negative | ." ]

[ "1. Patient is a 10-year-old boy.", "2. Patient has had fever and bloody diarrhea for the past few days.", "3. Patient has become increasingly lethargic and irritable.", "4. Patient's temperature is 38.6°C (101.4°F).", "5. Patient's pulse is 102/min.", "6. Patient's respirations are 22/min.", "7. Patient has no significant past medical history.", "8. Patient's diet consists mostly of chicken, hamburgers, fries, cheese, and milk.", "9. On physical examination, pallor and edema in both legs are present.", "10. Patient's hemoglobin is 8.9 gm/dL.", "11. Patient's leukocyte count is 9,300/mm3.", "12. Patient's platelet count is 67,000/mm3.", "13. Patient's blood urea nitrogen is 43 mg/dL.", "14. Patient's serum creatinine is 2.46 mg/dL.", "15. Patient's Coombs test is Negative." ]

[ "1. The patient is increasingly lethargic and irritable according to his parents.", "2. The patient's temperature is 38.6°C (101.4°F).", "3. The patient's pulse is 102/min.", "4. The patient's respirations are 22/min.", "5. The patient has no significant past medical history.", "6. The patient's diet mainly consists of chicken, hamburgers, fries, cheese, and milk.", "7. On physical examination, pallor and edema in both legs are present.", "8. The patient's hemoglobin level is 8.9 gm/dL.", "9. The patient's leukocyte count is 9,300/mm3.", "10. The patient's platelet count is 67,000/mm3.", "11. The patient's blood urea nitrogen level is 43 mg/dL.", "12. The patient's serum creatinine level is 2.46 mg/dL.", "13. The Coombs test is negative." ]

[ "A 50-year-old white male who works in construction comes to your office because of pain in his upper arm.", "He states that over the last few months, he has been having pain in his upper arm that worsens with raising objects overhead.", "He states that he also recently fell on his outstretched hand and that seemed to worsen his pain.", "His vital signs are within normal limits.", "He has no pain on internal or external rotation.", "He also had no pain with the lift off test, but does have significant pain with the empty can test and the arm drop test." ]

[ "1. A 50-year-old white male comes to the office.", "2. He works in construction.", "3. He has pain in his upper arm.", "4. The pain has been worsening over the last few months.", "5. He recently fell on his outstretched hand.", "6. His vital signs are within normal limits.", "7. He has no pain on internal or external rotation.", "8. He has no pain with the lift off test.", "9. He has significant pain with the empty can test.", "10. He has significant pain with the arm drop test." ]

[ "1. He has been having pain in his upper arm over the last few months.", "2. The pain worsens with raising objects overhead.", "3. He recently fell on his outstretched hand.", "4. The fall seemed to worsen his pain.", "5. His vital signs are within normal limits.", "6. He has no pain on internal or external rotation.", "7. He had no pain with the lift off test.", "8. He has significant pain with the empty can test.", "9. He has significant pain with the arm drop test." ]

[ "A 76-year-old man presents to the physician with a severe, pruritic rash as shown in the image.", "He has lost sleep over the past week because of itchiness and discomfort.", "He has not noticed any insect bites.", "He is not experiencing any pain.", "He currently lives in an elderly home where several other residents are experiencing a similar problem.", "He has no history of a serious illness and does not take any medications.", "His vital signs are within normal limits.", "A similar rash is seen on his face and below the knees on both sides.", "The skin of the groin, genital and perianal area, buttocks, and thighs show no abnormalities.", "The remainder of the physical examination is unremarkable." ]

[ "1. A 76-year-old man presents to the physician with a severe, pruritic rash.", "2. He has lost sleep over the past week because of itchiness and discomfort.", "3. He has not noticed any insect bites.", "4. He is not experiencing any pain.", "5. He currently lives in an elderly home where several other residents are experiencing a similar problem.", "6. He has no history of a serious illness and does not take any medications.", "7. His vital signs are within normal limits.", "8. A similar rash is seen on his face and below the knees on both sides.", "9. The skin of the groin, genital and perianal area, buttocks, and thighs show no abnormalities.", "10. The remainder of the physical examination is unremarkable." ]

[ "1. He has lost sleep over the past week due to itchiness and discomfort.", "2. He has not noticed any insect bites.", "3. He is not experiencing any pain.", "4. He currently lives in an elderly home where several other residents are experiencing a similar problem.", "5. He has no history of a serious illness and does not take any medications.", "6. His vital signs are within normal limits.", "7. A similar rash is seen on his face and below the knees on both sides.", "8. The skin of the groin, genital and perianal area, buttocks, and thighs show no abnormalities.", "9. The remainder of the physical examination is unremarkable." ]

[ "A 6-month-old girl is brought to the hospital by her parents for evaluation due to poor feeding for the last month.", "Her parents say that she has not been eating well over the last two months, yet her abdomen has grown larger.", "Physical exam shows a thin female infant with an enlarged liver and palpable spleen.", "Eye exam reveals a red spot on the retina.", "She has an intact muscle tone and reflexes." ]

[ "1. A 6-month-old girl is brought to the hospital by her parents.", "2. Her parents say that she has not been eating well over the last two months.", "3. Her abdomen has grown larger.", "4. Physical exam shows a thin female infant.", "5. Physical exam reveals an enlarged liver.", "6. Physical exam reveals a palpable spleen.", "7. Eye exam reveals a red spot on the retina.", "8. She has an intact muscle tone.", "9. She has intact reflexes." ]

[ "1. Her parents report poor eating over the last two months.", "2. Her abdomen has grown larger.", "3. Physical exam shows a thin female infant.", "4. She has an enlarged liver.", "5. She has a palpable spleen.", "6. Eye exam reveals a red spot on the retina.", "7. She has intact muscle tone.", "8. She has intact reflexes." ]

[ "A 24-year-old female is brought to the ED from a nearby nightclub by the local police due to aggressive and violent behavior over the past hour.", "A friend accompanying the patient reports that the patient smoked marijuana that \"seemed different\" approximately one hour ago.", "The patient has never had this kind of reaction to marijuana use in the past.", "On examination, the patient is combative with slurred speech and active visual hallucinations; eye examination shows prominent vertical nystagmus." ]

[ "1. A 24-year-old female was brought to the ED from a nearby nightclub by the local police.", "2. The patient had been exhibiting aggressive and violent behavior for the past hour.", "3. A friend accompanying the patient reported that the patient had smoked marijuana approximately one hour ago.", "4. The friend reported that the marijuana \"seemed different\".", "5. The patient had never had this kind of reaction to marijuana use in the past.", "6. On examination, the patient was combative with slurred speech and active visual hallucinations.", "7. Eye examination showed prominent vertical nystagmus." ]

[ "1. A friend accompanying the patient reports that the patient smoked marijuana approximately one hour ago.", "2. The marijuana \"seemed different\" to the patient's friend.", "3. The patient has never had this kind of reaction to marijuana use in the past.", "4. On examination, the patient is combative.", "5. The patient has slurred speech.", "6. The patient has active visual hallucinations.", "7. Eye examination shows prominent vertical nystagmus." ]

[ "A 2-month-old infant comes to the clinic because of progressive weakness and fatigue over the past 4 weeks.", "He is his mother’s first-born boy.", "She was in Mexico during the delivery and says that she had a regular 39-week gestation.", "She took folic acid during her pregnancy.", "The infant was born through vaginal delivery with no complications.", "Apgar scores were 10 and 9 at 1 and 5 minutes, respectively.", "The neonate did not go through a newborn screening process.", "His pulse is 130/min, respiratory rate is 43/min, temperature is 37.2°C (99.0°F), and blood pressure is 90/60 mm Hg.", "Physical examination shows lethargy, hypotonia, and a weak response to primitive reflexes.", "There is a “honey-like” odor around his diaper which the mother says has been present since birth." ]

[ "1. A 2-month-old infant comes to the clinic because of progressive weakness and fatigue over the past 4 weeks.", "2. He is his mother’s first-born boy.", "3. She was in Mexico during the delivery.", "4. She says that she had a regular 39-week gestation.", "5. She took folic acid during her pregnancy.", "6. The infant was born through vaginal delivery with no complications.", "7. Apgar scores were 10 and 9 at 1 and 5 minutes, respectively.", "8. The neonate did not go through a newborn screening process.", "9. His pulse is 130/min.", "10. Respiratory rate is 43/min.", "11. Temperature is 37.2°C (99.0°F).", "12. Blood pressure is 90/60 mm Hg.", "13. Physical examination shows lethargy, hypotonia, and a weak response to primitive reflexes.", "14. There is a “honey-like” odor around his diaper which the mother says has been present since birth." ]

[ "1. He is his mother’s first-born boy.", "2. She was in Mexico during the delivery and says that she had a regular 39-week gestation.", "3. She took folic acid during her pregnancy.", "4. The infant was born through vaginal delivery with no complications.", "5. Apgar scores were 10 and 9 at 1 and 5 minutes, respectively.", "6. The neonate did not go through a newborn screening process.", "7. His pulse is 130/min, respiratory rate is 43/min, temperature is 37.2°C (99.0°F), and blood pressure is 90/60 mm Hg.", "8. Physical examination shows lethargy, hypotonia, and a weak response to primitive reflexes.", "9. There is a “honey-like” odor around his diaper which the mother says has been present since birth." ]

[ "A 35-year-old engineer is told by his boss that his team will need to work extra evening hours in the coming week in order to meet a project deadline.", "This frustrates the engineer, who already feels he is working too many hours.", "Instead of discussing this directly with his boss, the engineer calls in sick and leaves his work for his boss to finish." ]

[ "1. A 35-year-old engineer is told by his boss that his team will need to work extra evening hours in the coming week.", "2. The extra evening hours are in order to meet a project deadline.", "3. The engineer already feels he is working too many hours.", "4. The engineer does not discuss this directly with his boss.", "5. The engineer calls in sick and leaves his work for his boss to finish." ]

[ "1. The engineer is frustrated.", "2. The engineer feels he is working too many hours.", "3. The engineer does not directly discuss the issue with his boss.", "4. The engineer calls in sick.", "5. The engineer leaves his work for his boss to finish." ]

[ "A 29-year-old woman comes to the physician because of a 4-month history of fever, progressive shortness of breath, and a dry cough.", "During this time, she has also had a 5-kg (11-lb) weight loss.", "Two months ago, she was in Kenya for several weeks to visit her family.", "Physical examination shows fine crackles and wheezing over both lung fields.", "Her serum calcium concentration is 11.8 mg/dL.", "An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy." ]

[ "1. A 29-year-old woman comes to the physician.", "2. She has had a 4-month history of fever, progressive shortness of breath, and a dry cough.", "3. She has had a 5-kg (11-lb) weight loss.", "4. Two months ago, she was in Kenya for several weeks to visit her family.", "5. Physical examination shows fine crackles and wheezing over both lung fields.", "6. Her serum calcium concentration is 11.8 mg/dL.", "7. An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy." ]

[ "1. She has had a 5-kg (11-lb) weight loss.", "2. Two months ago, she was in Kenya for several weeks to visit her family.", "3. Physical examination shows fine crackles and wheezing over both lung fields.", "4. Her serum calcium concentration is 11.8 mg/dL.", "5. An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy." ]

[ "A 58-year-old man undergoes coronary angiography that demonstrates a 90% stenosis of the left anterior descending coronary artery.", "The circumflex branch of the left coronary artery is not significantly obstructed.", "Prior to the angiogram, he underwent a pharmacologic cardiac stress test.", "When administered, the pharmacologic agent caused the left circumflex artery to vasodilate, with resulting increased blood supply to its supplied myocardium that was already well-perfused at baseline.", "This increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery, resulting in ischemia that manifested as a perfusion defect on radionuclide imaging." ]

[ "1. A 58-year-old man underwent coronary angiography.", "2. The angiography demonstrated a 90% stenosis of the left anterior descending coronary artery.", "3. The circumflex branch of the left coronary artery was not significantly obstructed.", "4. The man underwent a pharmacologic cardiac stress test prior to the angiogram.", "5. The pharmacologic agent caused the left circumflex artery to vasodilate.", "6. This increased blood supply to its supplied myocardium that was already well-perfused at baseline.", "7. This increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery.", "8. This resulted in ischemia that manifested as a perfusion defect on radionuclide imaging." ]

[ "1. The circumflex branch of the left coronary artery is not significantly obstructed.", "2. Prior to the angiogram, the patient underwent a pharmacologic cardiac stress test.", "3. The pharmacologic agent caused the left circumflex artery to vasodilate when administered.", "4. The vasodilation resulted in increased blood supply to the supplied myocardium, which was already well-perfused at baseline.", "5. The increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery.", "6. This resulted in ischemia that manifested as a perfusion defect on radionuclide imaging." ]

