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stellalisy

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[ "A 37-year-old man comes to the emergency room with fever, chills, and left lower leg pain for 2 days.", "He was recently discharged from the hospital after arthroscopic knee surgery.", "Physical examination shows an erythematous lesion with poorly defined margins over the left shin but no fluctuance.", "Treatment with an intravenous antibiotic is begun.", "Shortly after starting the infusion, the patient develops flushing, erythema, and pruritus of the upper body.", "The symptoms resolve after discontinuation of the infusion.", "Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine and the antibiotic is subsequently given at a slower infusion rate without complications." ]

[ "1. A 37-year-old man comes to the emergency room with fever, chills, and left lower leg pain for 2 days.", "2. He was recently discharged from the hospital after arthroscopic knee surgery.", "3. Physical examination shows an erythematous lesion with poorly defined margins over the left shin but no fluctuance.", "4. Treatment with an intravenous antibiotic is begun.", "5. Shortly after starting the infusion, the patient develops flushing, erythema, and pruritus of the upper body.", "6. The symptoms resolve after discontinuation of the infusion.", "7. Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine.", "8. The antibiotic is subsequently given at a slower infusion rate without complications." ]

[ "1. The patient recently had arthroscopic knee surgery.", "2. Physical examination shows an erythematous lesion with poorly defined margins over the left shin but no fluctuance.", "3. Treatment with an intravenous antibiotic is begun.", "4. Shortly after starting the infusion, the patient develops flushing, erythema, and pruritus of the upper body.", "5. The symptoms resolve after discontinuation of the infusion.", "6. Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine.", "7. The antibiotic is subsequently given at a slower infusion rate without complications." ]

[ "A 55-year-old man presents with worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.", "He says he was previously healthy and active, hiking every weekend, but because of his increasing weakness and incoordination while walking, he stopped his weekly hiking excursion.", "His past medical history is unremarkable.", "Current medications are a daily multivitamin and occasional acetaminophen for headaches.", "He has no significant family history.", "The patient denies smoking, recreational drug use, or drinking.", "His vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.", "Physical examination reveals fasciculations in the tongue and distal extremities.", "The left forearm shows significant atrophy, and mild lower limb muscle atrophy is also seen bilaterally.", "Hyporeflexia (1+) is present in the left arm, while hyperreflexia (3+) is seen in the legs bilaterally.", "Babinski’s sign is positive bilaterally.", "The patient's speech is notably slow but no evidence of productive or expressive aphasia is present.", "The cranial nerves are intact." ]

[ "1. Patient is a 55-year-old man.", "2. Patient has been experiencing worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.", "3. Patient was previously healthy and active, hiking every weekend.", "4. Patient stopped his weekly hiking excursion due to increasing weakness and incoordination while walking.", "5. Patient's past medical history is unremarkable.", "6. Patient's current medications are a daily multivitamin and occasional acetaminophen for headaches.", "7. Patient has no significant family history.", "8. Patient denies smoking, recreational drug use, or drinking.", "9. Patient's vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.", "10. Physical examination reveals fasciculations in the tongue and distal extremities.", "11. Left forearm shows significant atrophy.", "12. Mild lower limb muscle atrophy is seen bilaterally.", "13. Hyporeflexia (1+) is present in the left arm.", "14. Hyperreflexia (3+) is seen in the legs bilaterally.", "15. Babinski’s sign is positive bilaterally.", "16. Patient's speech is notably slow.", "17. No evidence of productive or expressive aphasia is present.", "18. Cranial nerves are intact." ]

[ "1. The patient was previously healthy and active, hiking every weekend.", "2. The patient stopped hiking due to increasing weakness and incoordination while walking.", "3. The patient's past medical history is unremarkable.", "4. The patient's current medications are a daily multivitamin and occasional acetaminophen for headaches.", "5. The patient has no significant family history.", "6. The patient denies smoking, recreational drug use, or drinking.", "7. The patient's vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.", "8. Physical examination reveals fasciculations in the tongue and distal extremities.", "9. The left forearm shows significant atrophy.", "10. Mild lower limb muscle atrophy is seen bilaterally.", "11. Hyporeflexia (1+) is present in the left arm.", "12. Hyperreflexia (3+) is seen in the legs bilaterally.", "13. Babinski’s sign is positive bilaterally.", "14. The patient's speech is notably slow.", "15. No evidence of productive or expressive aphasia is present.", "16. The cranial nerves are intact." ]

[ "A 14-year-old male who is a recent immigrant from India visits your office complaining of difficulty walking.", "Physical examination reveals weakness upon right leg extension and absent right patellar tendon reflex.", "PCR of a stool sample and a swab of the pharynx both yield viral RNA." ]

[ "1. Patient is a 14-year-old male.", "2. Patient is a recent immigrant from India.", "3. Patient is visiting office complaining of difficulty walking.", "4. Physical examination reveals weakness upon right leg extension.", "5. Physical examination reveals absent right patellar tendon reflex.", "6. PCR of a stool sample yields viral RNA.", "7. PCR of a swab of the pharynx yields viral RNA." ]

[ "1. Physical examination reveals weakness upon right leg extension.", "2. Physical examination reveals absent right patellar tendon reflex.", "3. PCR of a stool sample yields viral RNA.", "4. PCR of a swab of the pharynx yields viral RNA." ]

[ "A 21-year-old woman is brought to the emergency department because of the sudden onset of left-sided back pain with radiation to the groin that began 2 hours ago.", "She has had similar episodes in the past.", "Her pulse is 103/min.", "Examination shows a soft and non-tender abdomen.", "Left costovertebral angle tenderness is present.", "Leukocyte count is 11,000/mm3.", "Urine dipstick is positive for blood and a urinary cyanide nitroprusside test is positive.", "An x-ray of the abdomen shows no abnormalities." ]

[ "1. A 21-year-old woman is brought to the emergency department.", "2. She has sudden onset of left-sided back pain with radiation to the groin that began 2 hours ago.", "3. She has had similar episodes in the past.", "4. Her pulse is 103/min.", "5. Examination shows a soft and non-tender abdomen.", "6. Left costovertebral angle tenderness is present.", "7. Leukocyte count is 11,000/mm3.", "8. Urine dipstick is positive for blood.", "9. Urinary cyanide nitroprusside test is positive.", "10. An x-ray of the abdomen shows no abnormalities." ]

[ "1. She has had similar episodes in the past.", "2. Her pulse is 103/min.", "3. Examination shows a soft and non-tender abdomen.", "4. Left costovertebral angle tenderness is present.", "5. Leukocyte count is 11,000/mm3.", "6. Urine dipstick is positive for blood.", "7. Urinary cyanide nitroprusside test is positive.", "8. An x-ray of the abdomen shows no abnormalities." ]

[ "A 45-year-old man presents to the emergency department with sudden left lower back pain and bloody urine.", "The pain is dull and constant.", "He can not localize exactly where it is.", "Over the past 2 weeks, he has also gained 3 kg (7 lb) and his shoes feel tight.", "He denies a history of any chronic medical conditions, recent abdominal trauma or illness, and has never noticed blood in his urine before.", "In the hospital, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, and the blood pressure is 135/85 mm Hg.", "A review of medical records shows that his blood pressure was 115/75 mm Hg 6 months ago.", "On physical exam, he appears distressed.", "There are bruises on his left upper arm, chest, and right thigh.", "The patient does not remember when he got them.", "His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.", "He has 2+ pitting edema in both legs up to the knee and his hands appear edematous.", "A urine dipstick shows 3+ blood and 4+ protein.", "Additional specimens are sent to chemistry for analysis." ]

[ "1. A 45-year-old man presents to the emergency department with sudden left lower back pain and bloody urine.", "2. The pain is dull and constant.", "3. He can not localize exactly where it is.", "4. Over the past 2 weeks, he has also gained 3 kg (7 lb).", "5. His shoes feel tight.", "6. He denies a history of any chronic medical conditions.", "7. He denies a history of recent abdominal trauma or illness.", "8. He has never noticed blood in his urine before.", "9. In the hospital, his temperature is 36.8°C (98.2°F).", "10. The heart rate is 98/min.", "11. The respiratory rate is 15/min.", "12. The blood pressure is 135/85 mm Hg.", "13. A review of medical records shows that his blood pressure was 115/75 mm Hg 6 months ago.", "14. On physical exam, he appears distressed.", "15. There are bruises on his left upper arm, chest, and right thigh.", "16. The patient does not remember when he got them.", "17. His heart has a regular rate and rhythm.", "18. His lungs are clear to auscultation bilaterally.", "19. He has 2+ pitting edema in both legs up to the knee.", "20. His hands appear edematous.", "21. A urine dipstick shows 3+ blood and 4+ protein.", "22. Additional specimens are sent to chemistry for analysis." ]

[ "1. The pain is dull and constant.", "2. He cannot localize exactly where it is.", "3. Over the past 2 weeks, he has gained 3 kg (7 lb) and his shoes feel tight.", "4. He denies a history of any chronic medical conditions, recent abdominal trauma or illness, and has never noticed blood in his urine before.", "5. In the hospital, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, and the blood pressure is 135/85 mm Hg.", "6. A review of medical records shows that his blood pressure was 115/75 mm Hg 6 months ago.", "7. On physical exam, he appears distressed.", "8. There are bruises on his left upper arm, chest, and right thigh.", "9. The patient does not remember when he got them.", "10. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.", "11. He has 2+ pitting edema in both legs up to the knee and his hands appear edematous.", "12. A urine dipstick shows 3+ blood and 4+ protein.", "13. Additional specimens are sent to chemistry for analysis." ]

[ "A 21-year-old man visits his primary care provider complaining of visual disturbance in both eyes for a month and an episode of abnormal uncontrollable shaking that occurred twice last week.", "He was previously healthy and did not take any medication.", "His mother has intermittent muscle weakness and his maternal uncle developed hemiplegia at the age of 35.", "Neuroimaging shows bilateral occipital lobe infarcts and a skeletal muscle biopsy reveals atypical muscle fibers that stain positive for subsarcomelar structures.", "The physician suspects a maternally inherited genetic disorder." ]

[ "1. A 21-year-old man visits his primary care provider.", "2. He is complaining of visual disturbance in both eyes for a month.", "3. He also had an episode of abnormal uncontrollable shaking that occurred twice last week.", "4. He was previously healthy and did not take any medication.", "5. His mother has intermittent muscle weakness.", "6. His maternal uncle developed hemiplegia at the age of 35.", "7. Neuroimaging shows bilateral occipital lobe infarcts.", "8. A skeletal muscle biopsy reveals atypical muscle fibers that stain positive for subsarcomelar structures.", "9. The physician suspects a maternally inherited genetic disorder." ]

[ "1. He was previously healthy.", "2. He did not take any medication.", "3. His mother has intermittent muscle weakness.", "4. His maternal uncle developed hemiplegia at the age of 35.", "5. Neuroimaging shows bilateral occipital lobe infarcts.", "6. A skeletal muscle biopsy reveals atypical muscle fibers.", "7. The atypical muscle fibers stain positive for subsarcomelar structures.", "8. The physician suspects a maternally inherited genetic disorder." ]

[ "Your hospital administrators want to provide you with a tool to analyze the usage of emergency department visits by patients in your high-risk practice.", "The following graph is displayed on the dashboard of your electronic medical record to show you how often your patients utilize the ED so that you can provide higher quality and more cost-effective care.", "The X-axis indicates the number of times a patient has been to the ED in the last year.", "The Y-axis indicates the number of patients who fit into that category." ]

[ "1. Hospital administrators want to provide a tool to analyze emergency department visits by patients in a high-risk practice.", "2. The dashboard of the electronic medical record displays a graph to show how often patients utilize the ED.", "3. The X-axis of the graph indicates the number of times a patient has been to the ED in the last year.", "4. The Y-axis of the graph indicates the number of patients who fit into that category." ]

[ "1. The graph is displayed on the dashboard of the electronic medical record.", "2. The graph shows how often patients utilize the ED.", "3. The purpose is to provide higher quality and more cost-effective care.", "4. The X-axis indicates the number of times a patient has been to the ED in the last year.", "5. The Y-axis indicates the number of patients who fit into that category." ]

[ "A 27-year-old G1P0000 at 17 weeks of gestation is interested in participating in a clinical trial for nausea management during pregnancy.", "The trial will be evaluating the effects of moderate ginger consumption on nausea symptoms.", "Prior to enrolling in the trial, the investigators explain to the patient that they will be doing a full exam and some special testing to make sure she is experiencing a healthy pregnancy." ]

[ "1. A 27-year-old G1P0000 is interested in participating in a clinical trial.", "2. The clinical trial is for nausea management during pregnancy.", "3. The trial will be evaluating the effects of moderate ginger consumption on nausea symptoms.", "4. The patient is 17 weeks of gestation.", "5. Prior to enrolling in the trial, the investigators explain to the patient that they will be doing a full exam.", "6. Prior to enrolling in the trial, the investigators explain to the patient that they will be doing some special testing.", "7. The special testing is to make sure the patient is experiencing a healthy pregnancy." ]

[ "1. The trial will be evaluating the effects of moderate ginger consumption.", "2. The trial will be evaluating the effects on nausea symptoms.", "3. The investigators will explain the trial to the patient.", "4. The investigators will do a full exam on the patient.", "5. The investigators will do some special testing on the patient.", "6. The testing is to ensure the patient is experiencing a healthy pregnancy." ]

[ "A 14-year-old Caucasian male of normal weight presents for a well-child checkup.", "During physical examination, his parents state that their son has been frequenting the bathroom more often than usual and his weight has decreased despite an increase in his caloric intake." ]

[ "1. A 14-year-old Caucasian male is presenting for a well-child checkup.", "2. His weight is normal.", "3. His parents state he has been frequenting the bathroom more often than usual.", "4. His weight has decreased.", "5. His caloric intake has increased." ]

[ "1. During physical examination", "2. His parents state", "3. Their son has been frequenting the bathroom more often than usual", "4. His weight has decreased", "5. Increase in his caloric intake" ]

[ "A 56-year-old woman with a history of stage IIA cervical cancer presents to your office after her 5th episode of a complicated urinary tract infection.", "She complains of easy fatigability, weakness, and has noted that her shoes no longer fit.", "The physical examination is unremarkable, except for a blood pressure of 165/90 mm Hg and mild pitting lower extremity edema.", "The rectovaginal exam revealed no masses.", "Given the patient’s medical history, the specialist makes a stage IIIB diagnosis; however, to confirm this, he orders abdominal and transvaginal ultrasounds and renal function tests." ]

[ "1. A 56-year-old woman presents to the office.", "2. She has a history of stage IIA cervical cancer.", "3. She has had 5 episodes of a complicated urinary tract infection.", "4. She complains of easy fatigability and weakness.", "5. Her shoes no longer fit.", "6. The physical examination is unremarkable, except for a blood pressure of 165/90 mm Hg and mild pitting lower extremity edema.", "7. The rectovaginal exam revealed no masses.", "8. The specialist makes a stage IIIB diagnosis.", "9. To confirm this, he orders abdominal and transvaginal ultrasounds.", "10. He also orders renal function tests." ]

[ "1. The patient complains of easy fatigability.", "2. The patient complains of weakness.", "3. The patient has noted that her shoes no longer fit.", "4. The physical examination is unremarkable.", "5. The patient has a blood pressure of 165/90 mm Hg.", "6. The patient has mild pitting lower extremity edema.", "7. The rectovaginal exam revealed no masses.", "8. The specialist makes a stage IIIB diagnosis based on the patient's medical history.", "9. The specialist orders abdominal and transvaginal ultrasounds.", "10. The specialist orders renal function tests." ]

[ "A 77-year-old man is brought to the physician because of a 2-day history of increasing shortness of breath and ankle swelling.", "He has type 2 diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure.", "Current medications include lisinopril, metformin, and aspirin.", "He has smoked half a pack of cigarettes daily for 50 years.", "His temperature is 37.2°C (98.9°F), pulse is 100/min and regular, respirations are 20/min, and blood pressure is 100/65 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 91%.", "There are jugular venous pulsations 5 cm above the sternal angle.", "Crackles are heard at both lung bases.", "Cardiac examination shows an S3 gallop.", "There is edema from the mid-tibia to the ankle bilaterally.", "Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 7100/mm3 | Serum | Na+ 129 mEq/L | Cl- 99 mEq/L | K+ 4.8 mEq/L | Urea nitrogen 48 mg/dL | Glucose 196 mg/dL | Creatinine 2.1 mg/dL | ." ]

[ "1. Patient is 77 years old.", "2. Patient has 2-day history of increasing shortness of breath and ankle swelling.", "3. Patient has type 2 diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure.", "4. Patient is taking lisinopril, metformin, and aspirin.", "5. Patient has smoked half a pack of cigarettes daily for 50 years.", "6. Patient's temperature is 37.2°C (98.9°F).", "7. Patient's pulse is 100/min and regular.", "8. Patient's respirations are 20/min.", "9. Patient's blood pressure is 100/65 mm Hg.", "10. Pulse oximetry on room air shows an oxygen saturation of 91%.", "11. Jugular venous pulsations 5 cm above the sternal angle.", "12. Crackles are heard at both lung bases.", "13. Cardiac examination shows an S3 gallop.", "14. Patient has edema from the mid-tibia to the ankle bilaterally.", "15. Laboratory studies show hemoglobin 14.1 g/dL.", "16. Laboratory studies show leukocyte count 7100/mm3.", "17. Laboratory studies show serum Na+ 129 mEq/L.", "18. Laboratory studies show Cl- 99 mEq/L.", "19. Laboratory studies show K+ 4.8 mEq/L.", "20. Laboratory studies show urea nitrogen 48 mg/dL.", "21. Laboratory studies show glucose 196 mg/dL.", "22. Laboratory studies show creatinine 2.1 mg/dL." ]

