A 27-year-old woman presents to your office complaining of progressing

nervousness, fatigue, palpitations, and the recent development of a resting hand

tremor. She also states that she is having difficulty concentrating at work and
has been more irritable with her coworkers. The patient also notes that she has
developed a persistent rash over her shins that has not improved with the use of
topical steroid creams. All of her symptoms have come on gradually over the
past few months and continue to get worse. Review of systems also reveals an
unintentional weight loss of about 10 lb, insomnia, and amenorrhea for the past
2 months (the patients menstrual cycles are usually quite regular). The patients
past medical history is unremarkable and she takes no oral medications. She is
currently not sexually active and does not drink alcohol, smoke, or use any
illicit drugs. On examination, she is afebrile. Her pulse varies from 70 to 110
beats/min. She appears restless and anxious. Her skin is warm and moist. Her
eyes show evidence of exophthalmos and lid retraction bilaterally, although
funduscopic examination is normal. Neck examination reveals symmetric
thyroid enlargement, without any discrete palpable masses. Cardiac examination
reveals an irregular rhythm. Her lungs are clear to auscultation. Extremity
examination reveals an erythematous,thickened rash on both shins. Neurologic
examination is normal except for a fine resting tremor in her hands when she
attempts to hold out her outstretched arms. Initial lab tests include a negative
regnancy test and an undetectable level of thyroid-stimulating hormone (TSH).
(15)

A 46-year-old woman presents to the clinic for the first time, complaining of
decreased urinary output for 5 months with a foamy appearance. She also
complains of swelling in both legs and nonbloody, nonbilious emesis a few
times a week. She was diagnosed with diabetes 10 years ago and has been
taking insulin for 2 years. She does not check her sugars at home because she
does not like to stick herself. When asked about her diet she states that she eats
the best she can for what she can afford but often has very little appetite. The
patient last saw her physician 8 months ago and insulin is her only medication.
On examination, the patient is an obese woman. Her temperature is 99F
(37.2C), her heart rate is 108 beats/min, her blood pressure is 198/105 mm Hg,
her respiration is 19 breaths/min, and her oxygen saturation is 94% on room air.
A head, ears, eyes, nose, and throat (HEENT) examination reveals periorbital
edema. Her skin is hyperpigmented on both lower extremities. Her heart is
tachycardic with an S1, S2, S4 gallop auscultated with no murmur or rub. When
palpating the hearts point of maximal impulse (PMI), it is lateral to the left
midclavicular line. There are vesicular breath sounds in both lungs throughout.
Her neck reveals no jugular venous distension and there are no carotid bruits.
Her abdomen is nontender, with no bruits or masses palpated. The lower
extremities reveal pitting pretibial edema with a pit recovery time less than 40
seconds. Laboratory studies in your office include a urinalysis showing hyaline
casts, 3+ proteinuria, and glucose, but negative for ketones. Her hemoglobin is
10.9 g/dL and her hematocrit is 32% with a mean corpuscular volume (MCV) of
82.3 g/dL.(21)

A 61-year-old woman presents to the emergency room complaining of cough for

2 weeks. The cough is productive of green sputum and is associated with
sweating, shaking chills, and fever up to 102F (38.8C). She was exposed to
her grandchildren who were told that they had upper respiratory infections 2
weeks ago but now are fine. Her past medical history is significant for diabetes
for 10 years, which is under good control using oral hypoglycemics. She denies
tobacco, alcohol, or drug use. On examination, she looks ill and in distress, with
continuous coughing and chills. Her blood pressure is 100/80 mm Hg, her pulse
is 110 beats/min, her temperature is 101F (38.3C), her respirations are 24
breaths/min, and her oxygen saturation is 97% on room air. Examination of the
head and neck is unremarkable. Her lungs have rhonchi and decreased breath
sounds, with dullness to percussion in bilateral bases. Her heart is tachycardic
but regular. Her extremities are without signs of cyanosis or edema. The
remainder of her examination is normal. A complete blood count (CBC) shows
a high white blood cell (WBC) count of 17,000 cells/mm3, with a differential of
85% neutrophils and 20% lymphocytes. Her blood sugar is 120 mg/dL.(24)

A 33-year-old African-American man presents to the office for an acute visit

with nausea and diarrhea that he has had for the past week. Along with these
symptoms, he has had a low-grade fever, some right upper quadrant (RUQ)
abdominal pain, and has noticed that his eyes seem yellow. He has no
significant medical history and takes no medications regularly. He denies
alcohol, tobacco, or IV drug use. He works as a pastor in a local church that
went on a mission to build a medical clinic in a rural area of Central America
about 5 weeks ago. He had a mild case of travelers diarrhea while there, but
otherwise has felt well. On examination, he is a well-developed man who
appears to be moderately ill. His temperature is 99.8F (37.6C), his blood
pressure is 110/80 mm Hg, his pulse is 90 beats/min, and his respiratory rate is
14 breaths/min. He has a prominent yellow color to his sclera and under his
tongue. His mucous membranes are moist. Lung and cardiac examinations are
normal. His abdomen has normal bowel sounds and tenderness in the right
upper quadrant. His liver edge is palpable just below the costal margin. There
are no other masses felt, no rebound, and no guarding. On rectal examination,
he has clay-colored soft stool that is fecal occult blood test negative.(46)

A 12-year-old boy is brought to the physicians office with right thigh pain and
a limp. His mother has noticed him limping for the past week or so. He denies
any injury to his leg but says that it hurts some when he plays basketball with
his friends. He denies back pain, hip pain, or ankle pain. He occasionally gets
some pain in the right knee but does not have any swelling or bruising. He has
no significant medical history, does not take any medications regularly, and
otherwise feels fine. On examination, he is an overweight adolescent. His vital
signs and a general physical examination are normal. When you have him walk,
he has a prominent limp. You note that he seems to keep his weight on his left
leg for a greater proportion of his gait cycle than he does on the right leg.
Examination of his back reveals a full range of motion, no tenderness, and no
muscle spasm. He gets pain in the right hip when it is passively internally
rotated. When the hip is passively flexed there is a noticeable external rotation.
There is no thigh muscle atrophy. His right knee and the remainder of his
orthopedic examination are normal. A 12-year-old boy is brought to the
physicians office with right thigh pain and a limp. His mother has noticed him
limping for the past week or so. He denies any injury to his leg but says that it
hurts some when he plays basketball with his friends. He denies back pain, hip
pain, or ankle pain. He occasionally gets some pain in the right knee but does
not have any swelling or bruising. He has no significant medical history, does
not take any medications regularly, and otherwise feels fine. On examination, he
is an overweight adolescent. His vital signs and a general physical examination
are normal. When you have him walk, he has a prominent limp. You note that
he seems to keep his weight on his left leg for a greater proportion of his gait
cycle than he does on the right leg. Examination of his back reveals a full range
of motion, no tenderness, and no muscle spasm. He gets pain in the right hip
when it is passively internally rotated. When the hip is passively flexed there is
a noticeable external rotation. There is no thigh muscle atrophy. His right knee
and the remainder of his orthopedic examination are normal. (37)