[ "A 51-year-old woman comes to the physician because of a 3-week history of fatigue, non-productive cough, and worsening shortness of breath while walking.", "She was diagnosed with HIV 11 years ago.", "Two years ago, she was treated for esophageal thrush with fluconazole.", "She takes no medications because she does not feel like she needs them.", "She occasionally uses intravenous illicit drugs and has smoked a pack of cigarettes daily for 35 years.", "She appears ill.", "Her temperature is 38.4°C (101.1°F), respiratory rate is 25/min, pulse is 116/min, and blood pressure is 115/70 mm Hg.", "Pulse oximetry shows an oxygen saturation of 89% on room air.", "Inspiratory crackles are heard over bilateral lung fields.", "Cardiac examination shows no abnormalities.", "Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3) and an elevated HIV viral load.", "An x-ray of the chest shows diffuse interstitial infiltrates bilaterally.", "In addition to starting antiretroviral therapy, the appropriate treatment for her current illness is initiated." ]

[ "1. A 51-year-old woman comes to the physician.", "2. She has a 3-week history of fatigue, non-productive cough, and worsening shortness of breath while walking.", "3. She was diagnosed with HIV 11 years ago.", "4. Two years ago, she was treated for esophageal thrush with fluconazole.", "5. She takes no medications.", "6. She occasionally uses intravenous illicit drugs.", "7. She has smoked a pack of cigarettes daily for 35 years.", "8. She appears ill.", "9. Her temperature is 38.4°C (101.1°F).", "10. Her respiratory rate is 25/min.", "11. Her pulse is 116/min.", "12. Her blood pressure is 115/70 mm Hg.", "13. Pulse oximetry shows an oxygen saturation of 89% on room air.", "14. Inspiratory crackles are heard over bilateral lung fields.", "15. Cardiac examination shows no abnormalities.", "16. Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3).", "17. Laboratory studies show an elevated HIV viral load.", "18. An x-ray of the chest shows diffuse interstitial infiltrates bilaterally.", "19. The appropriate treatment for her current illness is initiated in addition to starting antiretroviral therapy." ]

[ "1. She was diagnosed with HIV 11 years ago.", "2. Two years ago, she was treated for esophageal thrush with fluconazole.", "3. She takes no medications because she does not feel like she needs them.", "4. She occasionally uses intravenous illicit drugs.", "5. She has smoked a pack of cigarettes daily for 35 years.", "6. She appears ill.", "7. Her temperature is 38.4°C (101.1°F).", "8. Her respiratory rate is 25/min.", "9. Her pulse is 116/min.", "10. Her blood pressure is 115/70 mm Hg.", "11. Pulse oximetry shows an oxygen saturation of 89% on room air.", "12. Inspiratory crackles are heard over bilateral lung fields.", "13. Cardiac examination shows no abnormalities.", "14. Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3).", "15. Laboratory studies show an elevated HIV viral load.", "16. An x-ray of the chest shows diffuse interstitial infiltrates bilaterally.", "17. In addition to starting antiretroviral therapy, the appropriate treatment for her current illness is initiated." ]

[ "A 37-year-old man presents with right lower extremity weakness and low back pain.", "The patient states that he has had chronic mild to moderate low back pain for several years, but, 3 days ago after lifting a box, the pain increased in intensity and spread to his right leg.", "He describes the pain as severe, electrical in character, and descending from his right gluteal region along his right posterior thigh and leg to his right lateral ankle and foot.", "The patient also says that he has been having difficulty walking due to stumbling over his right foot.", "His temperature is 37.0℃ (98.6℉), the blood pressure is 125/80 mm Hg, the pulse is 72/min, the respiratory rate is 16/min, and the oxygen saturation is 98% on room air.", "On physical examination, the patient is alert and cooperative.", "Musculoskeletal examination of the lower extremities shows the following results: | Functional Muscle Group/DTR Tested Right Side Left Side | Strength | Hip extension 5/5 5/5 | Hip abduction 4/5 5/5 | Hip adduction 5/5 5/5 | Hip flexion 5/5 5/5 | Knee flexion 5/5 5/5 | Knee extension 5/5 5/5 | Foot plantar flexion 5/5 5/5 | Foot dorsiflexion 4/5 5/5 | Foot inversion 4/5 5/5 | Foot eversion 4/5 5/5 | Toe extension 3/5 5/5 | Reflexes | Knee 3+ 3+ | Achilles 1+ 3+ | Plantar 2+ 3+ | Sensory | Sensation Decreased on the lateral aspect of the lower leg and dorsum of the foot Normal over all the surface | Lassegue test Positive at 30 deg.", "Negative | ." ]

[ "1. Patient is 37-years-old.", "2. Patient presents with right lower extremity weakness and low back pain.", "3. Patient has had chronic mild to moderate low back pain for several years.", "4. Pain increased in intensity and spread to right leg 3 days ago after lifting a box.", "5. Patient describes pain as severe, electrical in character, and descending from right gluteal region along right posterior thigh and leg to right lateral ankle and foot.", "6. Patient has been having difficulty walking due to stumbling over right foot.", "7. Temperature is 37.0℃ (98.6℉).", "8. Blood pressure is 125/80 mm Hg.", "9. Pulse is 72/min.", "10. Respiratory rate is 16/min.", "11. Oxygen saturation is 98% on room air.", "12. Patient is alert and cooperative on physical examination.", "13. Strength of hip extension is 5/5 on right side and 5/5 on left side.", "14. Strength of hip abduction is 4/5 on right side and 5/5 on left side.", "15. Strength of hip adduction is 5/5 on right side and 5/5 on left side.", "16. Strength of hip flexion is 5/5 on right side and 5/5 on left side.", "17. Strength of knee flexion is 5/5 on right side and 5/5 on left side.", "18. Strength of knee extension is 5/5 on right side and 5/5 on left side.", "19. Strength of foot plantar flexion is 5/5 on right side and 5/5 on left side.", "20. Strength of foot dorsiflexion is 4/5 on right side and 5/5 on left side.", "21. Strength of foot inversion is 4/5 on right side and 5/5 on left side.", "22. Strength of foot eversion is 4/5 on right side and 5/5 on left side.", "23. Strength of toe extension is 3/5 on right side and 5/5 on left side.", "24. Knee reflex is 3+ on right side and 3+ on left side.", "25. Achilles reflex is 1+ on right side and 3+ on left side.", "26. Plantar reflex is 2+ on right side and 3+ on left" ]

[ "1. The patient has chronic mild to moderate low back pain for several years.", "2. The pain increased in intensity and spread to his right leg after lifting a box 3 days ago.", "3. The pain is described as severe, electrical in character, and descending from his right gluteal region along his right posterior thigh and leg to his right lateral ankle and foot.", "4. The patient has been having difficulty walking due to stumbling over his right foot.", "5. The patient's temperature is 37.0℃ (98.6℉).", "6. The blood pressure is 125/80 mm Hg.", "7. The pulse is 72/min.", "8. The respiratory rate is 16/min.", "9. The oxygen saturation is 98% on room air.", "10. On physical examination, the patient is alert and cooperative.", "11. Musculoskeletal examination of the lower extremities shows various strength and reflex test results, as well as sensory and Lassegue test results." ]

[ "A 21-year-old woman comes to the physician because of a 5-day history of pain with urination and vaginal itching.", "She is sexually active with multiple partners and uses condoms inconsistently.", "Pelvic examination shows erythema of the vulva and vaginal mucosa, punctate hemorrhages on the cervix, and green-yellow, malodorous discharge.", "A photomicrograph of the discharge is shown." ]

[ "1. A 21-year-old woman comes to the physician.", "2. She has a 5-day history of pain with urination and vaginal itching.", "3. She is sexually active with multiple partners.", "4. She uses condoms inconsistently.", "5. Pelvic examination shows erythema of the vulva and vaginal mucosa.", "6. Pelvic examination shows punctate hemorrhages on the cervix.", "7. Pelvic examination shows green-yellow, malodorous discharge.", "8. A photomicrograph of the discharge is shown." ]

[ "1. She is sexually active with multiple partners.", "2. She uses condoms inconsistently.", "3. Pelvic examination shows erythema of the vulva.", "4. Pelvic examination shows erythema of the vaginal mucosa.", "5. Pelvic examination shows punctate hemorrhages on the cervix.", "6. Pelvic examination shows green-yellow, malodorous discharge.", "7. A photomicrograph of the discharge is shown." ]

[ "A 9-year-old girl has recently begun having daily staring-spells in which she becomes unresponsive for several seconds.", "Following these episodes, she rapidly returns to normal with no recollection of the event.", "Her performance in school has begun to deteriorate.", "The child's pediatrician refers her to a pediatric neurologist, and, after an appropriate neurological work-up, the child is diagnosed with absence seizures.", "Her neurologist recommends initiating an anti-seizure medication, but the patient adamantly refuses due to fear of side effects and her belief that the condition is not affecting her quality of life." ]

[ "1. A 9-year-old girl has recently begun having daily staring-spells.", "2. During these episodes, she becomes unresponsive for several seconds.", "3. Following the episodes, she rapidly returns to normal with no recollection of the event.", "4. Her performance in school has begun to deteriorate.", "5. The child's pediatrician refers her to a pediatric neurologist.", "6. After an appropriate neurological work-up, the child is diagnosed with absence seizures.", "7. Her neurologist recommends initiating an anti-seizure medication.", "8. The patient adamantly refuses due to fear of side effects.", "9. The patient also refuses due to her belief that the condition is not affecting her quality of life." ]

[ "1. Following episodes, the patient rapidly returns to normal with no recollection of the event.", "2. The patient's performance in school has begun to deteriorate.", "3. The child's pediatrician refers her to a pediatric neurologist.", "4. After an appropriate neurological work-up, the child is diagnosed with absence seizures.", "5. Her neurologist recommends initiating an anti-seizure medication.", "6. The patient adamantly refuses the medication due to fear of side effects and her belief that the condition is not affecting her quality of life." ]

[ "A 44-year-old woman comes to the physician because of pain and swelling below her left eye for 3 days.", "She has also had excessive watering from her eyes during this period.", "She has no history of serious illness and takes no medications.", "Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 110/70 mm Hg.", "Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye.", "There is purulent discharge from the lower lacrimal punctum on palpation of the swelling.", "The remainder of the examination shows no abnormalities.", "The discharge is sent for cultures." ]

[ "1. A 44-year-old woman comes to the physician.", "2. She has pain and swelling below her left eye for 3 days.", "3. She has had excessive watering from her eyes during this period.", "4. She has no history of serious illness.", "5. She takes no medications.", "6. Her temperature is 37°C (98.6°F).", "7. Her pulse is 90/min.", "8. Her blood pressure is 110/70 mm Hg.", "9. Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye.", "10. There is purulent discharge from the lower lacrimal punctum on palpation of the swelling.", "11. The remainder of the examination shows no abnormalities.", "12. The discharge is sent for cultures." ]

[ "1. Excessive watering from her eyes", "2. No history of serious illness", "3. Takes no medications", "4. Temperature is 37°C (98.6°F)", "5. Pulse is 90/min", "6. Blood pressure is 110/70 mm Hg", "7. Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye", "8. Purulent discharge from the lower lacrimal punctum on palpation of the swelling", "9. The remainder of the examination shows no abnormalities", "10. The discharge is sent for cultures" ]

[ "A 40-year-old man comes to the physician because of decreased sexual arousal and erectile dysfunction that has put strain on his marriage for the last year.", "He has also had fatigue and generalized weakness for the past 9 months.", "He has noticed his bowel movements have not been as frequent as usual.", "He has occasional dry coughing and back pain.", "He has not had fever, headache, or changes in vision.", "One year ago, he traveled to South Africa with his wife.", "He looks fatigued.", "He is 168 cm (5 ft 6 in) tall and weighs 89 kg (196 lb); BMI is 31.6 kg/m2.", "His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 125/90 mm Hg.", "Physical examination shows dry skin and a distended abdomen.", "Neurological examination reveals delayed deep tendon reflexes.", "Laboratory studies show: | Hemoglobin 11.0 g/dL | Platelet count 380,000/mm3 | Serum | Na+ 130 mEq/L | Cl- 97 mEq/L | K+ 4.5 mEq/L | HCO3- 25 mEq/L | Glucose 95 mg/dL | TSH 0.2 μU/mL | ." ]

[ "1. A 40-year-old man comes to the physician.", "2. He has decreased sexual arousal and erectile dysfunction.", "3. This has put strain on his marriage for the last year.", "4. He has had fatigue and generalized weakness for the past 9 months.", "5. He has noticed his bowel movements have not been as frequent as usual.", "6. He has occasional dry coughing and back pain.", "7. He has not had fever, headache, or changes in vision.", "8. One year ago, he traveled to South Africa with his wife.", "9. He looks fatigued.", "10. He is 168 cm (5 ft 6 in) tall.", "11. He weighs 89 kg (196 lb).", "12. His BMI is 31.6 kg/m2.", "13. His temperature is 36.5°C (97.7°F).", "14. His pulse is 50/min.", "15. His blood pressure is 125/90 mm Hg.", "16. Physical examination shows dry skin and a distended abdomen.", "17. Neurological examination reveals delayed deep tendon reflexes.", "18. Laboratory studies show: Hemoglobin 11.0 g/dL.", "19. Laboratory studies show: Platelet count 380,000/mm3.", "20. Laboratory studies show: Serum Na+ 130 mEq/L.", "21. Laboratory studies show: Cl- 97 mEq/L.", "22. Laboratory studies show: K+ 4.5 mEq/L.", "23. Laboratory studies show: HCO3- 25 mEq/L.", "24. Laboratory studies show: Glucose 95 mg/dL.", "25. Laboratory studies show: TSH 0.2 μU/mL." ]