[ "1. He has type 2 diabetes mellitus.", "2. He has hypertension.", "3. He has coronary artery disease.", "4. He has congestive heart failure.", "5. Current medications include lisinopril, metformin, and aspirin.", "6. He has smoked half a pack of cigarettes daily for 50 years.", "7. His temperature is 37.2°C (98.9°F).", "8. His pulse is 100/min and regular.", "9. His respirations are 20/min.", "10. His blood pressure is 100/65 mm Hg.", "11. Pulse oximetry on room air shows an oxygen saturation of 91%.", "12. There are jugular venous pulsations 5 cm above the sternal angle.", "13. Crackles are heard at both lung bases.", "14. Cardiac examination shows an S3 gallop.", "15. There is edema from the mid-tibia to the ankle bilaterally.", "16. Laboratory studies show: Hemoglobin 14.1 g/dL.", "17. Laboratory studies show: Leukocyte count 7100/mm3.", "18. Laboratory studies show: Serum Na+ 129 mEq/L.", "19. Laboratory studies show: Serum Cl- 99 mEq/L.", "20. Laboratory studies show: Serum K+ 4.8 mEq/L.", "21. Laboratory studies show: Urea nitrogen 48 mg/dL.", "22. Laboratory studies show: Glucose 196 mg/dL.", "23. Laboratory studies show: Creatinine 2.1 mg/dL." ]

[ "A 32-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital 30 minutes after spontaneous rupture of membranes without labor pains.", "She delivered her first child vaginally at 38 weeks' gestation.", "Pregnancy was complicated by hypothyroidism.", "She has no other history of serious illness.", "Medications include levothyroxine and a multivitamin.", "Her pulse is 90/min, respirations are 16/min, and blood pressure is 134/76 mm Hg.", "Pelvic examination shows a uterus consistent in size with a 40 week gestation.", "A cardiotocography reading is shown." ]

[ "1. A 32-year-old woman is admitted to the hospital.", "2. She is gravida 2, para 1.", "3. She is at 40 weeks' gestation.", "4. She experienced spontaneous rupture of membranes 30 minutes prior to admission.", "5. She had no labor pains.", "6. She delivered her first child vaginally at 38 weeks' gestation.", "7. Her pregnancy was complicated by hypothyroidism.", "8. She has no other history of serious illness.", "9. Her medications include levothyroxine and a multivitamin.", "10. Her pulse is 90/min.", "11. Her respirations are 16/min.", "12. Her blood pressure is 134/76 mm Hg.", "13. Pelvic examination shows a uterus consistent in size with a 40 week gestation.", "14. A cardiotocography reading is shown." ]

[ "1. She delivered her first child vaginally at 38 weeks' gestation.", "2. Pregnancy was complicated by hypothyroidism.", "3. She has no other history of serious illness.", "4. Medications include levothyroxine and a multivitamin.", "5. Her pulse is 90/min.", "6. Her respirations are 16/min.", "7. Her blood pressure is 134/76 mm Hg.", "8. Pelvic examination shows a uterus consistent in size with a 40 week gestation.", "9. A cardiotocography reading is shown." ]

[ "A 55-year-old man presents for a routine check-up.", "He currently has no complaints, and his last physical and laboratory studies were unremarkable.", "His past medical history is significant for hypercholesterolemia, well managed with rosuvastatin, and hypertension, well managed with hydrochlorothiazide.", "His current medications also include aspirin.", "The patient is afebrile and his vital signs are within normal limits.", "Physical examination reveals some generalized lymphadenopathy.", "Laboratory findings are significant for the following: | ." ]

[ "1. A 55-year-old man presents for a routine check-up.", "2. He currently has no complaints.", "3. His last physical and laboratory studies were unremarkable.", "4. His past medical history is significant for hypercholesterolemia.", "5. Hypercholesterolemia is well managed with rosuvastatin.", "6. His past medical history is also significant for hypertension.", "7. Hypertension is well managed with hydrochlorothiazide.", "8. His current medications also include aspirin.", "9. The patient is afebrile.", "10. His vital signs are within normal limits.", "11. Physical examination reveals some generalized lymphadenopathy.", "12. Laboratory findings are significant for the following." ]

[ "1. The patient currently has no complaints.", "2. His last physical and laboratory studies were unremarkable.", "3. His past medical history includes hypercholesterolemia.", "4. His hypercholesterolemia is well managed with rosuvastatin.", "5. His past medical history also includes hypertension.", "6. His hypertension is well managed with hydrochlorothiazide.", "7. His current medications include aspirin.", "8. The patient is afebrile.", "9. His vital signs are within normal limits.", "10. Physical examination reveals some generalized lymphadenopathy.", "11. Laboratory findings are significant for certain results." ]

[ "A 72-year-old man with a history of diabetes, dyslipidemia, and hypertension presents to the emergency department with sudden-onset right-sided facial paresthesia, word-finding difficulty, and lightheadedness.", "He was at a restaurant, in general good health, enjoying a dinner with friends when the 1st symptoms started.", "He takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin every day.", "A review of symptoms was negative.", "His symptoms spontaneously resolved after 5 minutes.", "In the emergency department, the vital signs included: blood pressure of 132/80 mm Hg, heart rate of 86/min, respiratory rate of 20/min, and oxygen saturation of 99% on room air.", "The laboratory results included: | Hemoglobin 11.3 g/dL | Hematocrit 33% | WBC count 9,800/mm3 | Platelet count 247,000/mm3 | International normalized ratio (INR) 1.1 | Prothrombin time (PT) 11.5 seconds | Partial thromboplastin time (PTT) 32 seconds | His electrocardiogram (ECG) and his head computed tomography (CT) scan were normal.", "A duplex ultrasound scan shows 70–89% stenosis in the left carotid artery and 50% in the right.", "In the course of evaluation, his aphasia recurred for 3 minutes.", "A brain magnetic resonance imaging (MRI) scan was negative for areas of ischemia or intracranial hemorrhage.", "His symptom recurrence prompted his hospital admission for inpatient care." ]

[ "1. Patient is 72 years old.", "2. Patient has a history of diabetes, dyslipidemia, and hypertension.", "3. Patient presented to the emergency department with sudden-onset right-sided facial paresthesia, word-finding difficulty, and lightheadedness.", "4. Patient was at a restaurant, in general good health, enjoying a dinner with friends when the 1st symptoms started.", "5. Patient takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin every day.", "6. Review of symptoms was negative.", "7. Symptoms spontaneously resolved after 5 minutes.", "8. Vital signs included: blood pressure of 132/80 mm Hg, heart rate of 86/min, respiratory rate of 20/min, and oxygen saturation of 99% on room air.", "9. Laboratory results included: Hemoglobin 11.3 g/dL, Hematocrit 33%, WBC count 9,800/mm3, Platelet count 247,000/mm3, International normalized ratio (INR) 1.1, Prothrombin time (PT) 11.5 seconds, Partial thromboplastin time (PTT) 32 seconds.", "10. Electrocardiogram (ECG) and head computed tomography (CT) scan were normal.", "11. Duplex ultrasound scan shows 70–89% stenosis in the left carotid artery and 50% in the right.", "12. In the course of evaluation, his aphasia recurred for 3 minutes.", "13. Brain magnetic resonance imaging (MRI) scan was negative for areas of ischemia or intracranial hemorrhage.", "14. Symptom recurrence prompted his hospital admission for inpatient care." ]

[ "1. The patient was at a restaurant when the first symptoms started.", "2. The patient takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin daily.", "3. A review of symptoms was negative.", "4. The symptoms spontaneously resolved after 5 minutes.", "5. In the emergency department, the patient's vital signs were: blood pressure 132/80 mm Hg, heart rate 86/min, respiratory rate 20/min, and oxygen saturation 99% on room air.", "6. Laboratory results showed: Hemoglobin 11.3 g/dL, Hematocrit 33%, WBC count 9,800/mm3, Platelet count 247,000/mm3, INR 1.1, PT 11.5 seconds, PTT 32 seconds.", "7. The patient's ECG and head CT scan were normal.", "8. A duplex ultrasound scan revealed 70–89% stenosis in the left carotid artery and 50% in the right.", "9. During evaluation, the patient's aphasia recurred for 3 minutes.", "10. A brain MRI scan showed no areas of ischemia or intracranial hemorrhage.", "11. The symptom recurrence prompted the patient's hospital admission for inpatient care." ]

[ "A 70-year-old woman visits her physician complaining of dry mouth and dry eyes.", "She states that she has recently been having difficulty wearing her dentures on account of her dry mouth.", "She also says that her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.", "Her eyes have also been burning, and she has had to use over the counter eye drops much more often.", "These symptoms have persisted for several months.", "On physical exam, mild bilateral enlargement of the parotid glands was noted, and an intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.", "The patient has a history of hypertension, for which she takes lisinopril." ]

[ "1. A 70-year-old woman visits her physician.", "2. She is complaining of dry mouth and dry eyes.", "3. She has difficulty wearing her dentures due to her dry mouth.", "4. Her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.", "5. Her eyes have been burning and she has been using over the counter eye drops more often.", "6. These symptoms have persisted for several months.", "7. On physical exam, mild bilateral enlargement of the parotid glands was noted.", "8. An intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.", "9. The patient has a history of hypertension.", "10. She takes lisinopril for her hypertension." ]

[ "1. The patient has been having difficulty wearing her dentures due to dry mouth.", "2. Her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.", "3. She has been experiencing burning eyes and has had to use over the counter eye drops more frequently.", "4. These symptoms have been present for several months.", "5. On physical exam, mild bilateral enlargement of the parotid glands was noted.", "6. An intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.", "7. The patient has a history of hypertension and takes lisinopril for it." ]

[ "A 61-year old obese nulliparous female presents to your office with right lower quadrant abdominal pain.", "Her medical history is significant for breast cancer and past use of postmenopausal estrogen replacement therapy." ]

[ "1. A 61-year old female presents to your office.", "2. The female is obese.", "3. The female is nulliparous.", "4. The female has right lower quadrant abdominal pain.", "5. The female has a medical history of breast cancer.", "6. The female has a history of past use of postmenopausal estrogen replacement therapy." ]

[ "1. Medical history includes breast cancer.", "2. Past use of postmenopausal estrogen replacement therapy." ]

[ "A 28-year-old man comes to the physician because of a swollen, tender left knee for the past 4 days.", "During this period, the patient has had pain with urination.", "The patient has no history of serious illness and takes no medications.", "He is sexually active with two male partners and they use condoms inconsistently.", "His older sister has systemic lupus erythematosus.", "He is 180 cm (5 ft 11 in) tall and weighs 98 kg (216 lb); BMI is 30.1 kg/m2.", "His temperature is 37°C (98.6°F), pulse is 83/min, and blood pressure is 140/75 mm Hg.", "Examination shows conjunctivitis bilaterally.", "The left knee is warm, erythematous, and tender to touch; range of motion is limited.", "Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h.", "Urinanalysis shows WBCs." ]

[ "1. Patient is 28 years old.", "2. Patient has had a swollen, tender left knee for the past 4 days.", "3. Patient has had pain with urination during this period.", "4. Patient has no history of serious illness and takes no medications.", "5. Patient is sexually active with two male partners and they use condoms inconsistently.", "6. Patient's older sister has systemic lupus erythematosus.", "7. Patient is 180 cm (5 ft 11 in) tall.", "8. Patient weighs 98 kg (216 lb); BMI is 30.1 kg/m2.", "9. Patient's temperature is 37°C (98.6°F).", "10. Patient's pulse is 83/min.", "11. Patient's blood pressure is 140/75 mm Hg.", "12. Patient has conjunctivitis bilaterally.", "13. Patient's left knee is warm, erythematous, and tender to touch.", "14. Patient's range of motion is limited.", "15. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h.", "16. Urinanalysis shows WBCs." ]

[ "1. The patient has had pain with urination.", "2. The patient has no history of serious illness and takes no medications.", "3. He is sexually active with two male partners and they use condoms inconsistently.", "4. His older sister has systemic lupus erythematosus.", "5. He is 180 cm (5 ft 11 in) tall and weighs 98 kg (216 lb); BMI is 30.1 kg/m2.", "6. His temperature is 37°C (98.6°F), pulse is 83/min, and blood pressure is 140/75 mm Hg.", "7. Examination shows conjunctivitis bilaterally.", "8. The left knee is warm, erythematous, and tender to touch; range of motion is limited.", "9. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h.", "10. Urinanalysis shows WBCs." ]

[ "A 21-year-old man comes to the physician because of nervousness and difficulty sleeping over the past 2 weeks.", "Three months ago, he started a new team project at his job.", "He says that he has trouble falling asleep at night because he thinks about the project.", "He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.", "He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.", "The project deadline has already been postponed once.", "He says, “My teammates never understand how important it is to do things the right way.” Ever since high school, he has used the majority of his time to plan out assignments and does not have time to regularly participate in social activities." ]

[ "1. A 21-year-old man comes to the physician because of nervousness and difficulty sleeping over the past 2 weeks.", "2. Three months ago, he started a new team project at his job.", "3. He says that he has trouble falling asleep at night because he thinks about the project.", "4. He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.", "5. He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.", "6. The project deadline has already been postponed once.", "7. He says, “My teammates never understand how important it is to do things the right way.”", "8. Ever since high school, he has used the majority of his time to plan out assignments.", "9. He does not have time to regularly participate in social activities." ]

[ "1. Three months ago, he started a new team project at his job.", "2. He says that he has trouble falling asleep at night because he thinks about the project.", "3. He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.", "4. He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.", "5. The project deadline has already been postponed once.", "6. He says, “My teammates never understand how important it is to do things the right way.”", "7. Ever since high school, he has used the majority of his time to plan out assignments and does not have time to regularly participate in social activities." ]

[ "A 52-years-old man presents with a history of recurrent episodes of unilateral headaches.", "He says the episodes are short-lived (usually lasting for a few seconds to 3-4 minutes), and he describes them as a severe throbbing orbital headache, accompanied by ipsilateral conjunctival injection and lacrimation.", "He says that often the episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.", "Sometimes, he says he experiences countless attacks during a single day.", "The headaches do not respond to indomethacin and any other non-steroidal anti-inflammatory drug (NSAID)." ]

[ "1. A 52-years-old man presents with a history of recurrent episodes of unilateral headaches.", "2. The episodes are short-lived, usually lasting for a few seconds to 3-4 minutes.", "3. He describes them as a severe throbbing orbital headache.", "4. The headaches are accompanied by ipsilateral conjunctival injection and lacrimation.", "5. The episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.", "6. Sometimes, he experiences countless attacks during a single day.", "7. The headaches do not respond to indomethacin.", "8. The headaches do not respond to any other non-steroidal anti-inflammatory drug (NSAID)." ]

[ "1. The episodes are short-lived, usually lasting for a few seconds to 3-4 minutes.", "2. The episodes are described as a severe throbbing orbital headache.", "3. The episodes are accompanied by ipsilateral conjunctival injection and lacrimation.", "4. The episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.", "5. Sometimes, countless attacks are experienced during a single day.", "6. The headaches do not respond to indomethacin.", "7. The headaches do not respond to any other non-steroidal anti-inflammatory drug (NSAID)." ]

[ "A 55-year-old obese man presents to the emergency department with abdominal pain.", "His pain started 2 days ago and has been worsening steadily.", "His only current medication is allopurinol.", "His temperature is 101.0°F (38.3°C), blood pressure is 157/98 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for left lower quadrant abdominal tenderness and rectal exam is unremarkable.", "A CT scan is performed demonstrating inflamed outpouchings of the colonic mucosa with a 4-cm abscess." ]

[ "1. A 55-year-old man presents to the emergency department with abdominal pain.", "2. His pain started 2 days ago and has been worsening steadily.", "3. His only current medication is allopurinol.", "4. His temperature is 101.0°F (38.3°C).", "5. His blood pressure is 157/98 mmHg.", "6. His pulse is 120/min.", "7. His respirations are 17/min.", "8. His oxygen saturation is 98% on room air.", "9. Physical exam is notable for left lower quadrant abdominal tenderness.", "10. Rectal exam is unremarkable.", "11. A CT scan is performed.", "12. CT scan demonstrates inflamed outpouchings of the colonic mucosa.", "13. CT scan demonstrates a 4-cm abscess." ]

[ "1. His pain started 2 days ago and has been worsening steadily.", "2. His only current medication is allopurinol.", "3. His temperature is 101.0°F (38.3°C).", "4. His blood pressure is 157/98 mmHg.", "5. His pulse is 120/min.", "6. His respirations are 17/min.", "7. His oxygen saturation is 98% on room air.", "8. Physical exam is notable for left lower quadrant abdominal tenderness.", "9. Rectal exam is unremarkable.", "10. A CT scan is performed demonstrating inflamed outpouchings of the colonic mucosa with a 4-cm abscess." ]

[ "A 32-year-old G2P2 woman gives birth to a boy at 39 weeks gestation.", "The mother recently immigrated from Somalia and had no prenatal care.", "She refused all intrapartum medications.", "The boy’s Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.", "His height and weight were in the 20th and 15th percentiles, respectively.", "Mother and child were discharged the day after birth.", "However, 7 days later, the mother presents to the pediatrician because she noticed redness and discharge in her baby's eyes.", "His temperature is 98.8°F (37.1°C), blood pressure is 105/65 mmHg, pulse is 120/min, and respirations are 22/min.", "On exam, the boy has scant non-purulent mucoid bilateral eye discharge and conjunctival hyperemia." ]

[ "1. A 32-year-old G2P2 woman gave birth to a boy.", "2. The gestation was 39 weeks.", "3. The mother recently immigrated from Somalia.", "4. The mother had no prenatal care.", "5. The mother refused all intrapartum medications.", "6. The boy's Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.", "7. The boy's height was in the 20th percentile.", "8. The boy's weight was in the 15th percentile.", "9. Mother and child were discharged the day after birth.", "10. Seven days later, the mother presented to the pediatrician.", "11. The mother noticed redness and discharge in her baby's eyes.", "12. The boy's temperature was 98.8°F (37.1°C).", "13. The boy's blood pressure was 105/65 mmHg.", "14. The boy's pulse was 120/min.", "15. The boy's respirations were 22/min.", "16. On exam, the boy had scant non-purulent mucoid bilateral eye discharge and conjunctival hyperemia." ]

