CASE 1

Gary is 55, divorced the only woman he was ever with 20 years ago, dated scarcely and without physical
relationship, raised 3 children alone after traumatic abandonment by wife/mother after 16 years of marriage. Very
little has changed in 20 years, as though his life is frozen in time. Whenever change is threatened, he becomes very
anxious, always holding out suicide as his way out if cornered or overwhelmed.
Gary has lived all his life on property in his family since 1800s, worked at the same job 35 years, driven same car
more than 20 years, and lives in the same manufactured home he lived in with his wife. Inside his home, cob webs
cover back of living room and dining room. Showers/bathrooms, and kitchen have not been cleaned since one of
the children did it years ago. Gary uses the same towels and washcloths for twenty years, now rags.Gary never
goes to a doctor, dentist, or psychiatrist, and refused any help. While providing extravagantly in a material way for
his children, Gary lives off frozen meal entree's, one or two per day, and wears the same clothes for all these years.
He won't accept gifts or help.
As a child, Gary was the youngest of six. He was unwanted, and often speaks of wishing they would have "made
him an abortion, like they considered to do." He had one brother and all the others sisters. He talks about being "in
the way" all the time. He spent his time roaming fields, with few if any friends. Still he has no close relationships,
and confides only in one of his sisters, who obviously attempts to translate her own opinions into him. He has
contradicting thoughts, some of the way he would like to live, and some, dominant ones, about how he "should"
live, by what principles and standards.
Gary does not, has not, will not expose himself to pornography, violence, abusive speech, or drugs. He is pristine.
He keeps himself physically clean and presentable, but spends nearly all his non-work hours at home in a chair
watching TV or reading to "escape," he says. He attends church on occasion when heavily prompted by, and
accompanied by, a few members of his family. He is afraid of "connections;" relationships. He fears the elders in
his church so much, that he parks his car near the entrance and leaves as soon as possible.
One more thing. Gary seems unable to be assertive or aggression, being polite and passive all the time.
CASE 2
A 43 year old previously well Pakistani housewife presented with headache, facial tenderness and
general weakness. Ten days previously she had visited her GP for a typhoid vaccine as she was due to
visit Pakistan for the first time in four years. One day after receiving the vaccine she developed fever,
lethargy and pain in her shoulder and left upper back muscles. A further 24 hours later she developed
bilateral facial pain with tenderness of the ears and in the parotid and submandibular regions. Non-
steroidals from her GP provided little benefit. Her face became weak and she was unable to close her
eyes or mouth. Saliva pooled in her mouth and her speech became slurred. She had dry eyes but no
diplopia or dysphagia. Nausea and vomiting precipitated her presentation to hospital. There were no
respiratory, autonomic or limb features. There was no history of tick bites or TB. Six months prior to the
presenting complaint she had been seen with painful paraesthesia affecting her fingers and feet. Nerve
conduction studies (NCS), ESR, rheumatoid factor and ANA were all normal. Her symptoms slowly
resolved though she was left with some residual symptoms in her feet.





CASE 3
A 3 year old child came in the ED with the following presenting symptoms: A fever (high temperature)
which last more than 5 days. During the physical exam, at least four of the following symptoms were
positive.
Redness of the eyes (conjunctivitis).
Changes in the mouth such as a red throat or tongue, or dry and cracked lips.
A blotchy red rash. This normally fades within a week.
Changes in the hands or feet such as mild swelling or redness. The skin often peels on some of
the fingers or toes after about 2-3 weeks.
One or more lymph glands in the neck become swollen.

The mother stated that he had flu-like symptoms accompanying the fever. During the interview, the
doctors found out that the childs grandfather, whos Japanese, had the same problem in the past.

CASE 4
Karen is a 38 yo white female in good health presenting with a chief complaint of a small lump in
the left breast of approximately 18 months duration.
A mammogram was performed in May 1991 and again in August 1992 with both normal.
Ultrasound was also performed in May 1991. Karen was informed by her physician that the lump
was fibrocystic and benign.
FAMILY HISTORY Father died age 62 from MI, mother and three sisters are healthy.
SOCIAL HISTORY Divorced with 2 daughters ages 10 and 11. She is employed as an
occupational therapist.
MEDICAL HISTORY Menses at age 16.
PHYSICAL EXAMINATION
Temp: 36 degrees
Pulse: 76
BP: 114/74
Respiration: 16
Wt.: 73 kg
Ht.: 5' 9"
After seeking a second opinion, the patient learned that a biopsy revealed stage IIa infiltrating
lobular carcinoma.