[ "1. He has had fatigue and generalized weakness for the past 9 months.", "2. His bowel movements have not been as frequent as usual.", "3. He has occasional dry coughing and back pain.", "4. He has not had fever, headache, or changes in vision.", "5. One year ago, he traveled to South Africa with his wife.", "6. He looks fatigued.", "7. He is 168 cm (5 ft 6 in) tall and weighs 89 kg (196 lb); BMI is 31.6 kg/m2.", "8. His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 125/90 mm Hg.", "9. Physical examination shows dry skin and a distended abdomen.", "10. Neurological examination reveals delayed deep tendon reflexes.", "11. Laboratory studies show: Hemoglobin 11.0 g/dL, Platelet count 380,000/mm3, Serum Na+ 130 mEq/L, Cl- 97 mEq/L, K+ 4.5 mEq/L, HCO3- 25 mEq/L, Glucose 95 mg/dL, TSH 0.2 μU/mL." ]

[ "A 52-year-old man with limited, unresectable small cell lung cancer comes to the emergency department because of fever for the past 2 days.", "He has been on numerous chemotherapy regimens.", "His last round of treatment was with cisplatin and etoposide and ended 10 days ago.", "He feels fatigued but has not had nausea or vomiting.", "His temperature is 38.5°C (101.3°F), blood pressure is 100/60 mm Hg, and pulse is 115/min.", "The lungs are clear to auscultation.", "Examination shows a soft, nontender abdomen.", "Laboratory studies show: | Hemoglobin 10.2 g/dL | Leukocyte count 4,000/mm3 | Total neutrophils 8% | Eosinophils 2% | Lymphocytes 80% | Monocytes 10% | Urinalysis shows no abnormalities.", "Blood culture samples are obtained." ]

[ "1. A 52-year-old man has limited, unresectable small cell lung cancer.", "2. He has been on numerous chemotherapy regimens.", "3. His last round of treatment was with cisplatin and etoposide and ended 10 days ago.", "4. He has had fever for the past 2 days.", "5. He feels fatigued but has not had nausea or vomiting.", "6. His temperature is 38.5°C (101.3°F).", "7. His blood pressure is 100/60 mm Hg.", "8. His pulse is 115/min.", "9. The lungs are clear to auscultation.", "10. His hemoglobin is 10.2 g/dL.", "11. His leukocyte count is 4,000/mm3.", "12. His total neutrophils are 8%.", "13. His eosinophils are 2%.", "14. His lymphocytes are 80%.", "15. His monocytes are 10%.", "16. His urinalysis shows no abnormalities.", "17. Blood culture samples are obtained." ]

[ "1. He has been on numerous chemotherapy regimens.", "2. His last round of treatment was with cisplatin and etoposide and ended 10 days ago.", "3. He feels fatigued but has not had nausea or vomiting.", "4. His temperature is 38.5°C (101.3°F), blood pressure is 100/60 mm Hg, and pulse is 115/min.", "5. The lungs are clear to auscultation.", "6. Examination shows a soft, nontender abdomen.", "7. Laboratory studies show: Hemoglobin 10.2 g/dL, Leukocyte count 4,000/mm3, Total neutrophils 8%, Eosinophils 2%, Lymphocytes 80%, Monocytes 10%.", "8. Urinalysis shows no abnormalities.", "9. Blood culture samples are obtained." ]

[ "A 28-year-old woman presents in respiratory distress.", "Auscultation of the lungs reveals bilateral crepitations and a friction rub.", "Lab findings show pancytopenia, proteinuria, and a false-positive test for syphilis.", "A chest X-ray shows bilateral pleural effusions." ]

[ "1. A 28-year-old woman presents in respiratory distress.", "2. Auscultation of the lungs reveals bilateral crepitations.", "3. Auscultation of the lungs reveals a friction rub.", "4. Lab findings show pancytopenia.", "5. Lab findings show proteinuria.", "6. Lab findings show a false-positive test for syphilis.", "7. A chest X-ray shows bilateral pleural effusions." ]

[ "1. Auscultation of the lungs reveals bilateral crepitations.", "2. Auscultation of the lungs reveals a friction rub.", "3. Lab findings show pancytopenia.", "4. Lab findings show proteinuria.", "5. Lab findings show a false-positive test for syphilis.", "6. A chest X-ray shows bilateral pleural effusions." ]

[ "A 2-month-old infant is brought in by his mother for runny nose and cough.", "She reports he had an ear infection 2 weeks ago, and since then he has had a productive cough and nasal congestion.", "His medical history is significant for multiple ear infections and eczematous dermatitis.", "He has also been hospitalized for 2 episodes of severe viral bronchiolitis.", "The mother reports that the infant has a good appetite but has had intermittent, non-bloody diarrhea.", "The patient is at the 20th percentile for weight.", "On physical examination, the patient has widespread, dry, erythematous patches, mucopurulent nasal drip, and crusting of the nares.", "His tongue is coated by a thick white film which is easily scraped off.", "Crackles are heard at the left lung base.", "Labs are drawn, as shown below: | | Hemoglobin: 12.8 g/dL | Platelets: 280,000/mm^3 | Leukocytes: 7,500/mm^3 | Neutrophils: 5,500/mm^3 | Lymphocytes: 2,000/mm^3 | | Serum: | Na+: 138 mEq/L | Cl-: 96 mEq/L | K+: 4.3 mEq/L | HCO3-: 23 mEq/L | Urea nitrogen: 18 mg/dL | Glucose: 90 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: : 9.2 mg/dL | | ." ]

[ "1. A 2-month-old infant is brought in by his mother.", "2. The infant has a runny nose and cough.", "3. The mother reports he had an ear infection 2 weeks ago.", "4. Since then he has had a productive cough and nasal congestion.", "5. His medical history is significant for multiple ear infections and eczematous dermatitis.", "6. He has also been hospitalized for 2 episodes of severe viral bronchiolitis.", "7. The mother reports that the infant has a good appetite.", "8. The infant has intermittent, non-bloody diarrhea.", "9. The patient is at the 20th percentile for weight.", "10. On physical examination, the patient has widespread, dry, erythematous patches.", "11. The patient has mucopurulent nasal drip and crusting of the nares.", "12. His tongue is coated by a thick white film which is easily scraped off.", "13. Crackles are heard at the left lung base.", "14. Hemoglobin: 12.8 g/dL", "15. Platelets: 280,000/mm^3", "16. Leukocytes: 7,500/mm^3", "17. Neutrophils: 5,500/mm^3", "18. Lymphocytes: 2,000/mm^3", "19. Serum Na+: 138 mEq/L", "20. Serum Cl-: 96 mEq/L", "21. Serum K+: 4.3 mEq/L", "22. Serum HCO3-: 23 mEq/L", "23. Serum Urea nitrogen: 18 mg/dL", "24. Serum Glucose: 90 mg/dL", "25. Serum Creatinine: 1.0 mg/dL", "26. Serum Ca2+: 9.2 mg/dL" ]

[ "1. She reports he had an ear infection 2 weeks ago", "2. Since then he has had a productive cough and nasal congestion", "3. His medical history is significant for multiple ear infections and eczematous dermatitis", "4. He has been hospitalized for 2 episodes of severe viral bronchiolitis", "5. The mother reports that the infant has a good appetite but has had intermittent, non-bloody diarrhea", "6. The patient is at the 20th percentile for weight", "7. On physical examination, the patient has widespread, dry, erythematous patches, mucopurulent nasal drip, and crusting of the nares", "8. His tongue is coated by a thick white film which is easily scraped off", "9. Crackles are heard at the left lung base", "10. Labs are drawn, as shown below:", "11. Hemoglobin: 12.8 g/dL", "12. Platelets: 280,000/mm^3", "13. Leukocytes: 7,500/mm^3", "14. Neutrophils: 5,500/mm^3", "15. Lymphocytes: 2,000/mm^3", "16. Serum: Na+: 138 mEq/L", "17. Cl-: 96 mEq/L", "18. K+: 4.3 mEq/L", "19. HCO3-: 23 mEq/L", "20. Urea nitrogen: 18 mg/dL", "21. Glucose: 90 mg/dL", "22. Creatinine: 1.0 mg/dL", "23. Ca2+: : 9.2 mg/dL" ]

[ "A 51-year-old inmate was released from prison 1 month ago and visits his general practitioner for evaluation of a positive HIV diagnosis he received from a local free clinic a week ago.", "The patient states that he had spent the last 2 years in prison and that, during that time, he had engaged in multiple unprotected sexual acts with fellow male inmates.", "When he was released from prison recently, he decided to get tested for HIV and was diagnosed positive.", "He is currently married with 2 children and has been paroled back to the home he shares with them.", "He has not told either his wife or his children of his diagnosis.", "He adamantly states that he is not homosexual, but that his wife would assume that he is if she found out he had contracted HIV while in prison.", "He states that he is terrified his wife will leave him or possibly keep his children from seeing him if she finds out about his HIV status.", " He wants to be treated without the threat of his wife finding out.", "He insists that he will use the proper precautions to ensure his wife and children don’t contract HIV from him and reiterates the importance of keeping his diagnosis a secret.", "He continues and states that “they are all I have.", "If they leave me, I have no one.” ." ]

[ "1. A 51-year-old inmate was released from prison 1 month ago.", "2. He visits his general practitioner for evaluation of a positive HIV diagnosis he received from a local free clinic a week ago.", "3. He had spent the last 2 years in prison.", "4. During that time, he had engaged in multiple unprotected sexual acts with fellow male inmates.", "5. He is currently married with 2 children.", "6. He has been paroled back to the home he shares with them.", "7. He has not told either his wife or his children of his HIV diagnosis.", "8. He adamantly states that he is not homosexual.", "9. He is terrified his wife will leave him or possibly keep his children from seeing him if she finds out about his HIV status.", "10. He wants to be treated without the threat of his wife finding out.", "11. He insists that he will use the proper precautions to ensure his wife and children don’t contract HIV from him.", "12. He reiterates the importance of keeping his diagnosis a secret.", "13. He states that “they are all I have. If they leave me, I have no one.”" ]

[ "1. The patient spent the last 2 years in prison.", "2. During his time in prison, he engaged in multiple unprotected sexual acts with fellow male inmates.", "3. He was diagnosed positive for HIV after getting tested upon release from prison.", "4. He is currently married with 2 children.", "5. He has been paroled back to the home he shares with his wife and children.", "6. He has not told his wife or children about his HIV diagnosis.", "7. He adamantly states that he is not homosexual.", "8. He fears his wife will assume he is homosexual if she finds out about his HIV status.", "9. He is terrified his wife will leave him or keep his children from seeing him if she finds out about his HIV status.", "10. He wants to be treated without his wife finding out.", "11. He insists on using proper precautions to ensure his wife and children don’t contract HIV from him.", "12. He emphasizes the importance of keeping his diagnosis a secret.", "13. He states that his family is all he has and fears losing them." ]

[ "A 62-year-old man with end-stage renal disease is brought to the emergency department because of fever, severe abdominal pain, and shaking chills for 4 hours.", "His last hemodialysis was 2 days ago.", "On arrival, he appears ill and is poorly responsive.", "Blood cultures grow gram-positive, catalase-positive cocci that express mecA.", "Intravenous antibiotic therapy is begun with an agent that disrupts cell membranes by creating transmembrane channels." ]

[ "1. A 62-year-old man with end-stage renal disease is brought to the emergency department.", "2. He has fever, severe abdominal pain, and shaking chills for 4 hours.", "3. His last hemodialysis was 2 days ago.", "4. On arrival, he appears ill and is poorly responsive.", "5. Blood cultures grow gram-positive, catalase-positive cocci that express mecA.", "6. Intravenous antibiotic therapy is begun with an agent that disrupts cell membranes by creating transmembrane channels." ]

[ "1. His last hemodialysis was 2 days ago.", "2. On arrival, he appears ill.", "3. On arrival, he is poorly responsive.", "4. Blood cultures grow gram-positive, catalase-positive cocci.", "5. The cocci express mecA.", "6. Intravenous antibiotic therapy is begun.", "7. The antibiotic disrupts cell membranes.", "8. The antibiotic creates transmembrane channels." ]

[ "A 25-year-old woman comes to the physician because of pain and weakness in her left leg that started 2 days ago while running a marathon.", "Physical examination shows impaired flexion of the left knee joint and impaired extension of the left hip joint.", "An MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle and the semitendinosus muscle." ]

[ "1. A 25-year-old woman comes to the physician.", "2. She has pain and weakness in her left leg.", "3. The pain and weakness started 2 days ago.", "4. She was running a marathon when the pain and weakness started.", "5. Physical examination shows impaired flexion of the left knee joint.", "6. Physical examination shows impaired extension of the left hip joint.", "7. An MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle.", "8. An MRI of the left lower extremity shows injury to the semitendinosus muscle." ]

[ "1. Physical examination shows impaired flexion of the left knee joint.", "2. Physical examination shows impaired extension of the left hip joint.", "3. MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle.", "4. MRI of the left lower extremity shows injury to the semitendinosus muscle." ]