[ "1. The mother recently immigrated from Somalia.", "2. The mother had no prenatal care.", "3. The mother refused all intrapartum medications.", "4. The boy’s Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.", "5. The boy’s height was in the 20th percentile.", "6. The boy’s weight was in the 15th percentile.", "7. Mother and child were discharged the day after birth.", "8. 7 days later, the mother presents to the pediatrician.", "9. The mother noticed redness and discharge in her baby's eyes.", "10. The boy's temperature is 98.8°F (37.1°C).", "11. The boy's blood pressure is 105/65 mmHg.", "12. The boy's pulse is 120/min.", "13. The boy's respirations are 22/min.", "14. On exam, the boy has scant non-purulent mucoid bilateral eye discharge.", "15. On exam, the boy has conjunctival hyperemia." ]

[ "A 21-year-old woman presents to her physician for a regular follow-up visit.", "She was diagnosed with relapsing-remitting multiple sclerosis 2 months ago when she suffered a second episode of optic neuritis.", "She was successfully treated with methylprednisolone pulse therapy and discharged.", "Today, she only complains of slight fatigue with upper and lower extremity weakness.", "Her blood pressure is 120/80 mm Hg, her heart rate is 63/min, her respiratory rate is 14/min, and her temperature is 36.7°C (98.0°F).", "Neurological examination reveals brisk deep reflexes (3+ equal) and decreased strength (4/4) in the upper limbs.", "The rest of the examination is unremarkable.", "The patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.", "She is concerned about the side effects of this drug, among which is increased susceptibility to the upper respiratory tract and urinary tract infections." ]

[ "1. Patient is 21 years old.", "2. Patient was diagnosed with relapsing-remitting multiple sclerosis 2 months ago.", "3. Patient suffered a second episode of optic neuritis.", "4. Patient was successfully treated with methylprednisolone pulse therapy and discharged.", "5. Patient only complains of slight fatigue with upper and lower extremity weakness.", "6. Patient's blood pressure is 120/80 mm Hg.", "7. Patient's heart rate is 63/min.", "8. Patient's respiratory rate is 14/min.", "9. Patient's temperature is 36.7°C (98.0°F).", "10. Neurological examination reveals brisk deep reflexes (3+ equal).", "11. Neurological examination reveals decreased strength (4/4) in the upper limbs.", "12. The rest of the examination is unremarkable.", "13. Patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.", "14. Patient is concerned about the side effects of this drug, among which is increased susceptibility to the upper respiratory tract and urinary tract infections." ]

[ "1. The patient was diagnosed with relapsing-remitting multiple sclerosis 2 months ago.", "2. The diagnosis was made after she suffered a second episode of optic neuritis.", "3. She was treated with methylprednisolone pulse therapy and discharged.", "4. Currently, she complains of slight fatigue with upper and lower extremity weakness.", "5. Her blood pressure is 120/80 mm Hg.", "6. Her heart rate is 63/min.", "7. Her respiratory rate is 14/min.", "8. Her temperature is 36.7°C (98.0°F).", "9. Neurological examination reveals brisk deep reflexes (3+ equal) and decreased strength (4/4) in the upper limbs.", "10. The rest of the examination is unremarkable.", "11. The patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.", "12. The patient is concerned about the side effects of the drug, including increased susceptibility to upper respiratory tract and urinary tract infections." ]

[ "A 64-year-old man presents to the clinic complaining of low back pain.", "He was diagnosed with benign prostatic hypertrophy several years ago, which worsened last year.", "A hard nodule was felt on a digital rectal exam, which led to a prostate biopsy that revealed high-grade adenocarcinoma.", "A bone scan at that time showed small, focal abnormalities in the lumbar spine.", "He subsequently underwent radiation therapy to his prostate and pelvic lymph nodes.", "He was then placed on leuprolide and an anti-androgen.", "He was doing well until 2 months ago when he developed low back pain, which has worsened since then.", "He reports that the pain is 8/10 and nearly constant.", "He states that the pain not only affects his ability to fall asleep but also wakes him up at night.", "The pain is mildly alleviated by ibuprofen.", "In addition to prostate cancer, his medical history is significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease.", "He takes aspirin, lisinopril, rosuvastatin, and pantoprazole.", "Upon physical examination, there is midline tenderness within the lumbar region.", "Magnetic resonance imaging of the spine is obtained, which shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression.", "His prostate-specific antigen is 17.5 ng/mL." ]

[ "1. Patient is 64 years old.", "2. Patient presents with low back pain.", "3. Patient was diagnosed with benign prostatic hypertrophy several years ago.", "4. Benign prostatic hypertrophy worsened last year.", "5. Digital rectal exam revealed a hard nodule.", "6. Prostate biopsy revealed high-grade adenocarcinoma.", "7. Bone scan showed small, focal abnormalities in the lumbar spine.", "8. Patient underwent radiation therapy to prostate and pelvic lymph nodes.", "9. Patient was placed on leuprolide and an anti-androgen.", "10. Patient was doing well until 2 months ago.", "11. Low back pain has worsened since then.", "12. Pain is 8/10 and nearly constant.", "13. Pain affects patient's ability to fall asleep and wakes him up at night.", "14. Pain is mildly alleviated by ibuprofen.", "15. Patient's medical history is significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease.", "16. Patient takes aspirin, lisinopril, rosuvastatin, and pantoprazole.", "17. Physical examination reveals midline tenderness within the lumbar region.", "18. Magnetic resonance imaging of the spine shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression.", "19. Patient's prostate-specific antigen is 17.5 ng/mL." ]

[ "1. Diagnosed with benign prostatic hypertrophy several years ago", "2. Diagnosis worsened last year", "3. Hard nodule felt on digital rectal exam", "4. Prostate biopsy revealed high-grade adenocarcinoma", "5. Bone scan showed small, focal abnormalities in the lumbar spine", "6. Underwent radiation therapy to prostate and pelvic lymph nodes", "7. Placed on leuprolide and an anti-androgen", "8. Developed low back pain 2 months ago", "9. Pain is 8/10 and nearly constant", "10. Pain affects ability to fall asleep and wakes him up at night", "11. Pain mildly alleviated by ibuprofen", "12. Medical history significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease", "13. Takes aspirin, lisinopril, rosuvastatin, and pantoprazole", "14. Midline tenderness within the lumbar region upon physical examination", "15. Magnetic resonance imaging shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression", "16. Prostate-specific antigen is 17.5 ng/mL" ]

[ "Two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident, a 34-year-old woman develops sudden shortness of breath.", "On examination, she is oriented only to person.", "Her temperature is 38.3°C (100.9°F), pulse is 122/min, respiratory rate is 31/min, and blood pressure is 152/90 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 83%.", "There are several scattered petechiae on the anterior chest wall.", "Her hemoglobin concentration is 10.3 g/dL, leukocyte count is 9,500/mm3, and platelet count is 140,000/mm3." ]

[ "1. A 34-year-old woman developed sudden shortness of breath two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident.", "2. On examination, she is oriented only to person.", "3. Her temperature is 38.3°C (100.9°F).", "4. Her pulse is 122/min.", "5. Her respiratory rate is 31/min.", "6. Her blood pressure is 152/90 mm Hg.", "7. Pulse oximetry on room air shows an oxygen saturation of 83%.", "8. There are several scattered petechiae on the anterior chest wall.", "9. Her hemoglobin concentration is 10.3 g/dL.", "10. Her leukocyte count is 9,500/mm3.", "11. Her platelet count is 140,000/mm3." ]

[ "1. On examination, she is oriented only to person.", "2. Her temperature is 38.3°C (100.9°F).", "3. Her pulse is 122/min.", "4. Her respiratory rate is 31/min.", "5. Her blood pressure is 152/90 mm Hg.", "6. Pulse oximetry on room air shows an oxygen saturation of 83%.", "7. There are several scattered petechiae on the anterior chest wall.", "8. Her hemoglobin concentration is 10.3 g/dL.", "9. Her leukocyte count is 9,500/mm3.", "10. Her platelet count is 140,000/mm3." ]

[ "A 15-year-old girl comes to the physician for the evaluation of a painless swelling under the left lower jaw for 5 months.", "Her 18-year-old sister has a history of acute lymphoblastic leukemia that has been in remission for 11 years.", "The patient's temperature is 37°C (98.6°F) Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.", "The swelling is soft and fluctuant.", "It does not move with swallowing, and forced exhalation against a closed glottis does not increase the size of the swelling.", "Ultrasound shows a round mass with uniform low echogenicity and no internal septations." ]

[ "1. Patient is a 15-year-old girl.", "2. Patient has a painless swelling under the left lower jaw for 5 months.", "3. Patient's 18-year-old sister has a history of acute lymphoblastic leukemia in remission for 11 years.", "4. Patient's temperature is 37°C (98.6°F).", "5. Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.", "6. Swelling is soft and fluctuant.", "7. Swelling does not move with swallowing.", "8. Forced exhalation against a closed glottis does not increase the size of the swelling.", "9. Ultrasound shows a round mass with uniform low echogenicity and no internal septations." ]

[ "1. Her 18-year-old sister has a history of acute lymphoblastic leukemia.", "2. The sister's leukemia has been in remission for 11 years.", "3. The patient's temperature is 37°C (98.6°F).", "4. Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.", "5. The swelling is soft and fluctuant.", "6. The swelling does not move with swallowing.", "7. Forced exhalation against a closed glottis does not increase the size of the swelling.", "8. Ultrasound shows a round mass with uniform low echogenicity and no internal septations." ]

[ "A 70-year-old man is brought to the emergency department by staff of the group home where he resides because of fever, a productive cough, and blood-tinged sputum for 2 days.", "The staff report that he developed myalgia, headache, and rhinorrhea 7 days ago, which improved initially before worsening again.", "He has hypertension and Alzheimer disease.", "Current medications include enalapril and donepezil.", "On arrival, he is obtunded.", "His temperature is 39.8°C (103.6°F), pulse is 120/min, respirations are 22/min and shallow, and blood pressure is 100/60 mm Hg.", "Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.", "Examination shows scattered crackles and rhonchi throughout both lung fields.", "An x-ray of the chest shows bilateral lung opacities and multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma." ]

[ "1. A 70-year-old man is brought to the emergency department.", "2. He resides in a group home.", "3. He has fever, a productive cough, and blood-tinged sputum for 2 days.", "4. He developed myalgia, headache, and rhinorrhea 7 days ago.", "5. His symptoms initially improved before worsening again.", "6. He has hypertension and Alzheimer disease.", "7. His current medications include enalapril and donepezil.", "8. On arrival, he is obtunded.", "9. His temperature is 39.8°C (103.6°F).", "10. His pulse is 120/min.", "11. His respirations are 22/min and shallow.", "12. His blood pressure is 100/60 mm Hg.", "13. Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.", "14. Examination shows scattered crackles and rhonchi throughout both lung fields.", "15. An x-ray of the chest shows bilateral lung opacities.", "16. An x-ray of the chest shows multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma." ]

[ "1. He developed myalgia, headache, and rhinorrhea 7 days ago.", "2. His symptoms improved initially before worsening again.", "3. He has hypertension.", "4. He has Alzheimer's disease.", "5. His current medications include enalapril and donepezil.", "6. On arrival, he is obtunded.", "7. His temperature is 39.8°C (103.6°F).", "8. His pulse is 120/min.", "9. His respirations are 22/min and shallow.", "10. His blood pressure is 100/60 mm Hg.", "11. Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.", "12. Examination shows scattered crackles and rhonchi throughout both lung fields.", "13. An x-ray of the chest shows bilateral lung opacities.", "14. An x-ray of the chest shows multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma." ]

[ "A 55-year-old man presents to his primary care physician with ear pain.", "The patient states he has had worsening ear pain for the past 2 days.", "He describes his pain as 9/10.", "The patient has a past medical history of diabetes, obesity, and hypertension.", "His current medications include insulin, metformin, lisinopril, aspirin, and atorvastatin.", "His temperature is 100.5°F (38.1°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a purulent drainage from the ear canal.", "Manipulation of the ear causes severe pain." ]

[ "1. Patient is 55 years old.", "2. Patient has ear pain for 2 days.", "3. Patient describes pain as 9/10.", "4. Patient has past medical history of diabetes, obesity, and hypertension.", "5. Patient is taking insulin, metformin, lisinopril, aspirin, and atorvastatin.", "6. Patient's temperature is 100.5°F (38.1°C).", "7. Patient's blood pressure is 177/99 mmHg.", "8. Patient's pulse is 100/min.", "9. Patient's respirations are 19/min.", "10. Patient's oxygen saturation is 98% on room air.", "11. Physical exam reveals purulent drainage from ear canal.", "12. Manipulation of ear causes severe pain." ]

[ "1. The patient has had worsening ear pain for the past 2 days.", "2. The patient describes his pain as 9/10.", "3. The patient has a past medical history of diabetes, obesity, and hypertension.", "4. The patient's current medications include insulin, metformin, lisinopril, aspirin, and atorvastatin.", "5. The patient's temperature is 100.5°F (38.1°C).", "6. The patient's blood pressure is 177/99 mmHg.", "7. The patient's pulse is 100/min.", "8. The patient's respirations are 19/min.", "9. The patient's oxygen saturation is 98% on room air.", "10. Physical exam reveals a purulent drainage from the ear canal.", "11. Manipulation of the ear causes severe pain." ]

[ "A 19-year-old male college student with no significant medical history presents to the emergency department with altered mental status.", "His girlfriend said that he drank multiple shots of vodka and gin throughout the weekend and was found slumped on the couch with some vomit on his shirt.", "He is afebrile, with a blood pressure of 128/60 mmHg, pulse of 100/min, respirations at 25/min, and SpO2 of 95% on room air.", "His pupils are equal and reactive to light bilaterally.", "He exhibits no tremors or myoclonus.", "The remainder of the physical exam is unremarkable.", "His basic metabolic panel is displayed below: | | Serum: | Na+: 138 mEq/L | Cl-: 90 mEq/L | K+: 4.0 mEq/L | HCO3-: 20 mEq/L | BUN: 30 mg/dL | Glucose: 100 mg/dL | Creatinine: 0.8 mg/dL | | An arterial blood gas reveals the following: | | pH: 7.32 | pCO2: 34 mmHg | pO2: 89 mmHg | | The girlfriend is concerned that the patient's breathing appears uncomfortable." ]

[ "1. A 19-year-old male college student with no significant medical history presents to the emergency department with altered mental status.", "2. His girlfriend said that he drank multiple shots of vodka and gin throughout the weekend and was found slumped on the couch with some vomit on his shirt.", "3. He is afebrile.", "4. His blood pressure is 128/60 mmHg.", "5. His pulse is 100/min.", "6. His respirations are 25/min.", "7. His SpO2 is 95% on room air.", "8. His pupils are equal and reactive to light bilaterally.", "9. He exhibits no tremors or myoclonus.", "10. The remainder of the physical exam is unremarkable.", "11. His serum Na+ is 138 mEq/L.", "12. His serum Cl- is 90 mEq/L.", "13. His serum K+ is 4.0 mEq/L.", "14. His serum HCO3- is 20 mEq/L.", "15. His BUN is 30 mg/dL.", "16. His glucose is 100 mg/dL.", "17. His creatinine is 0.8 mg/dL.", "18. His pH is 7.32.", "19. His pCO2 is 34 mmHg.", "20. His pO2 is 89 mmHg.", "21. The girlfriend is concerned that the patient's breathing appears uncomfortable." ]

[ "1. The patient drank multiple shots of vodka and gin throughout the weekend.", "2. The patient was found slumped on the couch with vomit on his shirt.", "3. The patient is afebrile.", "4. The patient's blood pressure is 128/60 mmHg.", "5. The patient's pulse is 100/min.", "6. The patient's respirations are at 25/min.", "7. The patient's SpO2 is 95% on room air.", "8. The patient's pupils are equal and reactive to light bilaterally.", "9. The patient exhibits no tremors or myoclonus.", "10. The remainder of the physical exam is unremarkable.", "11. The patient's basic metabolic panel shows: Na+: 138 mEq/L, Cl-: 90 mEq/L, K+: 4.0 mEq/L, HCO3-: 20 mEq/L, BUN: 30 mg/dL, Glucose: 100 mg/dL, Creatinine: 0.8 mg/dL.", "12. An arterial blood gas reveals: pH: 7.32, pCO2: 34 mmHg, pO2: 89 mmHg.", "13. The girlfriend is concerned that the patient's breathing appears uncomfortable." ]

[ "A 56-year-old man presents to his primary care provider for a check-up.", "His past medical history is significant for type 2 diabetes mellitus for 20 years and insomnia.", " He takes metformin and insulin NPH.", "Both of his parents died in a car accident several years ago.", "He smokes a half of a pack of cigarettes every day and drinks 1-2 beers a day and more on the weekends.", "Today, his blood pressure is 130/80 mm Hg, pulse is 76/min, respiratory rate is 18/min, and temperature is 36.5°C (97.7°F).", "On physical exam, he appears obese.", "His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.", "A foot exam is performed and is unremarkable.", "A urinalysis reveals glucose (++), and protein (+++)." ]

[ "1. A 56-year-old man presents to his primary care provider for a check-up.", "2. His past medical history is significant for type 2 diabetes mellitus for 20 years and insomnia.", "3. He takes metformin and insulin NPH.", "4. Both of his parents died in a car accident several years ago.", "5. He smokes a half of a pack of cigarettes every day and drinks 1-2 beers a day and more on the weekends.", "6. Today, his blood pressure is 130/80 mm Hg.", "7. Today, his pulse is 76/min.", "8. Today, his respiratory rate is 18/min.", "9. Today, his temperature is 36.5°C (97.7°F).", "10. On physical exam, he appears obese.", "11. His heart has a regular rate and rhythm.", "12. His lungs are clear to auscultation bilaterally.", "13. A foot exam is performed and is unremarkable.", "14. A urinalysis reveals glucose (++).", "15. A urinalysis reveals protein (+++)." ]