[ "A 32-year-old man and his 29-year-old wife come to the physician because they have been unable to conceive despite regular unprotected sexual intercourse for 13 months.", "The woman reports regular menstrual cycles since the age of 13.", "Menses occur at regular 28-day intervals and last 5–7 days.", "Ovulation predictor kits consistently turn positive around day 14.", "The man has a negative history of mumps.", "They each smoked one pack of cigarettes per day until one year ago.", "The man works in construction and his wife is a secretary for a law firm.", "Examination of the scrotum in a standing position shows soft bands palpated in the upper pole of the left scrotum with an intact left testicle.", "Following Valsalva maneuver, the patient reports a dull, aching pain in his left hemiscrotum.", "A light held behind the scrotum does not shine through.", "The right scrotum appears normal.", "Semen studies show normal sperm count with moderately decreased motility and abnormal morphology." ]

[ "1. A 32-year-old man and a 29-year-old wife come to the physician.", "2. They have been unable to conceive despite regular unprotected sexual intercourse for 13 months.", "3. The woman reports regular menstrual cycles since the age of 13.", "4. Menses occur at regular 28-day intervals and last 5–7 days.", "5. Ovulation predictor kits consistently turn positive around day 14.", "6. The man has a negative history of mumps.", "7. They each smoked one pack of cigarettes per day until one year ago.", "8. The man works in construction.", "9. The wife is a secretary for a law firm.", "10. Examination of the scrotum in a standing position shows soft bands palpated in the upper pole of the left scrotum with an intact left testicle.", "11. Following Valsalva maneuver, the patient reports a dull, aching pain in his left hemiscrotum.", "12. A light held behind the scrotum does not shine through.", "13. The right scrotum appears normal.", "14. Semen studies show normal sperm count with moderately decreased motility and abnormal morphology." ]

[ "1. The woman reports regular menstrual cycles since the age of 13.", "2. Menses occur at regular 28-day intervals and last 5–7 days.", "3. Ovulation predictor kits consistently turn positive around day 14.", "4. The man has a negative history of mumps.", "5. They each smoked one pack of cigarettes per day until one year ago.", "6. The man works in construction and his wife is a secretary for a law firm.", "7. Examination of the scrotum in a standing position shows soft bands palpated in the upper pole of the left scrotum with an intact left testicle.", "8. Following Valsalva maneuver, the patient reports a dull, aching pain in his left hemiscrotum.", "9. A light held behind the scrotum does not shine through.", "10. The right scrotum appears normal.", "11. Semen studies show normal sperm count with moderately decreased motility and abnormal morphology." ]

[ "A 29-year-old man comes into his primary care physician's office with a chief complaint of a cough.", "The patient states that the cough started yesterday and he is asking if he needs antibiotics.", "While conversing with the patient, you note that he seems cold, mistrustful, and does not display much emotion.", "The patient worked for a software company but recently took a different position that allows him to work from home.", "The patient states that he switched positions because while at the office he made a mistake during a presentation.", "He felt that afterwards, his fellow workers thought less of him and he was embarrassed to show his face around the office.", "The patient wishes he could have related better to his coworkers.", "He currently lives in a barn on the outskirts of town with his many cats.", "On physical exam you note a healthy young man, adorned in overalls and denim shoes.", "His physical exam is notable for erythema of the posterior pharynx.", "The patient is informed that he has a viral upper respiratory infection and is sent home with instructions to rest and hydrate himself." ]

[ "1. Patient is 29 years old.", "2. Chief complaint is a cough.", "3. Cough started yesterday.", "4. Patient is cold, mistrustful, and does not display much emotion.", "5. Patient worked for a software company.", "6. Patient recently took a different position that allows him to work from home.", "7. Patient switched positions because of a mistake during a presentation.", "8. Patient felt his coworkers thought less of him after the mistake.", "9. Patient wishes he could have related better to his coworkers.", "10. Patient currently lives in a barn on the outskirts of town with his many cats.", "11. On physical exam patient is healthy and adorned in overalls and denim shoes.", "12. Physical exam is notable for erythema of the posterior pharynx.", "13. Patient has a viral upper respiratory infection.", "14. Patient is sent home with instructions to rest and hydrate himself." ]

[ "1. The patient states that the cough started yesterday.", "2. The patient is asking if he needs antibiotics.", "3. The patient seems cold, mistrustful, and does not display much emotion.", "4. The patient worked for a software company.", "5. The patient recently took a different position that allows him to work from home.", "6. The patient switched positions because he made a mistake during a presentation at the office.", "7. The patient felt embarrassed to show his face around the office.", "8. The patient wishes he could have related better to his coworkers.", "9. The patient currently lives in a barn on the outskirts of town with his many cats.", "10. On physical exam, a healthy young man is noted, adorned in overalls and denim shoes.", "11. The physical exam is notable for erythema of the posterior pharynx.", "12. The patient is informed that he has a viral upper respiratory infection.", "13. The patient is sent home with instructions to rest and hydrate himself." ]

[ "A 49-year-old man is undergoing an elective hernia repair.", "No significant past medical history or current medications.", "The patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years.", "In obtaining informed consent, the patient’s doctor has described all the available options for the procedure with their pros and cons, has offered different materials for the hernioplasty, and described the exact procedure.", "He has not focused too much on the possible complications and the risks and benefits of not performing the operation, because the patient insists he already knows everything that can happen since he is a surgeon himself.", "The patient has given his consent, but on the day of the operation, he changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty." ]

[ "1. Patient is 49 years old.", "2. Patient has no significant past medical history or current medications.", "3. Patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years.", "4. Doctor has described all the available options for the procedure with their pros and cons.", "5. Doctor has offered different materials for the hernioplasty.", "6. Doctor has described the exact procedure.", "7. Doctor has not focused too much on the possible complications and the risks and benefits of not performing the operation.", "8. Patient has given his consent.", "9. On the day of the operation, patient changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty." ]

[ "1. No significant past medical history", "2. No current medications", "3. The patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years", "4. The patient's doctor has described all the available options for the procedure with their pros and cons", "5. The doctor has offered different materials for the hernioplasty", "6. The doctor has described the exact procedure", "7. The doctor has not focused too much on the possible complications and the risks and benefits of not performing the operation", "8. The patient insists he already knows everything that can happen since he is a surgeon himself", "9. The patient has given his consent", "10. On the day of the operation, the patient changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty" ]

[ "A 55-year-old man presents to his primary care provider complaining of blood clots in his urine.", "On further questioning, he also reports suprapubic discomfort and a feeling of bladder fullness with difficulty voiding.", "The patient reports recently starting treatment for a newly diagnosed non-Hodgkin lymphoma.", "Vital signs are within normal limits.", "Physical exam reveals pain on palpation of the suprapubic region." ]

[ "1. A 55-year-old man presents to his primary care provider.", "2. He is complaining of blood clots in his urine.", "3. On further questioning, he also reports suprapubic discomfort.", "4. He also reports a feeling of bladder fullness with difficulty voiding.", "5. The patient reports recently starting treatment for a newly diagnosed non-Hodgkin lymphoma.", "6. Vital signs are within normal limits.", "7. Physical exam reveals pain on palpation of the suprapubic region." ]

[ "1. The patient reports suprapubic discomfort.", "2. The patient reports a feeling of bladder fullness.", "3. The patient reports difficulty voiding.", "4. The patient has been recently diagnosed with non-Hodgkin lymphoma.", "5. Vital signs are within normal limits.", "6. Physical exam reveals pain on palpation of the suprapubic region." ]

[ "A 25-year-old man presents to his primary care physician with lower back pain.", "He states that he has had the pain for the past two years.", "The patient works as a butcher, and recently was moving heavy meat carcasses.", "The patient states that his pain is worse in the morning and that nothing improves it aside from swimming.", "The patient has a past medical history of anabolic steroid abuse, acne, hypertension and obesity.", "His current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen.", "On physical exam there is no tenderness upon palpation of the spine.", "There is limited range of motion of the spine in all 4 directions." ]

[ "1. Patient is 25 years old.", "2. Patient has lower back pain for two years.", "3. Patient works as a butcher.", "4. Patient recently moved heavy meat carcasses.", "5. Patient's pain is worse in the morning.", "6. Nothing improves patient's pain aside from swimming.", "7. Patient has past medical history of anabolic steroid abuse, acne, hypertension, and obesity.", "8. Patient's current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen.", "9. On physical exam, there is no tenderness upon palpation of the spine.", "10. On physical exam, there is limited range of motion of the spine in all 4 directions." ]

[ "1. The patient has had pain for the past two years.", "2. The patient works as a butcher and recently moved heavy meat carcasses.", "3. The patient's pain is worse in the morning and only improves with swimming.", "4. The patient has a past medical history of anabolic steroid abuse, acne, hypertension, and obesity.", "5. The patient's current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen.", "6. On physical exam, there is no tenderness upon palpation of the spine.", "7. There is limited range of motion of the spine in all 4 directions." ]

[ "A 42-year-old African American female presents to your clinic complaining of excessive thirst and urination.", "She reports that these symptoms began one week ago, and they have been affecting her ability to work as a schoolteacher.", "Labs are drawn and are listed below. | | Serum: | Na+: 145 mEq/L | Cl-: 101 mEq/L | K+: 4.4 mEq/L | HCO3-: 25 mEq/L | Urea nitrogen: 24 mg/dL | Glucose: 115 mg/dL | Creatinine: 0.7 mg/dL | Hemoglobin: 10.5 g/dL | Hematocrit: 25% | Leukocyte count: 11,000/mm^3 | Platelets: 200,000/mm^3 | | Urine: | Specific gravity: 1.006 | Epithelial cells: 5/hpf | Glucose: negative | Protein: 20 mg/dL | RBC: 6/hpf | WBC: 1/hpf | Leukocyte esterase: negative | Nitrites: negative | Bacterial: none | | A water deprivation test is performed with the following results: | | Serum osmolality: 305 mOsm/kg | Urine osmolality: 400 mOsm/kg | Urine specific gravity: 1.007 | | Desmopressin is administered, and the patient's urine osmolality increases to 490 mOsm/kg.", "The patient's antidiuretic hormone is measured and is within normal limits." ]

[ "1. Patient is a 42-year-old African American female.", "2. Patient is complaining of excessive thirst and urination.", "3. Symptoms began one week ago.", "4. Symptoms are affecting patient's ability to work as a schoolteacher.", "5. Serum Na+: 145 mEq/L", "6. Serum Cl-: 101 mEq/L", "7. Serum K+: 4.4 mEq/L", "8. Serum HCO3-: 25 mEq/L", "9. Serum Urea nitrogen: 24 mg/dL", "10. Serum Glucose: 115 mg/dL", "11. Serum Creatinine: 0.7 mg/dL", "12. Serum Hemoglobin: 10.5 g/dL", "13. Serum Hematocrit: 25%", "14. Serum Leukocyte count: 11,000/mm^3", "15. Serum Platelets: 200,000/mm^3", "16. Urine Specific gravity: 1.006", "17. Urine Epithelial cells: 5/hpf", "18. Urine Glucose: negative", "19. Urine Protein: 20 mg/dL", "20. Urine RBC: 6/hpf", "21. Urine WBC: 1/hpf", "22. Urine Leukocyte esterase: negative", "23. Urine Nitrites: negative", "24. Urine Bacterial: none", "25. Serum osmolality after water deprivation test: 305 mOsm/kg", "26. Urine osmolality after water deprivation test: 400 mOsm/kg", "27. Urine specific gravity after water deprivation test: 1.007", "28. Urine osmolality after desmopressin administration: 490 mOsm/kg", "29. Patient's antidiuretic hormone is within normal limits." ]

[ "1. Symptoms began one week ago", "2. Symptoms affecting ability to work as a schoolteacher", "3. Serum sodium level: 145 mEq/L", "4. Serum chloride level: 101 mEq/L", "5. Serum potassium level: 4.4 mEq/L", "6. Serum bicarbonate level: 25 mEq/L", "7. Serum urea nitrogen level: 24 mg/dL", "8. Serum glucose level: 115 mg/dL", "9. Serum creatinine level: 0.7 mg/dL", "10. Serum hemoglobin level: 10.5 g/dL", "11. Serum hematocrit level: 25%", "12. Serum leukocyte count: 11,000/mm^3", "13. Serum platelet count: 200,000/mm^3", "14. Urine specific gravity: 1.006", "15. Urine epithelial cells: 5/hpf", "16. Urine glucose: negative", "17. Urine protein: 20 mg/dL", "18. Urine RBC: 6/hpf", "19. Urine WBC: 1/hpf", "20. Urine leukocyte esterase: negative", "21. Urine nitrites: negative", "22. Urine bacteria: none", "23. Serum osmolality: 305 mOsm/kg", "24. Urine osmolality: 400 mOsm/kg", "25. Urine specific gravity: 1.007", "26. Desmopressin administered", "27. Patient's urine osmolality increases to 490 mOsm/kg", "28. Patient's antidiuretic hormone within normal limits" ]