[ "1. His past medical history includes type 2 diabetes mellitus for 20 years.", "2. His past medical history includes insomnia.", "3. He takes metformin.", "4. He takes insulin NPH.", "5. Both of his parents died in a car accident several years ago.", "6. He smokes half a pack of cigarettes every day.", "7. He drinks 1-2 beers a day and more on the weekends.", "8. His blood pressure is 130/80 mm Hg.", "9. His pulse is 76/min.", "10. His respiratory rate is 18/min.", "11. His temperature is 36.5°C (97.7°F).", "12. On physical exam, he appears obese.", "13. His heart has a regular rate and rhythm.", "14. His lungs are clear to auscultation bilaterally.", "15. A foot exam is performed and is unremarkable.", "16. A urinalysis reveals glucose (++).", "17. A urinalysis reveals protein (+++)." ]

[ "A 64-year-old man comes to the physician because of a 1-month history of progressively worsening back pain that wakes him up at night.", "He also reports symptoms of urinary urgency and a weak urine stream.", "He has no history of serious illness and takes no medications.", "Rectal examination shows an enlarged and hardened prostate with a nodular surface.", "After further evaluation and confirmation of the diagnosis, he is started on a new drug.", "Initially, there is an increase in serum testosterone and dihydrotestosterone levels, followed by a sustained decrease in both serum hormone levels." ]

[ "1. A 64-year-old man comes to the physician.", "2. He has a 1-month history of progressively worsening back pain that wakes him up at night.", "3. He also reports symptoms of urinary urgency and a weak urine stream.", "4. He has no history of serious illness and takes no medications.", "5. Rectal examination shows an enlarged and hardened prostate with a nodular surface.", "6. After further evaluation and confirmation of the diagnosis, he is started on a new drug.", "7. Initially, there is an increase in serum testosterone and dihydrotestosterone levels.", "8. This is followed by a sustained decrease in both serum hormone levels." ]

[ "1. Patient reports symptoms of urinary urgency", "2. Patient reports symptoms of a weak urine stream", "3. Patient has no history of serious illness", "4. Patient takes no medications", "5. Rectal examination shows an enlarged prostate", "6. Rectal examination shows a hardened prostate", "7. Rectal examination shows a nodular surface of the prostate", "8. Patient is started on a new drug", "9. Initially, there is an increase in serum testosterone levels", "10. Initially, there is an increase in dihydrotestosterone levels", "11. There is a sustained decrease in serum testosterone levels", "12. There is a sustained decrease in dihydrotestosterone levels" ]

[ "A 46-year-old man presents to a physician three days after arriving in Morocco.", "He endorses acute onset of painless, profuse watery diarrhea that appears white and cloudy.", "The patient denies bloody stool, vomiting, or subjective fevers.", "Vital signs are T 98.6, HR 120, RR 17, and BP 85/50.", "On physical exam, the patient has dry mouth, decreased skin turgor, and cold clammy skin.", "His peripheral pulse is rapid and thready." ]

[ "1. A 46-year-old man presents to a physician.", "2. He arrived in Morocco three days ago.", "3. He has acute onset of painless, profuse watery diarrhea.", "4. The diarrhea appears white and cloudy.", "5. The patient denies bloody stool, vomiting, or subjective fevers.", "6. His temperature is 98.6.", "7. His heart rate is 120.", "8. His respiratory rate is 17.", "9. His blood pressure is 85/50.", "10. On physical exam, he has dry mouth.", "11. He has decreased skin turgor.", "12. His skin is cold and clammy.", "13. His peripheral pulse is rapid and thready." ]

[ "1. The patient endorses acute onset of painless, profuse watery diarrhea.", "2. The diarrhea appears white and cloudy.", "3. The patient denies bloody stool, vomiting, or subjective fevers.", "4. Vital signs are T 98.6, HR 120, RR 17, and BP 85/50.", "5. On physical exam, the patient has dry mouth.", "6. The patient has decreased skin turgor.", "7. The patient has cold clammy skin.", "8. His peripheral pulse is rapid and thready." ]

[ "A 25-year-old woman presents to the urgent care center with a one month history of intermittent chest pain that occurs about 2-3 times per week in the early mornings.", "She does not smoke and has never suffered from chest pain before.", "She has no family history of early MI.", "A 12 lead ECG does not show any abnormalities.", "Creatine kinase and troponin I enzymes are within normal limits." ]

[ "1. A 25-year-old woman presents to the urgent care center.", "2. She has a one month history of intermittent chest pain.", "3. The chest pain occurs about 2-3 times per week in the early mornings.", "4. She does not smoke.", "5. She has never suffered from chest pain before.", "6. She has no family history of early MI.", "7. A 12 lead ECG does not show any abnormalities.", "8. Creatine kinase and troponin I enzymes are within normal limits." ]

[ "1. She does not smoke.", "2. She has never suffered from chest pain before.", "3. She has no family history of early MI.", "4. A 12 lead ECG does not show any abnormalities.", "5. Creatine kinase enzymes are within normal limits.", "6. Troponin I enzymes are within normal limits." ]

[ "A 28-year-old man is scheduled for skin grafting of the right leg.", "Four weeks earlier, he underwent open reduction and internal fixation of an open right tibial fracture.", "The postoperative period at that time was complicated by necrosis of the overlying skin.", "In the operating room, he is placed on continuous hemodynamic monitoring and anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.", "Thirty minutes later, he has severe shortness of breath and lightheadedness and loses consciousness.", "His temperature is 37.1°C (98.8°F), pulse is 38/min, respirations are 24/min, and palpable systolic blood pressure is 58 mmHg.", "The skin is diaphoretic and flushed.", "He withdraws the upper extremities to painful stimuli above the navel.", "The lungs are clear to auscultation.", "Heart sounds are not audible." ]

[ "1. A 28-year-old man is scheduled for skin grafting of the right leg.", "2. Four weeks earlier, he underwent open reduction and internal fixation of an open right tibial fracture.", "3. The postoperative period at that time was complicated by necrosis of the overlying skin.", "4. In the operating room, he is placed on continuous hemodynamic monitoring.", "5. Anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.", "6. Thirty minutes later, he has severe shortness of breath and lightheadedness and loses consciousness.", "7. His temperature is 37.1°C (98.8°F).", "8. Pulse is 38/min.", "9. Respirations are 24/min.", "10. Palpable systolic blood pressure is 58 mmHg.", "11. The skin is diaphoretic and flushed.", "12. He withdraws the upper extremities to painful stimuli above the navel.", "13. The lungs are clear to auscultation.", "14. Heart sounds are not audible." ]

[ "1. Four weeks earlier, open reduction and internal fixation of an open right tibial fracture", "2. Postoperative period complicated by necrosis of the overlying skin", "3. Placed on continuous hemodynamic monitoring in the operating room", "4. Anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace", "5. Thirty minutes later, severe shortness of breath and lightheadedness", "6. Loss of consciousness", "7. Temperature is 37.1°C (98.8°F)", "8. Pulse is 38/min", "9. Respirations are 24/min", "10. Palpable systolic blood pressure is 58 mmHg", "11. Skin is diaphoretic and flushed", "12. Withdraws upper extremities to painful stimuli above the navel", "13. Lungs are clear to auscultation", "14. Heart sounds are not audible" ]

[ "A 42-year-old man with no significant medical history presents to the emergency department with complaints of headache, nausea, and dizziness.", "He states that he was at home working on his car when he started to feel dizzy and experienced a headache.", "This progressed to him feeling nauseous.", "The patient states he went inside and drank some water and felt better; however, when he started working on his car again his symptoms returned.", "Upon presentation, he states his symptoms have mostly improved except for a persistent headache.", "His temperature is 98.1°F (36.7°C), blood pressure is 125/84 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "Neurologic exam is unremarkable." ]

[ "1. Patient is 42 years old.", "2. Patient has no significant medical history.", "3. Patient presented to the emergency department with complaints of headache, nausea, and dizziness.", "4. Patient was at home working on his car when he started to feel dizzy and experienced a headache.", "5. Symptoms progressed to feeling nauseous.", "6. Patient went inside and drank some water and felt better.", "7. Symptoms returned when patient started working on his car again.", "8. Upon presentation, patient states his symptoms have mostly improved except for a persistent headache.", "9. Patient's temperature is 98.1°F (36.7°C).", "10. Patient's blood pressure is 125/84 mmHg.", "11. Patient's pulse is 87/min.", "12. Patient's respirations are 18/min.", "13. Patient's oxygen saturation is 98% on room air.", "14. Neurologic exam is unremarkable." ]

[ "1. The patient was at home working on his car when he started to feel dizzy and experienced a headache.", "2. His symptoms progressed to feeling nauseous.", "3. After drinking water, he felt better, but his symptoms returned when he resumed working on his car.", "4. Upon presentation, his symptoms had mostly improved except for a persistent headache.", "5. His temperature is 98.1°F (36.7°C).", "6. His blood pressure is 125/84 mmHg.", "7. His pulse is 87/min.", "8. His respirations are 18/min.", "9. His oxygen saturation is 98% on room air.", "10. His neurologic exam is unremarkable." ]

[ "A 19-year-old woman comes to the physician because of severe headaches for the past 3 months.", "The headaches are pulsating in nature and she describes the pain as 8 out of 10 in intensity.", "She has visited the emergency department for headaches twice in the past month; during both visits, her blood pressure was elevated.", "She has polycystic ovarian disease.", "Her medications include metformin and an oral contraceptive pill.", "She is 162 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 32.8 kg/m2.", "Her temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 168/98 mm Hg.", "Examination shows hirsutism.", "Cardiopulmonary examination shows no abnormalities.", "The abdomen is soft and nontender.", "An abdominal bruit is heard on the left side.", "Neurologic examination shows no focal findings.", "A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.", "Plasma free metanephrines are within the reference range.", "An abdominal ultrasound shows an increased peak systolic velocity in the distal portion of the left renal artery.", "A contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.", "A CT scan of the brain shows no abnormalities." ]

[ "1. Patient is 19 years old.", "2. Patient has had severe headaches for 3 months.", "3. Headaches are pulsating in nature.", "4. Patient describes pain as 8 out of 10 in intensity.", "5. Patient has visited the emergency department twice in the past month.", "6. Both visits showed elevated blood pressure.", "7. Patient has polycystic ovarian disease.", "8. Medications include metformin and an oral contraceptive pill.", "9. Patient is 162 cm tall and weighs 86 kg.", "10. BMI is 32.8 kg/m2.", "11. Temperature is 37°C (98.6°F).", "12. Pulse is 99/min.", "13. Blood pressure is 168/98 mm Hg.", "14. Examination shows hirsutism.", "15. Cardiopulmonary examination shows no abnormalities.", "16. Abdomen is soft and nontender.", "17. Abdominal bruit is heard on the left side.", "18. Neurologic examination shows no focal findings.", "19. Complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.", "20. Plasma free metanephrines are within the reference range.", "21. Abdominal ultrasound shows increased peak systolic velocity in the distal portion of the left renal artery.", "22. Contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.", "23. CT scan of the brain shows no abnormalities." ]

[ "1. The headaches are pulsating in nature.", "2. She describes the pain as 8 out of 10 in intensity.", "3. She has visited the emergency department for headaches twice in the past month.", "4. During both visits, her blood pressure was elevated.", "5. She has polycystic ovarian disease.", "6. Her medications include metformin and an oral contraceptive pill.", "7. She is 162 cm (5 ft 4 in) tall and weighs 86 kg (190 lb).", "8. Her BMI is 32.8 kg/m2.", "9. Her temperature is 37°C (98.6°F).", "10. Her pulse is 99/min.", "11. Her blood pressure is 168/98 mm Hg.", "12. Examination shows hirsutism.", "13. Cardiopulmonary examination shows no abnormalities.", "14. The abdomen is soft and nontender.", "15. An abdominal bruit is heard on the left side.", "16. Neurologic examination shows no focal findings.", "17. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.", "18. Plasma free metanephrines are within the reference range.", "19. An abdominal ultrasound shows an increased peak systolic velocity in the distal portion of the left renal artery.", "20. A contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.", "21. A CT scan of the brain shows no abnormalities." ]

[ "A 28-year-old male is found to have 93% HbA, 2% HbF, and 5% HbA2 on hemoglobin electrophoresis." ]

[ "1. Patient is 28 years old.", "2. Patient is male.", "3. Hemoglobin electrophoresis reveals 93% HbA.", "4. Hemoglobin electrophoresis reveals 2% HbF.", "5. Hemoglobin electrophoresis reveals 5% HbA2." ]

[ "1. A 28-year-old male", "2. Found to have 93% HbA", "3. Found to have 2% HbF", "4. Found to have 5% HbA2", "5. On hemoglobin electrophoresis" ]

[ "A 76-year-old female is brought to the emergency department for altered mental status.", "She is accompanied by a nurse from her nursing home.", "The nurse says that usually the patient is interactive even though she is sometimes forgetful.", "In the last two days, the patient has been increasingly lethargic and doesn’t respond to the staff’s questions.", "She also has not been able to get up and use the restroom so the staff has had to change multiple soiled sheets.", "Her temperature is 102.1°F (38.9°C), blood pressure is 100/74 mmHg, pulse is 120/min, and respirations are 24/min.", "The patient is combative on arrival but can be subdued with reorientation by the care team.", "She is not oriented to person, place, or time.", "Urinalysis shows positive leukocyte esterase and nitrites.", "Urine culture grows >100,000 CFU of E.", "coli.", "The physician team would like to consent this patient for a Foley catheter." ]

[ "1. Patient is 76 years old.", "2. Patient is female.", "3. Patient is accompanied by a nurse from her nursing home.", "4. Patient is usually interactive, but sometimes forgetful.", "5. Patient has been increasingly lethargic in the last two days.", "6. Patient does not respond to staff's questions.", "7. Patient has not been able to get up and use the restroom.", "8. Staff has had to change multiple soiled sheets.", "9. Patient's temperature is 102.1°F (38.9°C).", "10. Patient's blood pressure is 100/74 mmHg.", "11. Patient's pulse is 120/min.", "12. Patient's respirations are 24/min.", "13. Patient is combative on arrival.", "14. Patient can be subdued with reorientation by the care team.", "15. Patient is not oriented to person, place, or time.", "16. Urinalysis shows positive leukocyte esterase and nitrites.", "17. Urine culture grows >100,000 CFU of E. coli.", "18. Physician team would like to consent this patient for a Foley catheter." ]

[ "1. The patient is accompanied by a nurse from her nursing home.", "2. The nurse states that the patient is usually interactive but sometimes forgetful.", "3. In the last two days, the patient has been increasingly lethargic and unresponsive to staff questions.", "4. The patient has not been able to get up and use the restroom, requiring staff to change multiple soiled sheets.", "5. The patient's temperature is 102.1°F (38.9°C), blood pressure is 100/74 mmHg, pulse is 120/min, and respirations are 24/min.", "6. The patient is combative on arrival but can be subdued with reorientation by the care team.", "7. The patient is not oriented to person, place, or time.", "8. Urinalysis shows positive leukocyte esterase and nitrites.", "9. Urine culture grows >100,000 CFU of E. coli.", "10. The physician team would like to consent this patient for a Foley catheter." ]

[ "A 19-year-old woman is brought to the emergency department by ambulance 1 hour after a motor vehicle accident.", "She has no history of serious illness.", "She is on mechanical ventilation without any sedation.", "Her vital signs are within a normal range.", "Her Glasgow Coma Scale (GCS) is 3.", "Examination by the attending trauma surgeon and neurologist shows brain death.", "Laboratory studies show no abnormalities.", "A search on the state donor registry shows that she has registered as an organ donor.", "Her father is shocked at the suggestion of organ donation and says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!” ." ]

[ "1. A 19-year-old woman is brought to the emergency department by ambulance 1 hour after a motor vehicle accident.", "2. She has no history of serious illness.", "3. She is on mechanical ventilation without any sedation.", "4. Her vital signs are within a normal range.", "5. Her Glasgow Coma Scale (GCS) is 3.", "6. Examination by the attending trauma surgeon and neurologist shows brain death.", "7. Laboratory studies show no abnormalities.", "8. A search on the state donor registry shows that she has registered as an organ donor.", "9. Her father is shocked at the suggestion of organ donation.", "10. He says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!”" ]

[ "1. She has no history of serious illness.", "2. She is on mechanical ventilation without any sedation.", "3. Her vital signs are within a normal range.", "4. Her Glasgow Coma Scale (GCS) is 3.", "5. Examination by the attending trauma surgeon and neurologist shows brain death.", "6. Laboratory studies show no abnormalities.", "7. A search on the state donor registry shows that she has registered as an organ donor.", "8. Her father is shocked at the suggestion of organ donation.", "9. Her father says that \"life is still circulating in her body because it is warm, and she has a normal heartbeat.\"" ]

[ "A 58-year-old male has had long-term involvement in the world of organized crime.", "He very recently retired from his post within this organization.", "This former mafia boss has now suddenly started making large contributions to several local charities." ]

[ "1. A 58-year-old male has had long-term involvement in the world of organized crime.", "2. He very recently retired from his post within this organization.", "3. This former mafia boss has now suddenly started making large contributions to several local charities." ]

[ "1. He very recently retired from his post within this organization.", "2. This former mafia boss has now suddenly started making large contributions to several local charities." ]

[ "A 45-year-old man presents with a chronic productive cough that he has had for the past few years.", "He admits to having smoked 1 pack of cigarettes a day for the past 25 years.", "A chest radiograph reveals an enlarged heart." ]

[ "1. A 45-year-old man presents with a chronic productive cough.", "2. The cough has been present for the past few years.", "3. The man has smoked 1 pack of cigarettes a day for the past 25 years.", "4. A chest radiograph reveals an enlarged heart." ]

[ "1. He admits to smoking 1 pack of cigarettes a day for the past 25 years.", "2. A chest radiograph reveals an enlarged heart." ]

[ "A 69-year-old gentleman presents to his primary care physician for a general checkup.", "He states that overall he is doing well.", "Ever since he retired, he has been working on projects at home, and taking time to exercise every day.", "He eats a balanced diet, and has been spending time with his wife every evening.", "Despite this, the patient claims that he feels less well rested when he awakes in the morning.", "The patient states that he used to sleep nine hours a night in his youth and felt excellent.", "Now he sleeps seven hours a night and doesn’t feel as well rested as he used to.", "The patient’s wife states that he seems to sleep peacefully.", "On physical exam the patient’s neurological exam is within normal limits.", "The patient is muscular and has a healthy weight and has a pleasant demeanor.", "He denies feeling fatigued or tired currently." ]