[ "A 42-year-old male with a history of schizophrenia presents to his psychiatrist for a normal follow-up visit.", "He is accompanied by his case manager.", "The patient was diagnosed with schizophrenia at the age of 27.", "After being trialed on two different medications, he was deemed to be stable on a third medication which he has been taking for the past 10 years.", "He reports that he occasionally hears voices.", "He lives in supportive housing, and his caretakers report that he prefers to be alone but is not disruptive.", "His temperature is 99°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min.", "On exam, he demonstrates a flattened affect and disorganized speech.", "A funduscopic examination reveals pigmented plaques at the retinal periphery.", "No deposits are seen in the cornea or anterior lens." ]

[ "1. Patient is 42 years old.", "2. Patient has a history of schizophrenia.", "3. Patient was diagnosed with schizophrenia at age 27.", "4. Patient was trialed on two different medications.", "5. Patient is stable on third medication for 10 years.", "6. Patient occasionally hears voices.", "7. Patient lives in supportive housing.", "8. Caretakers report patient prefers to be alone.", "9. Patient's temperature is 99°F (37.2°C).", "10. Patient's blood pressure is 130/90 mmHg.", "11. Patient's pulse is 105/min.", "12. Patient's respirations are 18/min.", "13. Patient demonstrates flattened affect and disorganized speech.", "14. Funduscopic examination reveals pigmented plaques at retinal periphery.", "15. No deposits seen in cornea or anterior lens." ]

[ "1. He is accompanied by his case manager.", "2. The patient was diagnosed with schizophrenia at the age of 27.", "3. After being trialed on two different medications, he was deemed to be stable on a third medication which he has been taking for the past 10 years.", "4. He reports that he occasionally hears voices.", "5. He lives in supportive housing, and his caretakers report that he prefers to be alone but is not disruptive.", "6. His temperature is 99°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min.", "7. On exam, he demonstrates a flattened affect and disorganized speech.", "8. A funduscopic examination reveals pigmented plaques at the retinal periphery.", "9. No deposits are seen in the cornea or anterior lens." ]

[ "A 6-month-old girl is brought to the emergency department because her lips turned blue for several minutes earlier during feeding.", "Her father reports that the patient had similar episodes while playing that resolved quickly.", "During the examination, she sits calmly in her father's lap.", "When her ears are examined, the patient begins to cry and her lips and fingers begin to turn blue." ]

[ "1. A 6-month-old girl was brought to the emergency department.", "2. Her lips had turned blue for several minutes earlier during feeding.", "3. Her father reported similar episodes while playing that resolved quickly.", "4. During the examination, she was sitting calmly in her father's lap.", "5. When her ears were examined, the patient began to cry.", "6. Her lips and fingers began to turn blue." ]

[ "1. The patient had similar episodes while playing.", "2. The episodes resolved quickly.", "3. The patient sits calmly in her father's lap during the examination.", "4. The patient begins to cry when her ears are examined.", "5. The patient's lips and fingers begin to turn blue during the examination." ]

[ "A 52-year-old female presents to clinic complaining of sudden onset of flank tenderness that was fluctuating and radiating into her groin.", "Laboratory analysis reveals a serum calcium of 12.4 (normal 8.4-10.2) and a serum phosphorous of 2.5 (normal 2.7-4.5) and a chloride:phosphorous ratio >33.", "You suspect primary hyperparathyroidism." ]

[ "1. A 52-year-old female presents to clinic.", "2. Complaining of sudden onset of flank tenderness.", "3. Flank tenderness was fluctuating and radiating into her groin.", "4. Laboratory analysis reveals a serum calcium of 12.4.", "5. Normal range for serum calcium is 8.4-10.2.", "6. Laboratory analysis reveals a serum phosphorous of 2.5.", "7. Normal range for serum phosphorous is 2.7-4.5.", "8. Laboratory analysis reveals a chloride:phosphorous ratio >33.", "9. You suspect primary hyperparathyroidism." ]

[ "1. Laboratory analysis reveals a serum calcium of 12.4 (normal 8.4-10.2).", "2. Laboratory analysis reveals a serum phosphorous of 2.5 (normal 2.7-4.5).", "3. Laboratory analysis reveals a chloride:phosphorous ratio >33.", "4. Suspected diagnosis: primary hyperparathyroidism." ]

[ "A 53-year-old man comes to the physician because of a 2-week history of fatigue, generalized itching, and yellowing of the eyes and skin.", "He underwent a liver transplantation because of acute liver failure following α-amanitin poisoning 1 year ago.", "Physical examination shows scleral icterus and abdominal distention with shifting dullness.", "A liver biopsy specimen shows decreased hepatic duct density." ]

[ "1. A 53-year-old man comes to the physician.", "2. He has a 2-week history of fatigue, generalized itching, and yellowing of the eyes and skin.", "3. He underwent a liver transplantation 1 year ago due to acute liver failure following α-amanitin poisoning.", "4. Physical examination shows scleral icterus and abdominal distention with shifting dullness.", "5. A liver biopsy specimen shows decreased hepatic duct density." ]

[ "1. The patient underwent a liver transplantation.", "2. The reason for the transplantation was acute liver failure.", "3. The cause of the acute liver failure was α-amanitin poisoning.", "4. The poisoning occurred 1 year ago.", "5. Physical examination shows scleral icterus.", "6. Physical examination shows abdominal distention.", "7. Abdominal distention exhibits shifting dullness.", "8. A liver biopsy specimen was taken.", "9. The biopsy specimen shows decreased hepatic duct density." ]

[ "A 23-year-old man comes to the emergency department because of a 5-day history of progressively worsening dyspnea.", "He has had intermittent episodes of chest pain, which was 4/10 in intensity and increased on inspiration.", "He does triathlons and has not been able to train because of the discomfort.", "He has had no fever or syncopal episodes.", "He had an upper respiratory tract infection 3 weeks ago.", "His father died of heart disease at the age of 55 years.", "His temperature is 36.8°C (98.2°F), pulse is 113/min, and blood pressure is 100/70 mm Hg.", "Examination shows jugular venous distention.", "Inspiratory crackles are heard throughout the thorax.", "Cardiac examination shows an S3 gallop.", "Laboratory studies show: | Hemoglobin 14.8 g/dL | Leukocyte count 9200/mm3 | Platelet count 230,000/mm3 | ESR 41 mm/hr | Serum | Creatinine 1.1 mg/dL | Glucose 92 mg/dL | LDH 120 U/L | Troponin I 0.204 ng/mL (N< 0.1 ng/mL) | An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields.", "An ECG shows diffuse T-wave inversions." ]

[ "1. A 23-year-old man comes to the emergency department.", "2. He has had a 5-day history of progressively worsening dyspnea.", "3. He has had intermittent episodes of chest pain, which was 4/10 in intensity and increased on inspiration.", "4. He does triathlons and has not been able to train because of the discomfort.", "5. He has had no fever or syncopal episodes.", "6. He had an upper respiratory tract infection 3 weeks ago.", "7. His father died of heart disease at the age of 55 years.", "8. His temperature is 36.8°C (98.2°F).", "9. His pulse is 113/min.", "10. His blood pressure is 100/70 mm Hg.", "11. Examination shows jugular venous distention.", "12. Inspiratory crackles are heard throughout the thorax.", "13. Cardiac examination shows an S3 gallop.", "14. Laboratory studies show: Hemoglobin 14.8 g/dL.", "15. Laboratory studies show: Leukocyte count 9200/mm3.", "16. Laboratory studies show: Platelet count 230,000/mm3.", "17. Laboratory studies show: ESR 41 mm/hr.", "18. Laboratory studies show: Serum Creatinine 1.1 mg/dL.", "19. Laboratory studies show: Glucose 92 mg/dL.", "20. Laboratory studies show: LDH 120 U/L.", "21. Laboratory studies show: Troponin I 0.204 ng/mL (N< 0.1 ng/mL).", "22. An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields.", "23. An ECG shows diffuse T-wave inversions." ]

[ "1. He has had intermittent episodes of chest pain, which was 4/10 in intensity and increased on inspiration.", "2. He does triathlons and has not been able to train because of the discomfort.", "3. He has had no fever or syncopal episodes.", "4. He had an upper respiratory tract infection 3 weeks ago.", "5. His father died of heart disease at the age of 55 years.", "6. His temperature is 36.8°C (98.2°F), pulse is 113/min, and blood pressure is 100/70 mm Hg.", "7. Examination shows jugular venous distention.", "8. Inspiratory crackles are heard throughout the thorax.", "9. Cardiac examination shows an S3 gallop.", "10. Laboratory studies show: Hemoglobin 14.8 g/dL, Leukocyte count 9200/mm3, Platelet count 230,000/mm3, ESR 41 mm/hr, Serum Creatinine 1.1 mg/dL, Glucose 92 mg/dL, LDH 120 U/L, Troponin I 0.204 ng/mL (N< 0.1 ng/mL).", "11. An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields.", "12. An ECG shows diffuse T-wave inversions." ]

[ "Two days after undergoing abdominal surgery for lysis of adhesions, a 52-year-old man has nausea and one episode of bilious vomiting.", "The patient's nausea is somewhat alleviated in the prone position.", "The patient has had a 70-kg (154-lb) weight loss since undergoing bariatric surgery 1 year ago.", "Physical examination shows abdominal distention.", "Sudden movement of the patient elicits a sloshing sound on auscultation of the abdomen.", "An upper gastrointestinal series of the abdomen with oral contrast shows no passage of contrast past the third segment of the duodenum." ]

[ "1. A 52-year-old man underwent abdominal surgery for lysis of adhesions two days ago.", "2. The patient has nausea and one episode of bilious vomiting.", "3. The patient's nausea is somewhat alleviated in the prone position.", "4. The patient has had a 70-kg (154-lb) weight loss since undergoing bariatric surgery 1 year ago.", "5. Physical examination shows abdominal distention.", "6. Sudden movement of the patient elicits a sloshing sound on auscultation of the abdomen.", "7. An upper gastrointestinal series of the abdomen with oral contrast shows no passage of contrast past the third segment of the duodenum." ]

[ "1. The patient's nausea is somewhat alleviated in the prone position.", "2. The patient has had a 70-kg (154-lb) weight loss since undergoing bariatric surgery 1 year ago.", "3. Physical examination shows abdominal distention.", "4. Sudden movement of the patient elicits a sloshing sound on auscultation of the abdomen.", "5. An upper gastrointestinal series of the abdomen with oral contrast shows no passage of contrast past the third segment of the duodenum." ]

[ "A 16-year-old girl is brought to the physician because her mother is concerned about her lack of appetite and poor weight gain.", "She has had a 7-kg (15-lb) weight loss over the past 3 months.", "The patient states that she should try to lose more weight because she does not want to be overweight anymore.", "She maintains a diary of her daily calorie intake.", "Menarche was at the age of 13 years, and her last menstrual period was 3 months ago.", "She is on the high school track team.", "She is sexually active with 2 male partners and uses condoms inconsistently.", "She is at 50th percentile for height and below the 5th percentile for weight and BMI.", "Her temperature is 37°C (98.6°F), pulse is 58/min and blood pressure is 96/60 mm Hg.", "Examination shows fine hair over the trunk and extremities." ]

[ "1. Patient is 16 years old.", "2. Patient has had a 7-kg (15-lb) weight loss over the past 3 months.", "3. Patient states she should try to lose more weight.", "4. Patient maintains a diary of her daily calorie intake.", "5. Patient's menarche was at the age of 13 years.", "6. Patient's last menstrual period was 3 months ago.", "7. Patient is on the high school track team.", "8. Patient is sexually active with 2 male partners.", "9. Patient uses condoms inconsistently.", "10. Patient is at 50th percentile for height.", "11. Patient is below the 5th percentile for weight and BMI.", "12. Patient's temperature is 37°C (98.6°F).", "13. Patient's pulse is 58/min.", "14. Patient's blood pressure is 96/60 mm Hg.", "15. Examination shows fine hair over the trunk and extremities." ]

[ "1. She has had a 7-kg (15-lb) weight loss over the past 3 months.", "2. The patient states that she should try to lose more weight because she does not want to be overweight anymore.", "3. She maintains a diary of her daily calorie intake.", "4. Menarche was at the age of 13 years, and her last menstrual period was 3 months ago.", "5. She is on the high school track team.", "6. She is sexually active with 2 male partners and uses condoms inconsistently.", "7. She is at 50th percentile for height and below the 5th percentile for weight and BMI.", "8. Her temperature is 37°C (98.6°F), pulse is 58/min and blood pressure is 96/60 mm Hg.", "9. Examination shows fine hair over the trunk and extremities." ]

[ "A 25-year-old male presents with progressively worsening headaches over the past two months.", "He also feels that he has been losing his balance more often over the past week, but he denies any motor weakness or sensory impairment.", "His neurological exam reveals impaired upward gaze, pupils that constrict poorly to light but react to accommodation, and bilateral upper eyelid retraction.", "On tandem walking, he tends to fall on both sides.", "The remainder of the physical examination is unremarkable." ]

[ "1. Patient is 25 years old.", "2. Patient is male.", "3. Patient has had progressively worsening headaches for two months.", "4. Patient has been losing balance more often over the past week.", "5. Patient denies motor weakness or sensory impairment.", "6. Neurological exam reveals impaired upward gaze.", "7. Neurological exam reveals pupils constrict poorly to light but react to accommodation.", "8. Neurological exam reveals bilateral upper eyelid retraction.", "9. Patient tends to fall on both sides when tandem walking.", "10. Remainder of physical examination is unremarkable." ]

[ "1. He feels that he has been losing his balance more often over the past week.", "2. He denies any motor weakness.", "3. He denies any sensory impairment.", "4. His neurological exam reveals impaired upward gaze.", "5. His pupils constrict poorly to light.", "6. His pupils react to accommodation.", "7. He has bilateral upper eyelid retraction.", "8. On tandem walking, he tends to fall on both sides.", "9. The remainder of the physical examination is unremarkable." ]

[ "A 32-year-old woman presents to an urgent care facility after having sustained a deep cut 8 hours ago while hiking in the Appalachian mountains.", "Immediately after she sustained the injury she rinsed out the dirt with a bottle of saline from her first aid kit.", "She immigrated to the United States at age 20 and was unvaccinated upon arrival.", "Her medical records indicate that she has since received one dose of Tdap and one Td booster 3 years ago.", "She is afebrile, well appearing, and her wound appears clean without signs of infection at this time." ]

[ "1. A 32-year-old woman presented to an urgent care facility.", "2. She sustained a deep cut 8 hours ago while hiking in the Appalachian mountains.", "3. Immediately after she sustained the injury she rinsed out the dirt with a bottle of saline from her first aid kit.", "4. She immigrated to the United States at age 20.", "5. She was unvaccinated upon arrival.", "6. Her medical records indicate that she has since received one dose of Tdap.", "7. She has also received one Td booster 3 years ago.", "8. She is afebrile.", "9. She is well appearing.", "10. Her wound appears clean without signs of infection at this time." ]

[ "1. She sustained an injury.", "2. She rinsed out the dirt with a bottle of saline from her first aid kit.", "3. She immigrated to the United States at age 20.", "4. She was unvaccinated upon arrival in the United States.", "5. Her medical records indicate that she has received one dose of Tdap.", "6. Her medical records indicate that she has received one Td booster 3 years ago.", "7. She is afebrile.", "8. She is well appearing.", "9. Her wound appears clean without signs of infection at this time." ]

[ "A 39-year-old woman presents to the emergency department with a chief concern of abdominal pain.", "She states that her symptoms occurred shortly after she began eating dinner that evening.", "She states that the pain is in the right side of her abdomen and travels to her right shoulder.", "She has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension.", "Her current medications include metformin, insulin, atorvastatin, aspirin, and lisinopril.", "Her temperature is 99.5°F (37.5°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "On abdominal exam, the patient demonstrates tenderness in the right upper quadrant.", "The patient is started on IV fluids and morphine.", "Four hours later, she states that the pain has abated." ]

[ "1. Patient is 39 years old.", "2. Patient presents to the emergency department with abdominal pain.", "3. Symptoms began shortly after eating dinner.", "4. Pain is in the right side of the abdomen and travels to the right shoulder.", "5. Patient has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension.", "6. Patient's current medications include metformin, insulin, atorvastatin, aspirin, and lisinopril.", "7. Patient's temperature is 99.5°F (37.5°C).", "8. Patient's blood pressure is 110/75 mmHg.", "9. Patient's pulse is 90/min.", "10. Patient's respirations are 13/min.", "11. Patient's oxygen saturation is 99% on room air.", "12. Abdominal exam demonstrates tenderness in the right upper quadrant.", "13. Patient is started on IV fluids and morphine.", "14. Four hours later, patient states that the pain has abated." ]

[ "1. The patient's symptoms occurred shortly after she began eating dinner that evening.", "2. The pain is in the right side of her abdomen and travels to her right shoulder.", "3. The patient has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension.", "4. Her current medications include metformin, insulin, atorvastatin, aspirin, and lisinopril.", "5. Her temperature is 99.5°F (37.5°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "6. On abdominal exam, the patient demonstrates tenderness in the right upper quadrant.", "7. The patient is started on IV fluids and morphine.", "8. Four hours later, she states that the pain has abated." ]

[ "A 12-year-old girl is brought to the primary physician because of severe ear pain and yellow discharge from her left ear for the past 2 days.", "It is also mildly pruritic.", "The pain started during her last day of summer camp, where she spent a lot of time outdoors hiking, horseback riding, and swimming.", "Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 110/75 mm Hg.", "Examination shows tragal tenderness and a red and edematous external auditory canal.", "A diagnostic tuning fork is placed in the middle of the patient's forehead.", "The patient reports hearing the sound more loudly in the left ear.", "To complete the workup, the tuning fork is placed on the mastoid process of the left ear.", "Once she can no longer hear the sound, the tuning fork is placed in front of the auricle, and she reports no longer hearing the sound.", "On the right side, once the sound from the mastoid process subsides and the tuning fork is placed in front of the right ear, she reports hearing the sound again." ]

[ "1. Patient is 12 years old.", "2. Patient has severe ear pain and yellow discharge from left ear for 2 days.", "3. Patient's ear is mildly pruritic.", "4. Patient's pain started during last day of summer camp.", "5. Patient spent time outdoors hiking, horseback riding, and swimming.", "6. Patient's temperature is 37°C (98.6°F).", "7. Patient's pulse is 76/min.", "8. Patient's blood pressure is 110/75 mm Hg.", "9. Examination shows tragal tenderness and red and edematous external auditory canal.", "10. Diagnostic tuning fork is placed in middle of patient's forehead.", "11. Patient reports hearing sound more loudly in left ear.", "12. Tuning fork is placed on mastoid process of left ear.", "13. Patient can no longer hear sound when tuning fork is placed in front of auricle.", "14. On right side, sound from mastoid process subsides and patient reports no longer hearing sound when tuning fork is placed in front of right ear." ]

[ "1. The patient is experiencing mild pruritus.", "2. The pain started during the patient's last day of summer camp.", "3. The patient spent a lot of time outdoors hiking, horseback riding, and swimming.", "4. The patient's temperature is 37°C (98.6°F).", "5. The patient's pulse is 76/min.", "6. The patient's blood pressure is 110/75 mm Hg.", "7. Examination shows tragal tenderness.", "8. Examination shows a red and edematous external auditory canal.", "9. A diagnostic tuning fork is placed in the middle of the patient's forehead.", "10. The patient reports hearing the sound more loudly in the left ear.", "11. The tuning fork is placed on the mastoid process of the left ear.", "12. Once the patient can no longer hear the sound, the tuning fork is placed in front of the auricle, and she reports no longer hearing the sound.", "13. On the right side, once the sound from the mastoid process subsides and the tuning fork is placed in front of the right ear, she reports hearing the sound again." ]

[ "A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour.", "The pain radiates to the back and is associated with nausea.", "He has had two episodes of non-bloody vomiting since the pain started.", "He has a history of hypertension and type 2 diabetes mellitus.", "He has smoked one pack of cigarettes daily for 30 years.", "He drinks five to six beers per day.", "His medications include enalapril and metformin.", "His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg.", "The lungs are clear to auscultation.", "Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased.", "Laboratory studies show: | Hemoglobin 14.5 g/dL | Leukocyte count 5,100/mm3 | Platelet count 280,000/mm3 | Serum | Na+ 133 mEq/L | K+ 3.5 mEq/L | Cl- 98 mEq/L | Total bilirubin 1.0 mg/dL | Amylase 160 U/L | Lipase 880 U/L (N = 14–280) | An ECG shows sinus tachycardia." ]

[ "1. Patient is a 50-year-old man.", "2. Patient has severe lower chest pain for the past hour that radiates to the back and is associated with nausea.", "3. Patient has had two episodes of non-bloody vomiting since the pain started.", "4. Patient has a history of hypertension and type 2 diabetes mellitus.", "5. Patient smokes one pack of cigarettes daily for 30 years.", "6. Patient drinks five to six beers per day.", "7. Patient's medications include enalapril and metformin.", "8. Patient's temperature is 38.5°C (101.3°F).", "9. Patient's pulse is 110/min.", "10. Patient's blood pressure is 90/60 mm Hg.", "11. Patient's lungs are clear to auscultation.", "12. Patient's abdomen is distended with epigastric tenderness and guarding but no rebound; bowel sounds are decreased.", "13. Patient's hemoglobin is 14.5 g/dL.", "14. Patient's leukocyte count is 5,100/mm3.", "15. Patient's platelet count is 280,000/mm3.", "16. Patient's serum Na+ is 133 mEq/L.", "17. Patient's serum K+ is 3.5 mEq/L.", "18. Patient's serum Cl- is 98 mEq/L.", "19. Patient's total bilirubin is 1.0 mg/dL.", "20. Patient's amylase is 160 U/L.", "21. Patient's lipase is 880 U/L (N = 14–280).", "22. An ECG shows sinus tachycardia." ]

[ "1. The pain radiates to the back and is associated with nausea.", "2. He has had two episodes of non-bloody vomiting since the pain started.", "3. He has a history of hypertension and type 2 diabetes mellitus.", "4. He has smoked one pack of cigarettes daily for 30 years.", "5. He drinks five to six beers per day.", "6. His medications include enalapril and metformin.", "7. His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg.", "8. The lungs are clear to auscultation.", "9. Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased.", "10. Laboratory studies show: Hemoglobin 14.5 g/dL, Leukocyte count 5,100/mm3, Platelet count 280,000/mm3, Serum Na+ 133 mEq/L, K+ 3.5 mEq/L, Cl- 98 mEq/L, Total bilirubin 1.0 mg/dL, Amylase 160 U/L, Lipase 880 U/L (N = 14–280).", "11. An ECG shows sinus tachycardia." ]

[ "A 29-year-old woman presents to the physician’s office complaining of swollen hands for the past 3 weeks.", "It is associated with stiffness in the morning, which lasts about 10 minutes.", "The patient’s medical history is significant for hypothyroidism that is managed with levothyroxine.", "She has no recent travel history.", "Vital signs are normal.", "On examination, the patient has a butterfly-shaped, non-blanching rash on her face with mild cervical lymphadenopathy.", "The metacarpophalangeal and proximal interphalangeal joints are tender and appear swollen.", "Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur heard best at the apex." ]

[ "1. A 29-year-old woman presents to the physician's office.", "2. She is complaining of swollen hands for the past 3 weeks.", "3. It is associated with stiffness in the morning, which lasts about 10 minutes.", "4. The patient's medical history is significant for hypothyroidism.", "5. She is managed with levothyroxine.", "6. She has no recent travel history.", "7. Vital signs are normal.", "8. On examination, the patient has a butterfly-shaped, non-blanching rash on her face.", "9. She has mild cervical lymphadenopathy.", "10. The metacarpophalangeal and proximal interphalangeal joints are tender and appear swollen.", "11. Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur heard best at the apex." ]

[ "1. Associated with stiffness in the morning", "2. Stiffness lasts about 10 minutes", "3. Patient's medical history includes hypothyroidism", "4. Hypothyroidism is managed with levothyroxine", "5. No recent travel history", "6. Vital signs are normal", "7. Patient has a butterfly-shaped, non-blanching rash on her face", "8. Patient has mild cervical lymphadenopathy", "9. Metacarpophalangeal joints are tender", "10. Proximal interphalangeal joints appear swollen", "11. Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur", "12. Murmur is heard best at the apex" ]

[ "A 61-year-old male dies in a motor vehicle accident.", "Autopsy of the heart reveals dilatation of the left atrium and expansion of the left ventricular cavity with associated eccentric hypertrophy." ]

[ "1. A 61-year-old male died.", "2. The cause of death was a motor vehicle accident.", "3. An autopsy of the heart was performed.", "4. The left atrium was dilated.", "5. The left ventricular cavity was expanded.", "6. Eccentric hypertrophy was associated with the expansion." ]

[ "1. Autopsy of the heart was performed.", "2. Dilatation of the left atrium was observed.", "3. Expansion of the left ventricular cavity was observed.", "4. Eccentric hypertrophy was associated with the left ventricular cavity expansion." ]

[ "A 52-year-old business executive presents to his physician with complaints of intermittent chest pain which started 2 months ago.", "He describes his pain as crushing, centrally located, and typically lasting about 5 minutes but never more than 10 minutes.", "The pain radiates to his left arm and jaw, occurs only when he climbs the stairs or runs on a treadmill, and is relieved by rest.", "He has been hypertensive and diabetic for the last 10 years and has been compliant with his medications.", "His physical exam findings are within normal limits.", "Lab tests are normal except for a significantly elevated LDL-cholesterol level.", "A stress ECG shows ST-segment depression in the anterior chest leads when his heart rate and blood pressure increase to over 40% from their baseline values.", "The physician decides to initiate a medication to relieve his symptoms." ]

[ "1. A 52-year-old business executive presents to his physician.", "2. He has intermittent chest pain which started 2 months ago.", "3. He describes his pain as crushing, centrally located, and typically lasting about 5 minutes but never more than 10 minutes.", "4. The pain radiates to his left arm and jaw.", "5. The pain occurs only when he climbs the stairs or runs on a treadmill.", "6. The pain is relieved by rest.", "7. He has been hypertensive and diabetic for the last 10 years.", "8. He has been compliant with his medications.", "9. His physical exam findings are within normal limits.", "10. Lab tests are normal except for a significantly elevated LDL-cholesterol level.", "11. A stress ECG shows ST-segment depression in the anterior chest leads when his heart rate and blood pressure increase to over 40% from their baseline values.", "12. The physician decides to initiate a medication to relieve his symptoms." ]