[ "1. A 69-year-old gentleman presents to his primary care physician for a general checkup.", "2. He states that overall he is doing well.", "3. Ever since he retired, he has been working on projects at home, and taking time to exercise every day.", "4. He eats a balanced diet, and has been spending time with his wife every evening.", "5. Despite this, the patient claims that he feels less well rested when he awakes in the morning.", "6. The patient states that he used to sleep nine hours a night in his youth and felt excellent.", "7. Now he sleeps seven hours a night and doesn’t feel as well rested as he used to.", "8. The patient’s wife states that he seems to sleep peacefully.", "9. On physical exam the patient’s neurological exam is within normal limits.", "10. The patient is muscular and has a healthy weight and has a pleasant demeanor.", "11. He denies feeling fatigued or tired currently." ]

[ "1. The patient states that overall he is doing well.", "2. Ever since he retired, he has been working on projects at home.", "3. He takes time to exercise every day.", "4. He eats a balanced diet.", "5. He has been spending time with his wife every evening.", "6. The patient claims that he feels less well rested when he awakes in the morning.", "7. He used to sleep nine hours a night in his youth and felt excellent.", "8. Now he sleeps seven hours a night and doesn’t feel as well rested as he used to.", "9. The patient’s wife states that he seems to sleep peacefully.", "10. On physical exam, the patient’s neurological exam is within normal limits.", "11. The patient is muscular and has a healthy weight.", "12. He has a pleasant demeanor.", "13. He denies feeling fatigued or tired currently." ]

[ "A 7-year-old boy with sickle cell disease is brought into the clinic by his mother for knee and hip pain.", "The child has been admitted several times in the past for pain crises managed with fluids and hydromorphone.", "He started complaining of worsening hip pain over the last several days and now walks with a limp.", "His temperature is 97.9°F (36.6°C), blood pressure is 84/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 99% on room air.", "On physical exam, the hip appears normal and is cool to the touch.", "There is decreased range of motion at the hip and pain with ambulation." ]

[ "1. Patient is a 7-year-old boy.", "2. Patient has sickle cell disease.", "3. Patient is brought into the clinic by his mother.", "4. Patient has knee and hip pain.", "5. Patient has been admitted several times in the past for pain crises.", "6. Patient's pain crises were managed with fluids and hydromorphone.", "7. Patient has been complaining of worsening hip pain over the last several days.", "8. Patient now walks with a limp.", "9. Patient's temperature is 97.9°F (36.6°C).", "10. Patient's blood pressure is 84/54 mmHg.", "11. Patient's pulse is 100/min.", "12. Patient's respirations are 19/min.", "13. Patient's oxygen saturation is 99% on room air.", "14. On physical exam, the hip appears normal.", "15. On physical exam, the hip is cool to the touch.", "16. On physical exam, there is decreased range of motion at the hip.", "17. On physical exam, there is pain with ambulation." ]

[ "1. The child has been admitted several times in the past for pain crises managed with fluids and hydromorphone.", "2. He started complaining of worsening hip pain over the last several days and now walks with a limp.", "3. His temperature is 97.9°F (36.6°C).", "4. His blood pressure is 84/54 mmHg.", "5. His pulse is 100/min.", "6. His respirations are 19/min.", "7. His oxygen saturation is 99% on room air.", "8. On physical exam, the hip appears normal and is cool to the touch.", "9. There is decreased range of motion at the hip.", "10. There is pain with ambulation." ]

[ "A 65-year-old asian man presents to his primary care physician because of abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks.", "He denies smoking or excess alcohol intake.", "His temperature is 37.1°C (98.7°F), blood pressure is 120/80 mm Hg, and pulse is 85/min.", "Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, and a palpable mass in the RUQ.", "Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver.", "Alpha fetoprotein (AFP) is 500 μg/L." ]

[ "1. A 65-year-old Asian man presents to his primary care physician.", "2. He has abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks.", "3. He denies smoking or excess alcohol intake.", "4. His temperature is 37.1°C (98.7°F).", "5. His blood pressure is 120/80 mm Hg.", "6. His pulse is 85/min.", "7. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, and a palpable mass in the RUQ.", "8. Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver.", "9. Alpha fetoprotein (AFP) is 500 μg/L." ]

[ "1. Patient denies smoking.", "2. Patient denies excess alcohol intake.", "3. Temperature is 37.1°C (98.7°F).", "4. Blood pressure is 120/80 mm Hg.", "5. Pulse is 85/min.", "6. Physical examination reveals a cachectic man.", "7. Physical examination reveals jaundice.", "8. Physical examination reveals palmar erythema.", "9. Physical examination reveals ascites.", "10. Physical examination reveals a palpable mass in the RUQ.", "11. Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver.", "12. Alpha fetoprotein (AFP) is 500 μg/L." ]

[ "A 71-year-old man from Puerto Rico presents to the emergency department with a 2-week history of abdominal pain.", "He does not speak much English so his family explains that he has been complaining of intermittent pain that is not associated with any particular actions.", "Furthermore, his family is concerned because he has been having weight loss and blood in his stool for 3 months.", "The physician explains that there is a concern for colon cancer and that a colonoscopy is required to evaluate his condition further.", "The family is afraid that the news will upset the patient so they ask that they be allowed to make healthcare decisions on the patient's behalf.", "They explain that this is the way that their culture handles medical decisions." ]

[ "1. A 71-year-old man from Puerto Rico presents to the emergency department.", "2. He has a 2-week history of abdominal pain.", "3. He does not speak much English.", "4. His family explains that he has been complaining of intermittent pain that is not associated with any particular actions.", "5. His family is concerned because he has been having weight loss and blood in his stool for 3 months.", "6. The physician explains that there is a concern for colon cancer.", "7. A colonoscopy is required to evaluate his condition further.", "8. The family is afraid that the news will upset the patient.", "9. They ask that they be allowed to make healthcare decisions on the patient's behalf.", "10. They explain that this is the way that their culture handles medical decisions." ]

[ "1. The patient does not speak much English.", "2. The patient has been complaining of intermittent pain.", "3. The pain is not associated with any particular actions.", "4. The patient has been experiencing weight loss for 3 months.", "5. The patient has been having blood in his stool for 3 months.", "6. The physician is concerned about colon cancer.", "7. A colonoscopy is required to evaluate the patient's condition further.", "8. The family is concerned about upsetting the patient with the news.", "9. The family wants to make healthcare decisions on the patient's behalf.", "10. The family's culture handles medical decisions in this way." ]

[ "A 45-year-old man presents to a physician with recurrent episodes of palpitations over the last 3 months.", "The episodes are self-limiting but cause significant distress and discomfort to the patient.", "After a detailed electrophysiological workup, the physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels, which primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients." ]

[ "1. A 45-year-old man presents to a physician.", "2. The patient has had recurrent episodes of palpitations over the last 3 months.", "3. The episodes are self-limiting.", "4. The episodes cause significant distress and discomfort to the patient.", "5. The physician performs a detailed electrophysiological workup.", "6. The physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels.", "7. The cardiac ion channels primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients." ]

[ "1. The episodes are self-limiting.", "2. The episodes cause significant distress and discomfort to the patient.", "3. A detailed electrophysiological workup was performed.", "4. The physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels.", "5. The abnormal function of the cardiac ion channels primarily produces the plateau phase of the action potential in cardiac myocytes in healthy patients." ]

[ "A 23-year-old man comes to the physician because of severe daytime sleepiness and random episodes of falling asleep during the day for short periods of time.", "When he wakes up from these episodes, he feels refreshed.", "He sleeps 6–7 hours at night.", "He reports that sometimes he is unable to move for a few minutes when he first wakes up in the morning.", "Last week, he suddenly “lost control” of his legs and neck for about 30 seconds after his classmate had told him a joke." ]

[ "1. A 23-year-old man comes to the physician.", "2. He has severe daytime sleepiness.", "3. He has random episodes of falling asleep during the day for short periods of time.", "4. When he wakes up from these episodes, he feels refreshed.", "5. He sleeps 6–7 hours at night.", "6. He reports that sometimes he is unable to move for a few minutes when he first wakes up in the morning.", "7. Last week, he suddenly “lost control” of his legs and neck for about 30 seconds.", "8. This happened after his classmate had told him a joke." ]

[ "1. He feels refreshed when he wakes up from these episodes.", "2. He sleeps 6–7 hours at night.", "3. Sometimes he is unable to move for a few minutes when he first wakes up in the morning.", "4. Last week, he suddenly “lost control” of his legs and neck for about 30 seconds.", "5. The loss of control occurred after his classmate had told him a joke." ]

[ "A 73-year-old man is brought to the emergency department 30 minutes after he lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.", "On arrival, he is lethargic and oriented only to person.", "Three weeks ago, he was treated for hepatitis A.", "He has type 2 diabetes mellitus and hypothyroidism.", "Current medications include metformin and levothyroxine.", "His temperature is 41.5 °C (106.7 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg.", "Examination shows hot, dry skin.", "The pupils are equal and reactive to light.", "Neurologic examination shows no focal findings.", "Fundoscopy shows proliferative diabetic retinopathy.", "Cardiopulmonary examination shows no abnormalities.", "His abdomen is soft and nontender.", "There is no costovertebral angle tenderness.", "His serum glucose concentration is 160 mg/dL.", "An ECG shows a normal sinus rhythm." ]

[ "1. A 73-year-old man was brought to the emergency department.", "2. He lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.", "3. On arrival, he is lethargic and oriented only to person.", "4. Three weeks ago, he was treated for hepatitis A.", "5. He has type 2 diabetes mellitus and hypothyroidism.", "6. Current medications include metformin and levothyroxine.", "7. His temperature is 41.5 °C (106.7 °F).", "8. His pulse is 106/min.", "9. His respirations are 26/min.", "10. His blood pressure is 128/70 mm Hg.", "11. Examination shows hot, dry skin.", "12. The pupils are equal and reactive to light.", "13. Neurologic examination shows no focal findings.", "14. Fundoscopy shows proliferative diabetic retinopathy.", "15. Cardiopulmonary examination shows no abnormalities.", "16. His abdomen is soft and nontender.", "17. There is no costovertebral angle tenderness.", "18. His serum glucose concentration is 160 mg/dL.", "19. An ECG shows a normal sinus rhythm." ]

[ "1. On arrival, he is lethargic and oriented only to person.", "2. Three weeks ago, he was treated for hepatitis A.", "3. He has type 2 diabetes mellitus and hypothyroidism.", "4. Current medications include metformin and levothyroxine.", "5. His temperature is 41.5 °C (106.7 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg.", "6. Examination shows hot, dry skin.", "7. The pupils are equal and reactive to light.", "8. Neurologic examination shows no focal findings.", "9. Fundoscopy shows proliferative diabetic retinopathy.", "10. Cardiopulmonary examination shows no abnormalities.", "11. His abdomen is soft and nontender.", "12. There is no costovertebral angle tenderness.", "13. His serum glucose concentration is 160 mg/dL.", "14. An ECG shows a normal sinus rhythm." ]

[ "A 3-year-old boy is brought to the physician for a well-child examination.", "He feels well.", "He was born at 38 weeks' gestation and weighed 2766 g (6 lb 2 oz).", "He now weighs 14 kg (31 lbs).", "There is no personal or family history of serious illness.", "His immunizations are up-to-date.", "He is at 60th percentile for height and 55th percentile for weight.", "Vital signs are within normal limits.", "The lungs are clear to auscultation.", "A grade 3/6 systolic ejection murmur is heard along the upper left sternal border.", "S2 is widely split and does not vary with respiration.", "There is a grade 2/6 mid-diastolic murmur along the lower left sternal border.", "The abdomen is soft and nontender; there is no organomegaly." ]

[ "1. Patient is a 3-year-old boy.", "2. Patient feels well.", "3. Patient was born at 38 weeks' gestation.", "4. Patient weighed 2766 g (6 lb 2 oz) at birth.", "5. Patient now weighs 14 kg (31 lbs).", "6. No personal or family history of serious illness.", "7. Immunizations are up-to-date.", "8. Patient is at 60th percentile for height.", "9. Patient is at 55th percentile for weight.", "10. Vital signs are within normal limits.", "11. Lungs are clear to auscultation.", "12. Grade 3/6 systolic ejection murmur heard along upper left sternal border.", "13. S2 is widely split and does not vary with respiration.", "14. Grade 2/6 mid-diastolic murmur heard along lower left sternal border.", "15. Abdomen is soft and nontender.", "16. No organomegaly." ]

[ "1. He was born at 38 weeks' gestation", "2. He weighed 2766 g (6 lb 2 oz) at birth", "3. He now weighs 14 kg (31 lbs)", "4. There is no personal or family history of serious illness", "5. His immunizations are up-to-date", "6. He is at 60th percentile for height", "7. He is at 55th percentile for weight", "8. Vital signs are within normal limits", "9. The lungs are clear to auscultation", "10. A grade 3/6 systolic ejection murmur is heard along the upper left sternal border", "11. S2 is widely split and does not vary with respiration", "12. There is a grade 2/6 mid-diastolic murmur along the lower left sternal border", "13. The abdomen is soft and nontender", "14. There is no organomegaly" ]

[ "A 30-year-old man presents to the emergency department after being attacked by 2 men a few minutes ago.", "He was suddenly approached by 2 men holding knives while he was walking on the street nearby.", "While trying to escape, he was stabbed once in the neck.", "He is complaining of difficulty breathing and chest pain.", "He is in apparent distress.", "His temperature is 36.8°C (98.2°F), the blood pressure is 100/60 mm Hg, the pulse is 110/min, the respirations are 28/min, and the SaO2 is 85% on 4 L oxygen by nasal cannula.", "Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins.", "The respiratory exam shows severe tenderness in the right chest, decreased inspiration in the right lung, and tracheal deviation to the left." ]

[ "1. A 30-year-old man presents to the emergency department.", "2. He was attacked by 2 men a few minutes ago.", "3. He was suddenly approached by 2 men holding knives while he was walking on the street nearby.", "4. While trying to escape, he was stabbed once in the neck.", "5. He is complaining of difficulty breathing and chest pain.", "6. He is in apparent distress.", "7. His temperature is 36.8°C (98.2°F).", "8. The blood pressure is 100/60 mm Hg.", "9. The pulse is 110/min.", "10. The respirations are 28/min.", "11. The SaO2 is 85% on 4 L oxygen by nasal cannula.", "12. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins.", "13. The respiratory exam shows severe tenderness in the right chest.", "14. The respiratory exam shows decreased inspiration in the right lung.", "15. The respiratory exam shows tracheal deviation to the left." ]

[ "1. He was suddenly approached by 2 men holding knives while walking on the street nearby.", "2. While trying to escape, he was stabbed once in the neck.", "3. He is complaining of difficulty breathing and chest pain.", "4. He is in apparent distress.", "5. His temperature is 36.8°C (98.2°F).", "6. The blood pressure is 100/60 mm Hg.", "7. The pulse is 110/min.", "8. The respirations are 28/min.", "9. The SaO2 is 85% on 4 L oxygen by nasal cannula.", "10. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins.", "11. The respiratory exam shows severe tenderness in the right chest, decreased inspiration in the right lung, and tracheal deviation to the left." ]

[ "An 8-month-old male presents to your office with a 5-day history of blood in his stool.", "Abdominal pain is notably absent on history obtained from his parents.", "Past medical history and physical exam findings are not remarkable.", "Laboratory findings are significant for mild iron deficiency." ]

[ "1. An 8-month-old male presents to your office.", "2. He has a 5-day history of blood in his stool.", "3. Abdominal pain is absent on history obtained from his parents.", "4. Past medical history and physical exam findings are not remarkable.", "5. Laboratory findings are significant for mild iron deficiency." ]

[ "1. Abdominal pain is notably absent on history obtained from his parents.", "2. Past medical history is not remarkable.", "3. Physical exam findings are not remarkable.", "4. Laboratory findings are significant for mild iron deficiency." ]

[ "A 19-year-old man is brought to a psychiatrist by his mother.", "The patient’s mother has become increasingly concerned about him since his high school graduation.", "Although she says that he had been an excellent student in high school, his grades have begun slipping in his second year in college, and he no longer socializes with friends.", "When she asked him why he no longer talks to his friends, she states that he told her, “They already know where I am.", "They can see me.", "They watch me from my bedroom window, so they already know what I’m doing.", "We don’t need to talk.” She found this to be bizarre, as nearly all of his friends live hours away.", "The patient states that he feels fine and doesn’t understand why everyone thinks he is crazy.", "The psychiatrist notices reduced spontaneous movements while the patient is speaking and that he speaks in a monotone with a voice that is soft in volume.", "He also appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.", "His mood is generally flat with little reactivity or engagement during the course of his interview, but he denies any symptoms of depression or psychosis.", "No significant past medical history.", "Family history is not available as he was adopted." ]

[ "1. A 19-year-old man is brought to a psychiatrist by his mother.", "2. His mother has become increasingly concerned about him since his high school graduation.", "3. He had been an excellent student in high school.", "4. His grades have begun slipping in his second year in college.", "5. He no longer socializes with friends.", "6. When she asked him why he no longer talks to his friends, he told her, “They already know where I am. They can see me. They watch me from my bedroom window, so they already know what I’m doing. We don’t need to talk.”", "7. Nearly all of his friends live hours away.", "8. The patient states that he feels fine and doesn’t understand why everyone thinks he is crazy.", "9. The psychiatrist notices reduced spontaneous movements while the patient is speaking.", "10. He speaks in a monotone with a voice that is soft in volume.", "11. He appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.", "12. His mood is generally flat with little reactivity or engagement during the course of his interview.", "13. He denies any symptoms of depression or psychosis.", "14. No significant past medical history.", "15. Family history is not available as he was adopted." ]