[ "1. Patient describes pain as crushing, centrally located, and lasting about 5 minutes but never more than 10 minutes.", "2. Pain radiates to left arm and jaw, occurs only when climbing stairs or running on a treadmill, and is relieved by rest.", "3. Patient has been hypertensive and diabetic for the last 10 years and has been compliant with medications.", "4. Physical exam findings are within normal limits.", "5. Lab tests are normal except for significantly elevated LDL-cholesterol level.", "6. Stress ECG shows ST-segment depression in the anterior chest leads when heart rate and blood pressure increase to over 40% from baseline values.", "7. Physician decides to initiate a medication to relieve symptoms." ]

[ "A 34-year-old man comes to the physician for a follow-up appointment.", "He was diagnosed with HIV 6 years ago and has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir.", "He reports that he has been compliant with his medication regimen.", "His last CD4+ T-lymphocyte count was 520/mm3 (N > 500) and HIV viral load was undetectable.", "Today, his CD4+ T-lymphocyte count is 410/mm3 and his HIV viral load is 240 copies/mL.", "Further evaluation shows resistance to emtricitabine and tenofovir." ]

[ "1. A 34-year-old man comes to the physician for a follow-up appointment.", "2. He was diagnosed with HIV 6 years ago.", "3. He has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir.", "4. He reports that he has been compliant with his medication regimen.", "5. His last CD4+ T-lymphocyte count was 520/mm3 (N > 500).", "6. His last HIV viral load was undetectable.", "7. Today, his CD4+ T-lymphocyte count is 410/mm3.", "8. Today, his HIV viral load is 240 copies/mL.", "9. Further evaluation shows resistance to emtricitabine and tenofovir." ]

[ "1. Diagnosed with HIV 6 years ago", "2. On highly active antiretroviral therapy", "3. Medication regimen includes emtricitabine, tenofovir, and darunavir", "4. Reports compliance with medication regimen", "5. Last CD4+ T-lymphocyte count was 520/mm3 (N > 500)", "6. Last HIV viral load was undetectable", "7. Today's CD4+ T-lymphocyte count is 410/mm3", "8. Today's HIV viral load is 240 copies/mL", "9. Shows resistance to emtricitabine and tenofovir" ]

[ "A 61-year-old woman with a history of stage IV pancreatic cancer comes to the emergency department with insomnia due to intractable midepigastric pain.", "The pain had been constant for months but has worsened over the past few weeks despite the fact that she is already taking hydrocodone 10 mg and ibuprofen 400 mg.", "She has a past medical history of chronic pain and major depressive disorder.", "In the past month, she has been taking her pain medications with increasing frequency, going from twice a day to four times a day.", "Her other medications include venlafaxine and eszopiclone.", "She describes her mood as low, but states she does not have any suicidal thoughts.", "She appears fatigued and slightly cachectic.", "Her temperature is 36°C (96.8°F), pulse is 100/min, and blood pressure is 128/65 mm Hg.", "Physical examination shows a mass in the midepigastric region." ]

[ "1. Patient is a 61-year-old woman.", "2. Patient has a history of stage IV pancreatic cancer.", "3. Patient presents to the emergency department with insomnia due to intractable midepigastric pain.", "4. Pain has been constant for months but has worsened over the past few weeks.", "5. Patient is already taking hydrocodone 10 mg and ibuprofen 400 mg.", "6. Patient has a past medical history of chronic pain and major depressive disorder.", "7. Patient has been taking her pain medications with increasing frequency, going from twice a day to four times a day.", "8. Patient's other medications include venlafaxine and eszopiclone.", "9. Patient describes her mood as low, but states she does not have any suicidal thoughts.", "10. Patient appears fatigued and slightly cachectic.", "11. Patient's temperature is 36°C (96.8°F).", "12. Patient's pulse is 100/min.", "13. Patient's blood pressure is 128/65 mm Hg.", "14. Physical examination shows a mass in the midepigastric region." ]

[ "1. The pain had been constant for months", "2. The pain has worsened over the past few weeks", "3. She is already taking hydrocodone 10 mg", "4. She is already taking ibuprofen 400 mg", "5. She has a past medical history of chronic pain", "6. She has a past medical history of major depressive disorder", "7. In the past month, she has been taking her pain medications with increasing frequency", "8. She has increased her pain medication frequency from twice a day to four times a day", "9. Her other medications include venlafaxine", "10. Her other medications include eszopiclone", "11. She describes her mood as low", "12. She states she does not have any suicidal thoughts", "13. She appears fatigued", "14. She appears slightly cachectic", "15. Her temperature is 36°C (96.8°F)", "16. Her pulse is 100/min", "17. Her blood pressure is 128/65 mm Hg", "18. Physical examination shows a mass in the midepigastric region" ]

[ "Two days into hospitalization for pyelonephritis and sepsis, a 48-year-old woman develops severe sudden-onset dyspnea.", "She has no history of serious cardiopulmonary disease.", "She is fatigued and pale.", "Her blood pressure is 115/65 mm Hg, the pulse is 120/min, the respiratory rate is 36/min, and the temperature is 39.7°C (103.5°F).", "Her oxygen saturation is 80% on 60% FiO2.", "She has severe nasal flaring, supraclavicular and intercostal respiratory retractions, and paradoxical abdominal movements.", "Inspiratory crackles are heard over both lung fields.", "Cardiac examination shows no murmurs.", "A chest X-ray, taken before orotracheal intubation, is shown." ]

[ "1. A 48-year-old woman is hospitalized for pyelonephritis and sepsis. ", "2. Two days into hospitalization, she develops severe sudden-onset dyspnea. ", "3. She has no history of serious cardiopulmonary disease. ", "4. She is fatigued and pale. ", "5. Her blood pressure is 115/65 mm Hg. ", "6. Her pulse is 120/min. ", "7. Her respiratory rate is 36/min. ", "8. Her temperature is 39.7°C (103.5°F). ", "9. Her oxygen saturation is 80% on 60% FiO2. ", "10. She has severe nasal flaring, supraclavicular and intercostal respiratory retractions, and paradoxical abdominal movements. ", "11. Inspiratory crackles are heard over both lung fields. ", "12. Cardiac examination shows no murmurs. ", "13. A chest X-ray is taken before orotracheal intubation." ]

[ "1. She has no history of serious cardiopulmonary disease.", "2. She is fatigued and pale.", "3. Her blood pressure is 115/65 mm Hg.", "4. Her pulse is 120/min.", "5. Her respiratory rate is 36/min.", "6. Her temperature is 39.7°C (103.5°F).", "7. Her oxygen saturation is 80% on 60% FiO2.", "8. She has severe nasal flaring.", "9. She has supraclavicular and intercostal respiratory retractions.", "10. She has paradoxical abdominal movements.", "11. Inspiratory crackles are heard over both lung fields.", "12. Cardiac examination shows no murmurs.", "13. A chest X-ray, taken before orotracheal intubation, is shown." ]

[ "A 48-year-old man presents to the physician with a cough with expectoration and breathlessness on exertion for the last 4 years.", "There is no history of any other medical conditions.", "He has been a smoker for the last 10 years.", "He recently immigrated from a developing country and his immunization status is unknown.", "After a complete physical examination of the patient, the physician orders a chest radiogram which shows increased bronchovascular markings and flattening of the diaphragm.", "His spirometry findings include an FEV1 of 82% of predicted, which increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol.", "The FEV1/FVC ratio is 0.66.", "The physician explains the diagnosis to the patient and emphasizes the importance of smoking cessation.", "He also offers him specific vaccinations.", "However, the patient mentions that he does not have medical insurance and due to his poor financial situation, he can afford only 1 of the suggested vaccines." ]

[ "1. A 48-year-old man presents to the physician with a cough with expectoration and breathlessness on exertion for the last 4 years.", "2. There is no history of any other medical conditions.", "3. He has been a smoker for the last 10 years.", "4. He recently immigrated from a developing country and his immunization status is unknown.", "5. After a complete physical examination of the patient, the physician orders a chest radiogram which shows increased bronchovascular markings and flattening of the diaphragm.", "6. His spirometry findings include an FEV1 of 82% of predicted, which increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol.", "7. The FEV1/FVC ratio is 0.66.", "8. The physician explains the diagnosis to the patient and emphasizes the importance of smoking cessation.", "9. He also offers him specific vaccinations.", "10. However, the patient mentions that he does not have medical insurance and due to his poor financial situation, he can afford only 1 of the suggested vaccines." ]

[ "1. No history of any other medical conditions.", "2. He has been a smoker for the last 10 years.", "3. Recently immigrated from a developing country.", "4. Immunization status is unknown.", "5. Chest radiogram shows increased bronchovascular markings and flattening of the diaphragm.", "6. Spirometry findings include an FEV1 of 82% of predicted.", "7. FEV1 increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol.", "8. FEV1/FVC ratio is 0.66.", "9. Physician emphasizes the importance of smoking cessation.", "10. Specific vaccinations offered.", "11. Patient does not have medical insurance.", "12. Can afford only 1 of the suggested vaccines." ]

[ "A five-year-old female presents to the pediatrician for a well visit.", "The patient’s parents report that she recently entered kindergarten and her teacher expressed concern that the patient is not meeting developmental milestones.", "She struggles to name colors and has not expressed any interest in learning to read.", "The patient’s parents have also noticed that the patient is not completing tasks that her older siblings were doing by this age, including dressing herself independently and going to the bathroom by herself.", "The patient rolled over at 9 months, sat without support at 12 months, and walked at 20 months.", "Her parents also report that the patient is very social, and that adults frequently comment on her friendly personality.", "The patient is in the 15th percentile for weight and 5th percentile for height.", "On physical exam, the patient has a broad forehead, flat nasal bridge, long philtrum, and a wide mouth.", "She has a strabismus on neurological exam, and her cardiac exam is significant for a heart murmur.", "Laboratory testing is below: | | Serum: | Na+: 145 mEq/L | K+: 3.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 24 mEq/ | Urea nitrogen: 11 mg/dL | Glucose: 76 mg/dL | Creatinine: 0.9 mg/dL | Ca2+: 11.9 mg/dL | | ." ]

[ "1. Patient is a five-year-old female.", "2. Patient recently entered kindergarten.", "3. Teacher expressed concern that patient is not meeting developmental milestones.", "4. Patient struggles to name colors.", "5. Patient has not expressed any interest in learning to read.", "6. Patient is not completing tasks that her older siblings were doing by this age.", "7. Patient rolled over at 9 months.", "8. Patient sat without support at 12 months.", "9. Patient walked at 20 months.", "10. Patient is very social.", "11. Adults frequently comment on patient's friendly personality.", "12. Patient is in the 15th percentile for weight.", "13. Patient is in the 5th percentile for height.", "14. Patient has a broad forehead.", "15. Patient has a flat nasal bridge.", "16. Patient has a long philtrum.", "17. Patient has a wide mouth.", "18. Patient has a strabismus on neurological exam.", "19. Patient has a heart murmur on cardiac exam.", "20. Serum Na+ is 145 mEq/L.", "21. Serum K+ is 3.9 mEq/L.", "22. Serum Cl- is 100 mEq/L.", "23. Serum HCO3- is 24 mEq/L.", "24. Serum urea nitrogen is 11 mg/dL.", "25. Serum glucose is 76 mg/dL.", "26. Serum creatinine is 0.9 mg/dL.", "27. Serum Ca2+ is 11.9 mg/dL." ]

[ "1. The patient recently entered kindergarten.", "2. The patient's teacher expressed concern about her not meeting developmental milestones.", "3. The patient struggles to name colors.", "4. The patient has not expressed any interest in learning to read.", "5. The patient is not completing tasks her older siblings were doing at her age.", "6. The patient rolled over at 9 months.", "7. The patient sat without support at 12 months.", "8. The patient walked at 20 months.", "9. The patient is very social.", "10. Adults frequently comment on the patient's friendly personality.", "11. The patient is in the 15th percentile for weight.", "12. The patient is in the 5th percentile for height.", "13. On physical exam, the patient has a broad forehead.", "14. On physical exam, the patient has a flat nasal bridge.", "15. On physical exam, the patient has a long philtrum.", "16. On physical exam, the patient has a wide mouth.", "17. On neurological exam, the patient has a strabismus.", "18. On cardiac exam, the patient has a heart murmur.", "19. Serum Na+: 145 mEq/L", "20. Serum K+: 3.9 mEq/L", "21. Serum Cl-: 100 mEq/L", "22. Serum HCO3-: 24 mEq/", "23. Serum Urea nitrogen: 11 mg/dL", "24. Serum Glucose: 76 mg/dL", "25. Serum Creatinine: 0.9 mg/dL", "26. Serum Ca2+: 11.9 mg/dL" ]

[ "A 20-year-old male comes to the physician because of a 1-week-history of a painless ulceration on his penis.", "The patient is sexually active with multiple partners and does not use barrier protection.", "Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis and nontender bilateral inguinal adenopathy." ]

[ "1. A 20-year-old male comes to the physician.", "2. The patient has a 1-week-history of a painless ulceration on his penis.", "3. The patient is sexually active with multiple partners.", "4. The patient does not use barrier protection.", "5. Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis.", "6. Physical examination shows nontender bilateral inguinal adenopathy." ]

[ "1. The patient is sexually active.", "2. The patient has multiple partners.", "3. The patient does not use barrier protection.", "4. Physical examination shows a shallow, firm ulcer.", "5. The ulcer has a smooth base.", "6. The ulcer is along the shaft of the penis.", "7. The ulcer is nontender.", "8. The patient has bilateral inguinal adenopathy." ]

[ "A 31-year-old man presents to the clinic as a follow-up visit after recently being diagnosed with medullary thyroid cancer.", "Last year, he was diagnosed with a pheochromocytoma that was successfully resected.", "His family history is positive for medullary thyroid cancer in his father and paternal grandmother with a mucosal neuroma in his brother." ]

[ "1. A 31-year-old man presents to the clinic as a follow-up visit.", "2. He was recently diagnosed with medullary thyroid cancer.", "3. Last year, he was diagnosed with a pheochromocytoma.", "4. The pheochromocytoma was successfully resected.", "5. His family history is positive for medullary thyroid cancer in his father.", "6. His family history is positive for medullary thyroid cancer in his paternal grandmother.", "7. His brother has a mucosal neuroma." ]

[ "1. Last year, he was diagnosed with a pheochromocytoma.", "2. The pheochromocytoma was successfully resected.", "3. His family history is positive for medullary thyroid cancer in his father.", "4. His family history is positive for medullary thyroid cancer in his paternal grandmother.", "5. His family history is positive for a mucosal neuroma in his brother." ]

[ "Digestion begins in the mouth by breaking food up into smaller particles through mastication and mixing it with saliva containing amylase.", "Food then enters the stomach, where gastric acid and pepsin initiate protein digestion.", "The resulting chyme is then expelled into the duodenum where pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids.", "These digested lipids are then ready for absorption across the gastrointestinal mucosa." ]

[ "1. Digestion begins in the mouth.", "2. Food is broken up into smaller particles through mastication.", "3. Food is mixed with saliva containing amylase.", "4. Food then enters the stomach.", "5. Gastric acid and pepsin initiate protein digestion in the stomach.", "6. The resulting chyme is expelled into the duodenum.", "7. Pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids in the duodenum.", "8. Digested lipids are ready for absorption across the gastrointestinal mucosa." ]

[ "1. Food enters the stomach.", "2. Gastric acid and pepsin initiate protein digestion in the stomach.", "3. The resulting chyme is expelled into the duodenum.", "4. Pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids in the duodenum.", "5. Digested lipids are ready for absorption across the gastrointestinal mucosa." ]

[ "A group of investigators is studying hemodynamic regulatory mechanisms in a human volunteer subject.", "The volunteer is administered a stimulant drug, and a sudden increase in blood pressure is observed.", "It is hypothesized that the increase in blood pressure causes stretching of the atria." ]

[ "1. A group of investigators is studying hemodynamic regulatory mechanisms.", "2. The study involves a human volunteer subject.", "3. The volunteer is administered a stimulant drug.", "4. A sudden increase in blood pressure is observed.", "5. It is hypothesized that the increase in blood pressure causes stretching of the atria." ]

[ "1. The volunteer is administered a stimulant drug.", "2. A sudden increase in blood pressure is observed.", "3. It is hypothesized that the increase in blood pressure causes stretching of the atria." ]

[ "A 26-month-old boy is presented to the outpatient clinic by his parents complaining of a productive cough for the last 5 days.", "His mother reports a history of recurrent chest infections during the past year.", "He also has a history of chronic bloody diarrhea and pronounced bleeding after his circumcision.", "The vital signs are as follows: blood pressure 100/60 mm Hg, pulse 100/min, temperature 38.0°C (100.4°F), and respiratory rate 27/min.", "On examination, there are purpuric eruptions over the extremities as well as eczematous patches on the flexural surfaces of his elbows and knees.", "Chest auscultation reveals crepitus over the base of the right lung.", "Chest radiography is suggestive of consolidation in the right lower lobe.", "Blood test results show anemia, thrombocytopenia with small platelets, and leukopenia.", "With a suspicion of a congenital immunodeficiency, flow cytometry is ordered which reveals a Wiskott-Aldrich syndrome protein (WASP) mutation." ]

[ "1. A 26-month-old boy is presented to the outpatient clinic by his parents.", "2. His parents are complaining of a productive cough for the last 5 days.", "3. His mother reports a history of recurrent chest infections during the past year.", "4. He also has a history of chronic bloody diarrhea and pronounced bleeding after his circumcision.", "5. The vital signs are as follows: blood pressure 100/60 mm Hg, pulse 100/min, temperature 38.0°C (100.4°F), and respiratory rate 27/min.", "6. On examination, there are purpuric eruptions over the extremities.", "7. On examination, there are also eczematous patches on the flexural surfaces of his elbows and knees.", "8. Chest auscultation reveals crepitus over the base of the right lung.", "9. Chest radiography is suggestive of consolidation in the right lower lobe.", "10. Blood test results show anemia, thrombocytopenia with small platelets, and leukopenia.", "11. With a suspicion of a congenital immunodeficiency, flow cytometry is ordered.", "12. Flow cytometry reveals a Wiskott-Aldrich syndrome protein (WASP) mutation." ]

[ "1. His mother reports a history of recurrent chest infections during the past year.", "2. He has a history of chronic bloody diarrhea.", "3. He has a history of pronounced bleeding after his circumcision.", "4. The vital signs are: blood pressure 100/60 mm Hg.", "5. The vital signs are: pulse 100/min.", "6. The vital signs are: temperature 38.0°C (100.4°F).", "7. The vital signs are: respiratory rate 27/min.", "8. On examination, there are purpuric eruptions over the extremities.", "9. On examination, there are eczematous patches on the flexural surfaces of his elbows and knees.", "10. Chest auscultation reveals crepitus over the base of the right lung.", "11. Chest radiography is suggestive of consolidation in the right lower lobe.", "12. Blood test results show anemia.", "13. Blood test results show thrombocytopenia with small platelets.", "14. Blood test results show leukopenia.", "15. Flow cytometry is ordered.", "16. Flow cytometry reveals a Wiskott-Aldrich syndrome protein (WASP) mutation." ]

[ "Four hours after undergoing an open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm, a 55-year-old man is unable to move both his legs.", "During the surgery, he had prolonged hypotension, which was corrected with IV fluids and vasopressors.", "He has a history of hypertension and hyperlipidemia.", "He has smoked one pack of cigarettes daily for 35 years.", "Prior to admission, his medications were hydrochlorothiazide and atorvastatin.", "The patient is conscious and oriented to place and person.", "His temperature is 37.7°C (99°F), pulse is 74/min, and blood pressure is 100/70 mm Hg.", "Examination shows muscle strength of 1/5 in the lower extremities." ]

[ "1. Patient is 55 years old.", "2. Patient underwent open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm four hours ago.", "3. Patient is unable to move both his legs.", "4. Patient had prolonged hypotension during surgery, which was corrected with IV fluids and vasopressors.", "5. Patient has a history of hypertension and hyperlipidemia.", "6. Patient has smoked one pack of cigarettes daily for 35 years.", "7. Patient's medications prior to admission were hydrochlorothiazide and atorvastatin.", "8. Patient is conscious and oriented to place and person.", "9. Patient's temperature is 37.7°C (99°F).", "10. Patient's pulse is 74/min.", "11. Patient's blood pressure is 100/70 mm Hg.", "12. Patient's muscle strength in lower extremities is 1/5." ]

[ "1. During the surgery, he had prolonged hypotension.", "2. The prolonged hypotension was corrected with IV fluids and vasopressors.", "3. He has a history of hypertension.", "4. He has a history of hyperlipidemia.", "5. He has smoked one pack of cigarettes daily for 35 years.", "6. Prior to admission, his medications were hydrochlorothiazide and atorvastatin.", "7. The patient is conscious.", "8. The patient is oriented to place and person.", "9. His temperature is 37.7°C (99°F).", "10. His pulse is 74/min.", "11. His blood pressure is 100/70 mm Hg.", "12. Examination shows muscle strength of 1/5 in the lower extremities." ]

[ "A 30-year-old woman seeks evaluation at a local walk-in clinic with a week-long history of lightheadedness and palpitations.", "She also complains of fatigability and shortness of breath of the same duration.", "The past medical history is significant for menarche at 9 years of age, heavy menstrual bleeding for the past several years and abdominal pain that worsens during menses.", "She stopped trying to conceive a child after 2 spontaneous abortions in the past 4 years and has been on iron oral supplementation for the last 2 years.", "She adds that she feels a dull pressure-like discomfort in her pelvis and constipation.", "The physical examination is significant for pale mucous membranes and a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.", "Pelvic examination reveals an enlarged, mobile uterus with an irregular contour.", "The hemoglobin level is 10 g/dL and the hematocrit is 27%." ]

[ "1. Patient is a 30-year-old woman.", "2. Patient has a week-long history of lightheadedness and palpitations.", "3. Patient has a week-long history of fatigability and shortness of breath.", "4. Patient had menarche at 9 years of age.", "5. Patient has had heavy menstrual bleeding for several years.", "6. Patient has abdominal pain that worsens during menses.", "7. Patient has had 2 spontaneous abortions in the past 4 years.", "8. Patient has been on iron oral supplementation for the last 2 years.", "9. Patient feels a dull pressure-like discomfort in her pelvis.", "10. Patient has constipation.", "11. Physical examination is significant for pale mucous membranes.", "12. Physical examination is significant for a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.", "13. Pelvic examination reveals an enlarged, mobile uterus with an irregular contour.", "14. Hemoglobin level is 10 g/dL.", "15. Hematocrit is 27%." ]

[ "1. She complains of fatigability and shortness of breath.", "2. Her past medical history includes menarche at 9 years of age.", "3. She has heavy menstrual bleeding for the past several years.", "4. She experiences abdominal pain that worsens during menses.", "5. She had 2 spontaneous abortions in the past 4 years.", "6. She has been on iron oral supplementation for the last 2 years.", "7. She feels a dull pressure-like discomfort in her pelvis.", "8. She experiences constipation.", "9. Physical examination shows pale mucous membranes.", "10. Physical examination reveals a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.", "11. Pelvic examination shows an enlarged, mobile uterus with an irregular contour.", "12. Her hemoglobin level is 10 g/dL.", "13. Her hematocrit is 27%." ]

[ "A study is conducted in a town with a population of 225,000, where the people are followed-up for the development of emphysema.", "A total of 1,000 smokers are selected and followed-up, out of which 200 actually develop the disease.", "A control group of 1,000 non-smokers is formed, out of which 20 develop emphysema.", "The prevalence of smoking in the general population is 40%.", "The researcher calculates all possible risk estimates, including the odds ratio." ]

[ "1. A study is conducted in a town with a population of 225,000.", "2. The people are followed-up for the development of emphysema.", "3. A total of 1,000 smokers are selected and followed-up.", "4. Out of the 1,000 smokers, 200 actually develop the disease.", "5. A control group of 1,000 non-smokers is formed.", "6. Out of the 1,000 non-smokers, 20 develop emphysema.", "7. The prevalence of smoking in the general population is 40%.", "8. The researcher calculates all possible risk estimates, including the odds ratio." ]

[ "1. A total of 1,000 smokers are selected and followed-up.", "2. 200 of the selected smokers develop the disease.", "3. A control group of 1,000 non-smokers is formed.", "4. 20 of the non-smokers in the control group develop emphysema.", "5. The prevalence of smoking in the general population is 40%.", "6. The researcher calculates all possible risk estimates, including the odds ratio." ]

[ "A medical student is performing clinical research by analyzing the aggregated data of all patients from a national database.", "In performing the study, she uses all the data collected from patients who had an appendectomy and analyzes the risk factors that are associated with readmission after discharge.", "She first excludes some of the data based on previously determined exclusion criteria and then performs analysis on the rest.", "She performs a multiple regression on all variables and finds that one of the risk factors demonstrates a < 5% probability of being the same between groups.", "She takes this result and presents it to faculty; however, they respond that the finding is meaningless." ]

[ "1. A medical student is performing clinical research.", "2. The research involves analyzing aggregated data from a national database.", "3. The data is from patients who had an appendectomy.", "4. The research is analyzing risk factors associated with readmission after discharge.", "5. The medical student excludes some of the data based on previously determined exclusion criteria.", "6. The medical student performs a multiple regression on all variables.", "7. The multiple regression finds that one of the risk factors has a < 5% probability of being the same between groups.", "8. The medical student presents the finding to faculty.", "9. The faculty respond that the finding is meaningless." ]

[ "1. She uses all the data collected from patients who had an appendectomy.", "2. She analyzes the risk factors associated with readmission after discharge.", "3. She excludes some of the data based on previously determined exclusion criteria.", "4. She performs analysis on the rest of the data.", "5. She performs a multiple regression on all variables.", "6. She finds that one of the risk factors demonstrates a < 5% probability of being the same between groups.", "7. She presents the result to faculty.", "8. The faculty responds that the finding is meaningless." ]