[ "1. The patient's mother is increasingly concerned about him since his high school graduation.", "2. The patient's grades have begun slipping in his second year of college.", "3. The patient no longer socializes with friends.", "4. The patient told his mother that his friends can see him from his bedroom window and don't need to talk to him.", "5. The patient's friends live hours away.", "6. The patient feels fine and doesn't understand why everyone thinks he is crazy.", "7. The psychiatrist notices reduced spontaneous movements while the patient is speaking.", "8. The patient speaks in a monotone with a soft voice.", "9. The patient appears suspicious and defensive during the evaluation.", "10. The patient's mood is generally flat with little reactivity or engagement.", "11. The patient denies any symptoms of depression or psychosis.", "12. The patient has no significant past medical history.", "13. The patient's family history is not available as he was adopted." ]

[ "A 26-year-old woman comes to the physician because of progressively worsening episodic pelvic pain for 2 years.", "The pain starts a few days before her menstrual period and lasts about 10 days.", "She has tried taking ibuprofen, but her symptoms do not improve.", "Menses have occurred at regular 29-day intervals since menarche at the age of 11 years and last for 5–7 days.", "The first day of her last menstrual period was 2 weeks ago.", "She is sexually active with her boyfriend and has noticed that intercourse is often painful; they use condoms inconsistently.", "Vital signs are within normal limits.", "Pelvic examination shows a normal vagina and cervix.", "Bimanual examination shows a normal-sized uterus and no palpable adnexal masses.", "Urine pregnancy test is negative." ]

[ "1. Patient is a 26-year-old woman.", "2. Patient has had progressively worsening episodic pelvic pain for 2 years.", "3. Pain starts a few days before her menstrual period and lasts about 10 days.", "4. Patient has tried taking ibuprofen, but her symptoms do not improve.", "5. Patient has had regular 29-day menstrual intervals since menarche at the age of 11 years.", "6. Menstrual periods last for 5–7 days.", "7. First day of patient's last menstrual period was 2 weeks ago.", "8. Patient is sexually active with her boyfriend.", "9. Patient has noticed that intercourse is often painful.", "10. Patient and her boyfriend use condoms inconsistently.", "11. Vital signs are within normal limits.", "12. Pelvic examination shows a normal vagina and cervix.", "13. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses.", "14. Urine pregnancy test is negative." ]

[ "1. The pain starts a few days before her menstrual period and lasts about 10 days.", "2. She has tried taking ibuprofen, but her symptoms do not improve.", "3. Menses have occurred at regular 29-day intervals since menarche at the age of 11 years and last for 5–7 days.", "4. The first day of her last menstrual period was 2 weeks ago.", "5. She is sexually active with her boyfriend and has noticed that intercourse is often painful; they use condoms inconsistently.", "6. Vital signs are within normal limits.", "7. Pelvic examination shows a normal vagina and cervix.", "8. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses.", "9. Urine pregnancy test is negative." ]

[ "A research group has developed a new screening test for HIV that can detect infection 2 weeks earlier than the current gold standard.", "A rigorous clinical study of this new screening test involving n subjects yields a false-positive probability α, and a false-negative probability, β." ]

[ "1. A research group has developed a new screening test for HIV.", "2. The new screening test can detect infection 2 weeks earlier than the current gold standard.", "3. A rigorous clinical study of the new screening test was conducted involving n subjects.", "4. The false-positive probability of the new screening test is α.", "5. The false-negative probability of the new screening test is β." ]

[ "1. A rigorous clinical study was conducted on a new screening test.", "2. The study involved n subjects.", "3. The study yielded a false-positive probability α.", "4. The study yielded a false-negative probability β." ]

[ "A 70-year-old female underwent a right total knee arthroplasty without complication.", "She was discharged to a rehab facility on post-operative day 3.", "Two days after her discharge from the hospital, she began experiencing pain and swelling of the right leg.", "Doppler ultrasound imaging at this time revealed a deep venous thrombosis in the right popliteal and tibial veins.", "The patient was re-admitted and started on an unfractionated heparin infusion.", "Five days later, doppler ultrasonography of the lower extremities revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins.", "In addition, a thrombus was noted in the left common femoral vein as well.", "CBC showed a decrease in platelet count from 195,000/uL on admission to 83,000/uL." ]

[ "1. Patient is 70-year-old female.", "2. Patient underwent right total knee arthroplasty without complication.", "3. Patient was discharged to rehab facility on post-operative day 3.", "4. Two days after discharge, patient began experiencing pain and swelling of right leg.", "5. Doppler ultrasound imaging revealed deep venous thrombosis in right popliteal and tibial veins.", "6. Patient was re-admitted and started on unfractionated heparin infusion.", "7. Five days later, doppler ultrasonography revealed extension of clot in right lower extremity to include common femoral, superficial femoral, popliteal, tibial, and saphenous veins.", "8. Doppler ultrasonography also revealed thrombus in left common femoral vein.", "9. CBC showed decrease in platelet count from 195,000/uL on admission to 83,000/uL." ]

[ "1. The patient was discharged to a rehab facility on post-operative day 3.", "2. Two days after her discharge from the hospital, she began experiencing pain and swelling of the right leg.", "3. Doppler ultrasound imaging revealed a deep venous thrombosis in the right popliteal and tibial veins.", "4. The patient was re-admitted and started on an unfractionated heparin infusion.", "5. Five days later, doppler ultrasonography revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins.", "6. A thrombus was noted in the left common femoral vein as well.", "7. CBC showed a decrease in platelet count from 195,000/uL on admission to 83,000/uL." ]

[ "Three days after surgical repair of a distal right radius fracture, a 62-year-old man develops severe wound pain and fever.", "His temperature is 39.1°C (102.4°F).", "Physical examination shows erythema and edema of the right arm that extends up to the elbow.", "Yellow pus drains from the surgical wound.", "Cultures from the wound fluid grow gram-positive bacteria in grape-like clusters that are resistant to nafcillin.", "While treating the patient's condition, the hospital also wants to eradicate the causal pathogen in asymptomatic carriers." ]

[ "1. A 62-year-old man developed severe wound pain and fever three days after surgical repair of a distal right radius fracture.", "2. His temperature was 39.1°C (102.4°F).", "3. Physical examination showed erythema and edema of the right arm that extended up to the elbow.", "4. Yellow pus drained from the surgical wound.", "5. Cultures from the wound fluid grew gram-positive bacteria in grape-like clusters.", "6. The bacteria were resistant to nafcillin.", "7. The hospital wanted to eradicate the causal pathogen in asymptomatic carriers." ]

[ "1. His temperature is 39.1°C (102.4°F).", "2. Physical examination shows erythema and edema of the right arm that extends up to the elbow.", "3. Yellow pus drains from the surgical wound.", "4. Cultures from the wound fluid grow gram-positive bacteria in grape-like clusters that are resistant to nafcillin.", "5. The hospital wants to eradicate the causal pathogen in asymptomatic carriers while treating the patient's condition." ]

[ "A research group from Europe is investigating a potential link between certain lifestyle risk factors and the development of potentially fatal renal disease.", "They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors, who were followed up for 4 years in total.", "During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group; thus, the risk ratio (RR) of the disease development (exposed vs.", "unexposed) was 1.", "During the initial 2 years, there was 1 death in the exposed group, and another death in the unexposed group.", "A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was in fact 0.5 (at 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%; and only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%), a value that deviates from the true RR (i.e.", "1)." ]

[ "1. A research group from Europe is investigating a potential link between certain lifestyle risk factors and the development of potentially fatal renal disease.", "2. They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors.", "3. The study was followed up for 4 years in total.", "4. During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group.", "5. The risk ratio (RR) of the disease development (exposed vs. unexposed) was 1.", "6. During the initial 2 years, there was 1 death in the exposed group, and another death in the unexposed group.", "7. A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was 0.5.", "8. At 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%.", "9. There were only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%.", "10. The prevalence ratio of 0.5 deviates from the true RR (i.e. 1)." ]

[ "1. A cohort study was designed with 68 individuals: 34 exposed and 34 unexposed to given risk factors.", "2. The individuals were followed up for 4 years in total.", "3. During the study, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group.", "4. The risk ratio (RR) of the disease development (exposed vs. unexposed) was 1.", "5. During the initial 2 years, there was 1 death in the exposed group and another death in the unexposed group.", "6. A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was 0.5.", "7. At 2 years of follow-up, there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%.", "8. At 2 years of follow-up, there were only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%.", "9. The prevalence ratio value deviates from the true RR, which is 1." ]

[ "A 55-year-old male with fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks presents to his family physician.", "On exam, he has bilateral submandibular lymphadenopathy and hepatosplenomegaly.", "CBC demonstrates decreased RBCs and mature WBCs.", "The patient is referred to an oncologist, and a bone marrow aspiration is performed, demonstrating >20% myeloblasts with Auer rods that are myeloperoxidase positive." ]

[ "1. A 55-year-old male presents to his family physician.", "2. He has had fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks.", "3. On exam, he has bilateral submandibular lymphadenopathy and hepatosplenomegaly.", "4. CBC demonstrates decreased RBCs and mature WBCs.", "5. The patient is referred to an oncologist.", "6. A bone marrow aspiration is performed.", "7. The bone marrow aspiration demonstrates >20% myeloblasts with Auer rods.", "8. The Auer rods are myeloperoxidase positive." ]

[ "1. On exam, he has bilateral submandibular lymphadenopathy.", "2. On exam, he has hepatosplenomegaly.", "3. CBC demonstrates decreased RBCs.", "4. CBC demonstrates mature WBCs.", "5. The patient is referred to an oncologist.", "6. A bone marrow aspiration is performed.", "7. The bone marrow aspiration demonstrates >20% myeloblasts.", "8. The myeloblasts have Auer rods.", "9. The Auer rods are myeloperoxidase positive." ]

[ "A 59-year-old man with Parkinson disease is brought to the emergency department 1 hour after he had a syncopal episode.", "Over the past two weeks, the patient has felt light-headed upon standing and has noticed that his legs have been swollen.", "He was started on a medication for early symptoms of Parkinson disease one month ago.", "Vital signs show blood pressure 114/70 mm Hg when supine and 92/38 mm Hg upon standing.", "Examination of the lower extremities shows a lacy, purple rash and 2+ pitting edema.", "Neurologic examination shows an ataxic gait.", "The physician decreases the dose of medication." ]

[ "1. A 59-year-old man with Parkinson disease is brought to the emergency department.", "2. He had a syncopal episode 1 hour prior.", "3. Over the past two weeks, the patient has felt light-headed upon standing.", "4. Over the past two weeks, the patient has noticed that his legs have been swollen.", "5. He was started on a medication for early symptoms of Parkinson disease one month ago.", "6. Vital signs show blood pressure 114/70 mm Hg when supine.", "7. Vital signs show blood pressure 92/38 mm Hg upon standing.", "8. Examination of the lower extremities shows a lacy, purple rash.", "9. Examination of the lower extremities shows 2+ pitting edema.", "10. Neurologic examination shows an ataxic gait.", "11. The physician decreases the dose of medication." ]

[ "1. Over the past two weeks, the patient has felt light-headed upon standing.", "2. The patient has noticed that his legs have been swollen.", "3. The patient was started on a medication for early symptoms of Parkinson disease one month ago.", "4. Vital signs show blood pressure 114/70 mm Hg when supine.", "5. Vital signs show blood pressure 92/38 mm Hg upon standing.", "6. Examination of the lower extremities shows a lacy, purple rash.", "7. Examination of the lower extremities shows 2+ pitting edema.", "8. Neurologic examination shows an ataxic gait.", "9. The physician decreases the dose of medication." ]

[ "A 50-year-old woman presents to her primary care physician for muscle weakness.", "Her symptoms have progressively worsened over the course of several months, where she has experienced difficulty getting up from a chair, climbing the stairs, and placing her groceries on the top shelves of her kitchen.", "She also reports feeling tired lately and is unsure when this began.", "Physical examination is notable for muscle weakness in the deltoids and hip flexors with 2+ biceps, triceps, patellar, and ankle tendon reflexes.", "Laboratory testing demonstrates a creatine kinase level of 4,200 U/L (normal is 10-70 U/L), lactate dehydrogenase level of 150 U/L (normal is 45-90 U/L), and thyroid-stimulating hormone level of 1.5 µU/mL (normal is 0.5-5.0 µU/mL)." ]

[ "1. A 50-year-old woman presents to her primary care physician for muscle weakness.", "2. Her symptoms have progressively worsened over the course of several months.", "3. She has experienced difficulty getting up from a chair.", "4. She has experienced difficulty climbing the stairs.", "5. She has experienced difficulty placing her groceries on the top shelves of her kitchen.", "6. She reports feeling tired lately.", "7. She is unsure when this began.", "8. Physical examination is notable for muscle weakness in the deltoids and hip flexors.", "9. Biceps, triceps, patellar, and ankle tendon reflexes are 2+.", "10. Laboratory testing demonstrates a creatine kinase level of 4,200 U/L.", "11. Normal creatine kinase level is 10-70 U/L.", "12. Laboratory testing demonstrates a lactate dehydrogenase level of 150 U/L.", "13. Normal lactate dehydrogenase level is 45-90 U/L.", "14. Laboratory testing demonstrates a thyroid-stimulating hormone level of 1.5 µU/mL.", "15. Normal thyroid-stimulating hormone level is 0.5-5.0 µU/mL." ]

[ "1. The patient's symptoms have progressively worsened over several months.", "2. The patient has difficulty getting up from a chair, climbing stairs, and placing groceries on high shelves.", "3. The patient reports feeling tired lately and is unsure when this began.", "4. Physical examination shows muscle weakness in the deltoids and hip flexors.", "5. The patient has 2+ biceps, triceps, patellar, and ankle tendon reflexes.", "6. Laboratory testing demonstrates a creatine kinase level of 4,200 U/L (normal is 10-70 U/L).", "7. Laboratory testing shows a lactate dehydrogenase level of 150 U/L (normal is 45-90 U/L).", "8. Laboratory testing reveals a thyroid-stimulating hormone level of 1.5 µU/mL (normal is 0.5-5.0 µU/mL)." ]

[ "A 22-year-old woman comes to the physician because of a 5-kg (11-lb) weight gain and hair loss over the past 4 months.", "Menarche occurred at the age of 12 years and menses occurred at irregular intervals until she stopped having periods 2 months ago.", "She is 165 cm (5 ft 5 in) tall and weighs 82 kg (180 lb); BMI is 30 kg/m2.", "Physical examination shows a receding hairline and hair loss over the vertex of the head.", "Serum studies show: | Thyroid-stimulating hormone 2 μU/mL | Luteinizing hormone 32 mIU/mL | Prolactin 11 ng/mL | Urine pregnancy test is negative.", "Withdrawal bleeding occurs after a progestin challenge test." ]

[ "1. A 22-year-old woman comes to the physician.", "2. She has experienced a 5-kg (11-lb) weight gain and hair loss over the past 4 months.", "3. Menarche occurred at the age of 12 years.", "4. Menses occurred at irregular intervals until she stopped having periods 2 months ago.", "5. She is 165 cm (5 ft 5 in) tall.", "6. She weighs 82 kg (180 lb).", "7. Her BMI is 30 kg/m2.", "8. Physical examination shows a receding hairline and hair loss over the vertex of the head.", "9. Serum studies show: Thyroid-stimulating hormone 2 μU/mL.", "10. Serum studies show: Luteinizing hormone 32 mIU/mL.", "11. Serum studies show: Prolactin 11 ng/mL.", "12. Urine pregnancy test is negative.", "13. Withdrawal bleeding occurs after a progestin challenge test." ]

[ "1. Menarche occurred at the age of 12 years.", "2. Menses occurred at irregular intervals until she stopped having periods 2 months ago.", "3. She is 165 cm (5 ft 5 in) tall.", "4. She weighs 82 kg (180 lb).", "5. Her BMI is 30 kg/m2.", "6. Physical examination shows a receding hairline.", "7. Hair loss is observed over the vertex of the head.", "8. Serum studies show: Thyroid-stimulating hormone 2 μU/mL.", "9. Serum studies show: Luteinizing hormone 32 mIU/mL.", "10. Serum studies show: Prolactin 11 ng/mL.", "11. Urine pregnancy test is negative.", "12. Withdrawal bleeding occurs after a progestin challenge test." ]

[ "A 70-year-old man with chronic myopia comes to the physician because of a 4-month history of difficulty seeing distant objects, especially at night, despite wearing glasses.", "Examination shows bilateral narrowing of peripheral visual fields, cupping of the optic discs, and elevated intraocular pressure.", "Gonioscopy shows no abnormalities.", "He is prescribed a drug.", "At a follow-up examination several months later, intraocular pressure is normal, but darkening of the iris and an increase in the length of the eyelashes is observed." ]

[ "1. A 70-year-old man has chronic myopia.", "2. He has had difficulty seeing distant objects for 4 months, especially at night, despite wearing glasses.", "3. Examination shows bilateral narrowing of peripheral visual fields, cupping of the optic discs, and elevated intraocular pressure.", "4. Gonioscopy shows no abnormalities.", "5. He is prescribed a drug.", "6. At a follow-up examination several months later, intraocular pressure is normal.", "7. At the follow-up examination, darkening of the iris is observed.", "8. At the follow-up examination, an increase in the length of the eyelashes is observed." ]

[ "1. Examination shows bilateral narrowing of peripheral visual fields.", "2. Examination shows cupping of the optic discs.", "3. Examination shows elevated intraocular pressure.", "4. Gonioscopy shows no abnormalities.", "5. He is prescribed a drug.", "6. At a follow-up examination several months later, intraocular pressure is normal.", "7. At a follow-up examination several months later, darkening of the iris is observed.", "8. At a follow-up examination several months later, an increase in the length of the eyelashes is observed." ]

[ "A 3-week-old female presents with her parents to her pediatrician for a routine visit.", "The parents report that the child is sleeping in regular two-hour intervals and feeding and stooling well.", "They are concerned because they have on occasion noticed a “swelling of the belly button.” Cord separation occurred at seven days of age.", "The parents report that the swelling seems to come and go but is never larger than the size of a blueberry.", "They deny any drainage from the swelling.", "On physical exam, the child is in no acute distress and appears developmentally appropriate for her age.", "Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus.", "The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain. | | ." ]

[ "1. A 3-week-old female presents with her parents to her pediatrician for a routine visit.", "2. The parents report that the child is sleeping in regular two-hour intervals and feeding and stooling well.", "3. They are concerned because they have on occasion noticed a “swelling of the belly button.”", "4. Cord separation occurred at seven days of age.", "5. The parents report that the swelling seems to come and go but is never larger than the size of a blueberry.", "6. They deny any drainage from the swelling.", "7. On physical exam, the child is in no acute distress and appears developmentally appropriate for her age.", "8. Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus.", "9. The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain." ]

[ "1. The child is sleeping in regular two-hour intervals.", "2. The child is feeding and stooling well.", "3. The parents have noticed a \"swelling of the belly button.\"", "4. Cord separation occurred at seven days of age.", "5. The swelling seems to come and go but is never larger than the size of a blueberry.", "6. There is no drainage from the swelling.", "7. On physical exam, the child is in no acute distress.", "8. The child appears developmentally appropriate for her age.", "9. The abdomen is soft and non-tender.", "10. There is a soft, 1 cm bulge at the umbilicus.", "11. The bulge increases in size when the child cries.", "12. The bulge can be easily reduced inside the umbilical ring without apparent pain." ]

[ "A 25-year-old man presents to the emergency department after a motor vehicle collision.", "He is currently complaining of chest pain and shortness of breath and seems rather confused.", "His temperature is 97.7°F (36.5°C), blood pressure is 94/54 mmHg, pulse is 170/min, respirations are 12/min, and oxygen saturation is 90% on room air.", "A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left, and his blood pressure increases to 104/74 mmHg and his pulse decreases to 100/min." ]

[ "1. A 25-year-old man presents to the emergency department after a motor vehicle collision.", "2. He is currently complaining of chest pain and shortness of breath and seems rather confused.", "3. His temperature is 97.7°F (36.5°C).", "4. His blood pressure is 94/54 mmHg.", "5. His pulse is 170/min.", "6. His respirations are 12/min.", "7. His oxygen saturation is 90% on room air.", "8. A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left.", "9. His blood pressure increases to 104/74 mmHg.", "10. His pulse decreases to 100/min." ]

[ "1. The patient is complaining of chest pain and shortness of breath.", "2. The patient is confused.", "3. The patient's temperature is 97.7°F (36.5°C).", "4. The patient's blood pressure is 94/54 mmHg.", "5. The patient's pulse is 170/min.", "6. The patient's respirations are 12/min.", "7. The patient's oxygen saturation is 90% on room air.", "8. A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left.", "9. The patient's blood pressure increases to 104/74 mmHg after the needle placement.", "10. The patient's pulse decreases to 100/min after the needle placement." ]

[ "A 13-year-old girl presents with a rash on her left hand and forearm.", "She went hiking with friends the day before yesterday and awoke this morning to find her hand and forearm red and itchy.", "She denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.", "She has no significant past medical history or known allergies.", "She is afebrile and her vital signs are within normal limits.", "On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm as shown in the exhibit (see image)." ]

[ "1. Patient is a 13-year-old girl.", "2. Patient went hiking with friends two days ago.", "3. Patient awoke this morning with a rash on her left hand and forearm.", "4. Patient denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.", "5. Patient has no significant past medical history or known allergies.", "6. Patient is afebrile.", "7. Patient's vital signs are within normal limits.", "8. On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm.", "9. Exhibit (see image) shows the rash on the patient's left hand and forearm." ]

[ "1. She went hiking with friends the day before yesterday.", "2. She awoke this morning to find her hand and forearm red and itchy.", "3. She denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.", "4. She has no significant past medical history or known allergies.", "5. She is afebrile.", "6. Her vital signs are within normal limits.", "7. On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm." ]

[ "A 12-year-old boy is brought to the physician for multiple bruises.", "He has fallen multiple times over the past 4 months and has difficulty walking without assistance.", "His speech is slow and difficult to understand.", "Neurological examination shows bilateral nystagmus, decreased muscle strength, 1+ reflexes bilaterally, and a wide-based gait with irregular and uneven steps.", "His proprioception and vibration senses are absent.", "The remainder of the examination shows kyphoscoliosis and foot inversion with hammer toes." ]

[ "1. A 12-year-old boy is brought to the physician.", "2. He has fallen multiple times over the past 4 months.", "3. He has difficulty walking without assistance.", "4. His speech is slow and difficult to understand.", "5. Neurological examination shows bilateral nystagmus.", "6. Neurological examination shows decreased muscle strength.", "7. Neurological examination shows 1+ reflexes bilaterally.", "8. Neurological examination shows a wide-based gait with irregular and uneven steps.", "9. Neurological examination shows absent proprioception and vibration senses.", "10. The remainder of the examination shows kyphoscoliosis.", "11. The remainder of the examination shows foot inversion with hammer toes." ]

[ "1. He has fallen multiple times over the past 4 months.", "2. He has difficulty walking without assistance.", "3. His speech is slow and difficult to understand.", "4. Neurological examination shows bilateral nystagmus.", "5. Neurological examination shows decreased muscle strength.", "6. Neurological examination shows 1+ reflexes bilaterally.", "7. Neurological examination shows a wide-based gait with irregular and uneven steps.", "8. His proprioception is absent.", "9. His vibration senses are absent.", "10. The remainder of the examination shows kyphoscoliosis.", "11. The remainder of the examination shows foot inversion with hammer toes." ]

[ "A 28-year-old nulligravid woman comes to the physician for a routine health maintenance examination.", "Upon questioning, she reports that she and her husband have been trying to conceive for more than 1 year; they have unprotected sexual intercourse 3–4 times per week.", "Recently, she has not been enjoying sexual intercourse with her husband because of painful penetration.", "She also reports episodic back and pelvic pain over the past 6 months that lasts for 2–3 days; she has missed several days of work each month because of the pain.", "Menarche was at the age of 13 years, and menses occur at 26–28 day intervals.", "Pelvic examination shows a normal-appearing vulva and vagina.", "There is rectovaginal tenderness.", "Ultrasonography of the pelvis shows a retroverted normal-sized uterus." ]

[ "1. Patient is 28 years old.", "2. Patient is nulligravid.", "3. Patient and her husband have been trying to conceive for more than 1 year.", "4. Patient and her husband have unprotected sexual intercourse 3-4 times per week.", "5. Patient has not been enjoying sexual intercourse with her husband because of painful penetration.", "6. Patient has episodic back and pelvic pain over the past 6 months.", "7. Pain lasts for 2-3 days.", "8. Patient has missed several days of work each month because of the pain.", "9. Patient's menarche was at the age of 13 years.", "10. Patient's menses occur at 26-28 day intervals.", "11. Pelvic examination shows a normal-appearing vulva and vagina.", "12. Pelvic examination shows rectovaginal tenderness.", "13. Ultrasonography of the pelvis shows a retroverted normal-sized uterus." ]

[ "1. She and her husband have been trying to conceive for more than 1 year.", "2. They have unprotected sexual intercourse 3–4 times per week.", "3. She has not been enjoying sexual intercourse with her husband because of painful penetration.", "4. She reports episodic back and pelvic pain over the past 6 months that lasts for 2–3 days.", "5. She has missed several days of work each month because of the pain.", "6. Menarche was at the age of 13 years.", "7. Menses occur at 26–28 day intervals.", "8. Pelvic examination shows a normal-appearing vulva and vagina.", "9. There is rectovaginal tenderness.", "10. Ultrasonography of the pelvis shows a retroverted normal-sized uterus." ]

[ "A 2-year-old Caucasian male presents with recurrent diaper rash and oral thrush.", "He has also experienced recurrent episodes of otitis media from repeat Streptoccous pneumoniae.", "He notably has reduced T and B cell counts." ]

[ "1. Patient is 2-year-old Caucasian male.", "2. Patient presents with recurrent diaper rash and oral thrush.", "3. Patient has experienced recurrent episodes of otitis media.", "4. Patient has repeat Streptoccous pneumoniae.", "5. Patient has reduced T and B cell counts." ]

[ "1. He has experienced recurrent episodes of otitis media.", "2. The otitis media is caused by repeat Streptococcus pneumoniae.", "3. He has reduced T cell counts.", "4. He has reduced B cell counts." ]

[ "A 42-year-old primigravida woman presents to her gynecologist for a routine prenatal visit at 11 weeks of gestation.", "Her pregnancy has been uneventful so far.", "She denies smoking, using alcohol, or any illicit drugs.", "Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine.", "Her blood pressure is 110/70 mm Hg, a heart rate of 95/min, a respiratory rate of 20/min, and a temperature of 36.4°C (97.5°F).", "Physical examination is unremarkable.", "A transvaginal ultrasound reveals increased nuchal translucency.", "Laboratory studies show decreased levels of PAPP-A and increased levels of β-hCG." ]

[ "1. A 42-year-old primigravida woman presents to her gynecologist for a routine prenatal visit at 11 weeks of gestation.", "2. Her pregnancy has been uneventful so far.", "3. She denies smoking, using alcohol, or any illicit drugs.", "4. Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine.", "5. Her blood pressure is 110/70 mm Hg.", "6. Her heart rate is 95/min.", "7. Her respiratory rate is 20/min.", "8. Her temperature is 36.4°C (97.5°F).", "9. Physical examination is unremarkable.", "10. A transvaginal ultrasound reveals increased nuchal translucency.", "11. Laboratory studies show decreased levels of PAPP-A.", "12. Laboratory studies show increased levels of β-hCG." ]

[ "1. Her pregnancy has been uneventful so far.", "2. She denies smoking, using alcohol, or any illicit drugs.", "3. Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine.", "4. Her blood pressure is 110/70 mm Hg.", "5. Her heart rate is 95/min.", "6. Her respiratory rate is 20/min.", "7. Her temperature is 36.4°C (97.5°F).", "8. Physical examination is unremarkable.", "9. A transvaginal ultrasound reveals increased nuchal translucency.", "10. Laboratory studies show decreased levels of PAPP-A.", "11. Laboratory studies show increased levels of β-hCG." ]

[ "An 18-month-old boy is brought to the emergency department by his babysitter because of lethargy and fever for 3 hours.", "He has not fully recovered from a middle ear infection that started a few days ago.", "The parents cannot be reached for further information.", "His temperature is 39.1°C (102.3°F).", "Physical examination shows nuchal rigidity.", "A pathogen is isolated from the patient's cerebrospinal fluid that does not grow on regular blood agar plate but produces colonies when cocultured with Staphylococcus aureus." ]

[ "1. An 18-month-old boy is brought to the emergency department by his babysitter.", "2. The boy has been lethargic and has had a fever for 3 hours.", "3. The boy had a middle ear infection a few days ago.", "4. The parents cannot be reached for further information.", "5. The boy's temperature is 39.1°C (102.3°F).", "6. Physical examination shows nuchal rigidity.", "7. A pathogen is isolated from the patient's cerebrospinal fluid.", "8. The pathogen does not grow on regular blood agar plate.", "9. The pathogen produces colonies when cocultured with Staphylococcus aureus." ]

[ "1. He has not fully recovered from a middle ear infection that started a few days ago.", "2. The parents cannot be reached for further information.", "3. His temperature is 39.1°C (102.3°F).", "4. Physical examination shows nuchal rigidity.", "5. A pathogen is isolated from the patient's cerebrospinal fluid.", "6. The pathogen does not grow on regular blood agar plate.", "7. The pathogen produces colonies when cocultured with Staphylococcus aureus." ]

[ "A 20-month-old boy is brought to the physician for the evaluation of intellectual and behavioral abnormalities and abnormal movements of his extremities.", "His mother reports that he often hits his head and limbs against furniture.", "He is unable to walk without support and speaks in unclear 2-word phrases.", "Examination shows multiple bruises on the forehead and several healing wounds over the fingers.", "There is increased muscle tone in all extremities.", "Laboratory studies show an increased serum uric acid concentration." ]

[ "1. A 20-month-old boy is brought to the physician for the evaluation of intellectual and behavioral abnormalities and abnormal movements of his extremities.", "2. His mother reports that he often hits his head and limbs against furniture.", "3. He is unable to walk without support.", "4. He speaks in unclear 2-word phrases.", "5. Examination shows multiple bruises on the forehead.", "6. Examination shows several healing wounds over the fingers.", "7. There is increased muscle tone in all extremities.", "8. Laboratory studies show an increased serum uric acid concentration." ]

[ "1. His mother reports that he often hits his head and limbs against furniture.", "2. He is unable to walk without support.", "3. He speaks in unclear 2-word phrases.", "4. Examination shows multiple bruises on the forehead.", "5. Examination shows several healing wounds over the fingers.", "6. There is increased muscle tone in all extremities.", "7. Laboratory studies show an increased serum uric acid concentration." ]

[ "A 24-year-old man presents to the office for a physical exam and drug screening requested by his parole officer.", "He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.", "Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.", "Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting at before 12.", "Although a single parent, his mother states there were no stressful changes or issues at home.", "Today's urine toxicology screens are negative." ]

[ "1. A 24-year-old man presents to the office for a physical exam and drug screening.", "2. The drug screening was requested by his parole officer.", "3. He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.", "4. Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.", "5. Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting before 12.", "6. His mother is a single parent.", "7. His mother states there were no stressful changes or issues at home.", "8. Today's urine toxicology screens are negative." ]

[ "1. He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.", "2. Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.", "3. Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting at before 12.", "4. Although a single parent, his mother states there were no stressful changes or issues at home.", "5. Today's urine toxicology screens are negative." ]

[ "A 47-year old woman is referred to a nephrologist due to hematuria over the last week and lower extremity edema.", "She first noticed her feet and legs would swell in the mornings about 2 weeks ago.", "Her past medical history is significant for systemic lupus erythematosus for the past 24 years.", "This causes her mild joint and muscle pain on most day and she manages her symptoms with ibuprofen and acetaminophen.", "Today, her heart rate is 90/min, the respiratory rate is 17/min, the blood pressure is 140/90 mm Hg, and the temperature is 37.1°C (98.8°F).", "Urine analysis shows 6-10 dysmorphic RBCs per high powered field and occasional cellular casts.", "Serum creatinine is 2.4 mg/dL and a 24 hour urine collection reveals 550mg of excreted protein.", "A kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis." ]

[ "1. A 47-year old woman is referred to a nephrologist.", "2. She has had hematuria over the last week.", "3. She has lower extremity edema.", "4. She first noticed her feet and legs would swell in the mornings about 2 weeks ago.", "5. Her past medical history is significant for systemic lupus erythematosus for the past 24 years.", "6. This causes her mild joint and muscle pain on most days.", "7. She manages her symptoms with ibuprofen and acetaminophen.", "8. Today, her heart rate is 90/min.", "9. The respiratory rate is 17/min.", "10. The blood pressure is 140/90 mm Hg.", "11. The temperature is 37.1°C (98.8°F).", "12. Urine analysis shows 6-10 dysmorphic RBCs per high powered field.", "13. Urine analysis also shows occasional cellular casts.", "14. Serum creatinine is 2.4 mg/dL.", "15. A 24 hour urine collection reveals 550mg of excreted protein.", "16. A kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis." ]

[ "1. Patient noticed swelling in feet and legs 2 weeks ago", "2. Past medical history includes systemic lupus erythematosus for 24 years", "3. SLE causes mild joint and muscle pain, managed with ibuprofen and acetaminophen", "4. Current vital signs: heart rate 90/min, respiratory rate 17/min, blood pressure 140/90 mm Hg, temperature 37.1°C (98.8°F)", "5. Urine analysis shows 6-10 dysmorphic RBCs per high powered field and occasional cellular casts", "6. Serum creatinine level is 2.4 mg/dL", "7. 24-hour urine collection reveals 550mg of excreted protein", "8. Kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis" ]

[ "A 6-year-old girl presents to your clinic two weeks after receiving a routine immunization in preparation for a trip overseas.", "Periorbital edema is present on exam, and 24 hour urine collection shows excretion of 4.3 grams of protein/day." ]

[ "1. A 6-year-old girl presents to a clinic.", "2. She received a routine immunization two weeks prior.", "3. The immunization was in preparation for a trip overseas.", "4. Periorbital edema is present on exam.", "5. A 24 hour urine collection was done.", "6. The urine collection showed excretion of 4.3 grams of protein/day." ]

[ "1. Periorbital edema is present on exam.", "2. 24 hour urine collection shows excretion of 4.3 grams of protein/day." ]

[ "A 9-year-old girl is brought to the physician by her father for evaluation of intermittent muscle cramps for the past year and short stature.", "She has had recurrent upper respiratory tract infections since infancy.", "She is at the 5th percentile for weight and 10th percentile for height.", "Physical examination shows nasal polyps and dry skin.", "An x-ray of the right wrist shows osteopenia with epiphyseal widening." ]

[ "1. A 9-year-old girl is brought to the physician by her father.", "2. She has had intermittent muscle cramps for the past year.", "3. She has had recurrent upper respiratory tract infections since infancy.", "4. She is at the 5th percentile for weight.", "5. She is at the 10th percentile for height.", "6. Physical examination shows nasal polyps.", "7. Physical examination shows dry skin.", "8. An x-ray of the right wrist shows osteopenia.", "9. An x-ray of the right wrist shows epiphyseal widening." ]

[ "1. She has had recurrent upper respiratory tract infections since infancy.", "2. She is at the 5th percentile for weight.", "3. She is at the 10th percentile for height.", "4. Physical examination shows nasal polyps.", "5. Physical examination shows dry skin.", "6. An x-ray of the right wrist shows osteopenia.", "7. An x-ray of the right wrist shows epiphyseal widening." ]

[ "A 24-year-old medical student presents to urgent care with cough and rhinorrhea.", "He has been learning about HIV and immunosuppression in medical school, and he is worried that he is seriously ill.", "He has no significant medical history, and he is sexually active with his girlfriend.", "He consumes alcohol on weekends but does not use tobacco or other recreational drugs.", "He candidly reports that, in microbiology lab, he cultured his own sputum on Sabouraud agar, and Candida grew on the agar.", "Examination of the oropharynx does not show any abnormalities.", "You perform a nasal viral swab, which confirms that he has a rhinovirus infection." ]

[ "1. Patient is 24 years old.", "2. Patient is a medical student.", "3. Patient presents to urgent care with cough and rhinorrhea.", "4. Patient has been learning about HIV and immunosuppression in medical school.", "5. Patient is worried that he is seriously ill.", "6. Patient has no significant medical history.", "7. Patient is sexually active with his girlfriend.", "8. Patient consumes alcohol on weekends.", "9. Patient does not use tobacco or other recreational drugs.", "10. Patient cultured his own sputum on Sabouraud agar, and Candida grew on the agar.", "11. Examination of the oropharynx does not show any abnormalities.", "12. Nasal viral swab confirms that patient has a rhinovirus infection." ]

[ "1. He has been learning about HIV and immunosuppression in medical school.", "2. He is worried that he is seriously ill.", "3. He has no significant medical history.", "4. He is sexually active with his girlfriend.", "5. He consumes alcohol on weekends.", "6. He does not use tobacco or other recreational drugs.", "7. In microbiology lab, he cultured his own sputum on Sabouraud agar.", "8. Candida grew on the agar.", "9. Examination of the oropharynx does not show any abnormalities.", "10. A nasal viral swab confirms that he has a rhinovirus infection." ]

[ "A 57-year-old woman comes to her physician with a persistent cough.", "She has observed an increase in the frequency of her cough over the past few months and also the production of yellowish sputum on several occasions.", "She says that sputum production is greater in the morning compared to the rest of the day.", "She has been a chain smoker for about 35 years now, smoking close to 3 packs a day.", "She has never had the will to quit.", "Over the last 2 years, she has had this cough and doesn't recall being free of it for 3 months at a stretch.", "On examination, there is a slight expiratory wheeze in the lower lung fields.", "Her respiratory rate is 18/min, pulse is 85/min, and blood pressure is 110/70 mm Hg.", "Her forced expiratory volume in the first second is 83% at this time.", "Her FEV1/FVC post-bronchodilator ratio is 0.65.", "Based on these findings, her physician recommends that she quit smoking.", "She is also advised to take pneumococcal and influenza vaccinations over the next few months." ]

[ "1. A 57-year-old woman comes to her physician with a persistent cough.", "2. She has observed an increase in the frequency of her cough over the past few months.", "3. She has also observed the production of yellowish sputum on several occasions.", "4. She says that sputum production is greater in the morning compared to the rest of the day.", "5. She has been a chain smoker for about 35 years now, smoking close to 3 packs a day.", "6. She has never had the will to quit.", "7. Over the last 2 years, she has had this cough and doesn't recall being free of it for 3 months at a stretch.", "8. On examination, there is a slight expiratory wheeze in the lower lung fields.", "9. Her respiratory rate is 18/min.", "10. Her pulse is 85/min.", "11. Her blood pressure is 110/70 mm Hg.", "12. Her forced expiratory volume in the first second is 83% at this time.", "13. Her FEV1/FVC post-bronchodilator ratio is 0.65.", "14. Based on these findings, her physician recommends that she quit smoking.", "15. She is also advised to take pneumococcal and influenza vaccinations over the next few months." ]

[ "1. She has observed an increase in the frequency of her cough over the past few months.", "2. She has observed the production of yellowish sputum on several occasions.", "3. Sputum production is greater in the morning compared to the rest of the day.", "4. She has been a chain smoker for about 35 years.", "5. She smokes close to 3 packs a day.", "6. She has never had the will to quit smoking.", "7. Over the last 2 years, she has had a cough and doesn't recall being free of it for 3 months at a stretch.", "8. On examination, there is a slight expiratory wheeze in the lower lung fields.", "9. Her respiratory rate is 18/min.", "10. Her pulse is 85/min.", "11. Her blood pressure is 110/70 mm Hg.", "12. Her forced expiratory volume in the first second is 83% at this time.", "13. Her FEV1/FVC post-bronchodilator ratio is 0.65.", "14. Her physician recommends that she quit smoking based on these findings.", "15. She is advised to take pneumococcal and influenza vaccinations over the next few months." ]

[ "A 56-year-old woman presents to her primary care physician for dizziness.", "She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears.", "She describes her dizziness as a spinning sensation that has a start and end and lasts approximately 25 minutes.", "This dizziness is severe enough that she cannot walk or stand.", "Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting.", "However, she has abruptly fallen to the ground in the past and denied losing consciousness.", "Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril.", "Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min.", "On physical exam, when words are whispered into her right ear, she is unable to repeat the whispered words aloud; however, this is normal in the left ear.", "Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing." ]

[ "1. Patient is a 56-year-old woman.", "2. Patient presents to primary care physician for dizziness.", "3. Symptoms began approximately 1 month prior to presentation.", "4. Symptoms associated with nausea and ringing of the ears.", "5. Dizziness described as a spinning sensation with a start and end, lasting approximately 25 minutes.", "6. Dizziness severe enough that patient cannot walk or stand.", "7. Symptoms fluctuating.", "8. Patient denies tunnel vision or feelings of fainting.", "9. Patient has abruptly fallen to the ground in the past and denied losing consciousness.", "10. Medical history significant for migraine with aura treated with zolmitriptan.", "11. Medical history significant for type 2 diabetes managed with metformin.", "12. Medical history significant for hypertension managed with lisinopril.", "13. Blood pressure is 125/75 mmHg.", "14. Pulse is 88/min.", "15. Respirations are 16/min.", "16. When words are whispered into right ear, patient is unable to repeat the whispered words aloud.", "17. When words are whispered into left ear, patient is able to repeat the whispered words aloud.", "18. Air conduction is greater than bone conduction with Rinne testing.", "19. Sound of tuning fork is loudest in left ear on Weber testing." ]

[ "1. Symptoms began approximately 1 month prior to presentation", "2. Symptoms are associated with nausea and ringing of the ears", "3. Dizziness is described as a spinning sensation with a start and end", "4. Dizziness lasts approximately 25 minutes", "5. Dizziness is severe enough that the patient cannot walk or stand", "6. Symptoms are fluctuating", "7. Denies tunnel vision or feelings of fainting", "8. Has abruptly fallen to the ground in the past", "9. Denies losing consciousness", "10. Medical history includes migraine with aura treated with zolmitriptan", "11. Medical history includes type 2 diabetes managed with metformin", "12. Medical history includes hypertension managed with lisinopril", "13. Blood pressure is 125/75 mmHg", "14. Pulse is 88/min", "15. Respirations are 16/min", "16. Unable to repeat whispered words aloud when whispered into the right ear", "17. Normal response when whispered into the left ear", "18. Air conduction is greater than bone conduction with Rinne testing", "19. Sound of the tuning fork is loudest in the left ear on Weber testing" ]

[ "A 3086-g (6-lb) male newborn is delivered at 39 weeks' gestation to a 29-year-old woman.", "Initial examination shows micrognathia, a broad nasal bridge, short philtrum, and a cleft palate.", "Intermittent muscle spasms are seen predominantly in the hands and feet.", "A harsh systolic murmur is heard over the lower left sternal border." ]

[ "1. A 3086-g (6-lb) male newborn is delivered.", "2. The newborn is delivered at 39 weeks' gestation.", "3. The mother is 29 years old.", "4. Initial examination shows micrognathia.", "5. Initial examination shows a broad nasal bridge.", "6. Initial examination shows a short philtrum.", "7. Initial examination shows a cleft palate.", "8. Intermittent muscle spasms are seen predominantly in the hands and feet.", "9. A harsh systolic murmur is heard over the lower left sternal border." ]

[ "1. Initial examination shows micrognathia.", "2. Initial examination shows a broad nasal bridge.", "3. Initial examination shows a short philtrum.", "4. Initial examination shows a cleft palate.", "5. Intermittent muscle spasms are seen predominantly in the hands and feet.", "6. A harsh systolic murmur is heard over the lower left sternal border." ]

[ "A 37-year-old woman comes to the emergency department because her eyes have had a yellow discoloration and she has had dark urine for the past 3 days.", "She has also had fever, itching, and severe fatigue.", "She reports having symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.", "She does not have diarrhea but says her stools are whitish in appearance.", "She has no personal history of serious illness.", "She does not smoke and drinks an average of 2 beers on weekends.", "She does not use illicit drugs.", "She has been sexually active with the same partner for 12 years and uses condoms consistently.", "She works as a flight attendant for an international airline.", "She appears ill.", "Her temperature is 39.3°C (102.7°F), pulse is 64/min, and blood pressure is 132/82 mm Hg.", "Examination shows scleral icterus, excoriation marks over her extremities, and parched lips.", "The liver is tender on palpation; there is no splenomegaly.", "Cardiopulmonary examination is normal.", "Laboratory studies show: | Hemoglobin 11.6 g/dL | Leukocyte count 10,300/mm3 | Platelet count 256,000/mm3 | ESR 19 mm/hr | Prothrombin time 13 seconds | Serum | Urea nitrogen 28 mg/dL | Glucose 89 mg/dL | Creatinine 0.7 mg/dL | Bilirubin | Total 8 mg/dL | Direct 4 mg/dL | ALP 80 U/L | AST 312 U/L | ALT 569 U/L | An ultrasound of the abdomen shows no abnormalities." ]

[ "1. A 37-year-old woman comes to the emergency department.", "2. She has had a yellow discoloration in her eyes for the past 3 days.", "3. She has had dark urine for the past 3 days.", "4. She has had fever, itching, and severe fatigue.", "5. She had symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.", "6. She does not have diarrhea but says her stools are whitish in appearance.", "7. She has no personal history of serious illness.", "8. She does not smoke.", "9. She drinks an average of 2 beers on weekends.", "10. She does not use illicit drugs.", "11. She has been sexually active with the same partner for 12 years and uses condoms consistently.", "12. She works as a flight attendant for an international airline.", "13. She appears ill.", "14. Her temperature is 39.3°C (102.7°F).", "15. Her pulse is 64/min.", "16. Her blood pressure is 132/82 mm Hg.", "17. Examination shows scleral icterus, excoriation marks over her extremities, and parched lips.", "18. The liver is tender on palpation; there is no splenomegaly.", "19. Cardiopulmonary examination is normal.", "20. Laboratory studies show: Hemoglobin 11.6 g/dL, Leukocyte count 10,300/mm3, Platelet count 256,000/mm3, ESR 19 mm/hr, Prothrombin time 13 seconds, Serum Urea nitrogen 28 mg/dL, Glucose 89 mg/dL, Creatinine 0.7 mg/dL, Bilirubin Total 8 mg/dL, Direct 4 mg/dL, ALP 80 U/L, AST 312 U/L, ALT 569 U/L.", "21. An ultrasound of the abdomen shows no abnormalities." ]

[ "1. She has had fever, itching, and severe fatigue.", "2. She had symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.", "3. She does not have diarrhea but says her stools are whitish in appearance.", "4. She has no personal history of serious illness.", "5. She does not smoke and drinks an average of 2 beers on weekends.", "6. She does not use illicit drugs.", "7. She has been sexually active with the same partner for 12 years and uses condoms consistently.", "8. She works as a flight attendant for an international airline.", "9. She appears ill.", "10. Her temperature is 39.3°C (102.7°F), pulse is 64/min, and blood pressure is 132/82 mm Hg.", "11. Examination shows scleral icterus, excoriation marks over her extremities, and parched lips.", "12. The liver is tender on palpation; there is no splenomegaly.", "13. Cardiopulmonary examination is normal.", "14. Laboratory studies show: Hemoglobin 11.6 g/dL, Leukocyte count 10,300/mm3, Platelet count 256,000/mm3, ESR 19 mm/hr, Prothrombin time 13 seconds, Serum Urea nitrogen 28 mg/dL, Glucose 89 mg/dL, Creatinine 0.7 mg/dL, Bilirubin Total 8 mg/dL, Direct 4 mg/dL, ALP 80 U/L, AST 312 U/L, ALT 569 U/L.", "15. An ultrasound of the abdomen shows no abnormalities." ]

[ "A 27-year-old man presents with diarrhea, fatigue and weight loss.", "He says he has been having occasional loose stools and abdominal pain for the past month, but he did not seek any medical attention because of work deadlines.", "He says the diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.", "His stool is loose, occasionally blood-tinged, and contains mucus.", "He also says he feels fatigued and has lost 11 kg (24 lb) over the last 2 months.", "The patient denies any fever, sick contacts, or a history of recent travel.", "No significant past medical history.", "Family history is significant for colon cancer in his father, who died at the age of 50.", "On physical examination, the patient has generalized pallor.", "Abdominal exam reveals mild tenderness to palpation in the left lower quadrant.", "Laboratory investigations reveal microcytic anemia with an elevated ESR.", "A colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum.", "Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses.", "No evidence of granulomatous disease." ]

[ "1. Patient is 27 years old.", "2. Patient has diarrhea, fatigue and weight loss.", "3. Patient has had occasional loose stools and abdominal pain for the past month.", "4. Patient did not seek medical attention due to work deadlines.", "5. Diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.", "6. Stool is loose, occasionally blood-tinged, and contains mucus.", "7. Patient feels fatigued and has lost 11 kg (24 lb) over the last 2 months.", "8. Patient denies any fever, sick contacts, or a history of recent travel.", "9. No significant past medical history.", "10. Family history is significant for colon cancer in his father, who died at the age of 50.", "11. On physical examination, patient has generalized pallor.", "12. Abdominal exam reveals mild tenderness to palpation in the left lower quadrant.", "13. Laboratory investigations reveal microcytic anemia with an elevated ESR.", "14. Colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum.", "15. Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses.", "16. No evidence of granulomatous disease." ]

[ "1. Patient has been having occasional loose stools and abdominal pain for the past month.", "2. Patient did not seek medical attention due to work deadlines.", "3. Diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.", "4. Stool is loose, occasionally blood-tinged, and contains mucus.", "5. Patient feels fatigued and has lost 11 kg (24 lb) over the last 2 months.", "6. Patient denies fever, sick contacts, or a history of recent travel.", "7. No significant past medical history.", "8. Family history is significant for colon cancer in his father, who died at the age of 50.", "9. Patient has generalized pallor on physical examination.", "10. Abdominal exam reveals mild tenderness to palpation in the left lower quadrant.", "11. Laboratory investigations reveal microcytic anemia with an elevated ESR.", "12. Colonoscopy with biopsy shows inflammation of the sigmoid colon and rectum.", "13. Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses.", "14. No evidence of granulomatous disease." ]

[ "A 61-year-old woman presents to your office complaining of mild fatigue and weight loss over the past 6 months.", "She states she has felt generally unwell and has had decreased appetite during this time frame.", "Her temperature is 98.1°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 88/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals splenomegaly and a nontender abdomen.", "A complete blood count with differential shows the following: | | Hemoglobin: 10 g/dL | Hematocrit: 30% | Leukocyte count: 166,500/mm^3 | Segmented neutrophils 92% | Leukocyte alkaline phosphatase: Low | Platelet count: 92,000/mm^3 | | A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils." ]

[ "1. A 61-year-old woman presents to your office complaining of mild fatigue and weight loss over the past 6 months.", "2. She states she has felt generally unwell and has had decreased appetite during this time frame.", "3. Her temperature is 98.1°F (36.7°C).", "4. Blood pressure is 122/80 mmHg.", "5. Pulse is 88/min.", "6. Respirations are 16/min.", "7. Oxygen saturation is 98% on room air.", "8. Physical exam reveals splenomegaly and a nontender abdomen.", "9. Hemoglobin: 10 g/dL.", "10. Hematocrit: 30%.", "11. Leukocyte count: 166,500/mm^3.", "12. Segmented neutrophils 92%.", "13. Leukocyte alkaline phosphatase: Low.", "14. Platelet count: 92,000/mm^3.", "15. A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils." ]

[ "1. The patient has felt generally unwell.", "2. The patient has had decreased appetite.", "3. The patient's temperature is 98.1°F (36.7°C).", "4. The patient's blood pressure is 122/80 mmHg.", "5. The patient's pulse is 88/min.", "6. The patient's respirations are 16/min.", "7. The patient's oxygen saturation is 98% on room air.", "8. Physical exam reveals splenomegaly.", "9. Physical exam reveals a nontender abdomen.", "10. Hemoglobin: 10 g/dL.", "11. Hematocrit: 30%.", "12. Leukocyte count: 166,500/mm^3.", "13. Segmented neutrophils: 92%.", "14. Leukocyte alkaline phosphatase: Low.", "15. Platelet count: 92,000/mm^3.", "16. A bone marrow biopsy demonstrates infiltration with a large number of normal-appearing neutrophils." ]

[ "A 44-year-old homeless man is brought to the emergency department after he was arrested when found intoxicated in someone's garage.", "The patient is acutely altered and is covered in urine, stool, and vomit.", "His temperature is 97.6°F (36.4°C), blood pressure is 104/64 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "The patient is aroused with pain and begins answering basic questions.", "He states his vision is blurry and he can't see anything.", "Laboratory values are ordered as seen below. | | Serum: | Na+: 141 mEq/L | Cl-: 102 mEq/L | K+: 4.4 mEq/L | HCO3-: 14 mEq/L | BUN: 25 mg/dL | Glucose: 99 mg/dL | Creatinine: 1.4 mg/dL | Ca2+: 10.2 mg/dL | | ." ]

[ "1. A 44-year-old homeless man is brought to the emergency department after he was arrested when found intoxicated in someone's garage.", "2. The patient is acutely altered and is covered in urine, stool, and vomit.", "3. His temperature is 97.6°F (36.4°C).", "4. His blood pressure is 104/64 mmHg.", "5. His pulse is 130/min.", "6. His respirations are 19/min.", "7. His oxygen saturation is 98% on room air.", "8. The patient is aroused with pain and begins answering basic questions.", "9. He states his vision is blurry and he can't see anything.", "10. Serum Na+ is 141 mEq/L.", "11. Serum Cl- is 102 mEq/L.", "12. Serum K+ is 4.4 mEq/L.", "13. Serum HCO3- is 14 mEq/L.", "14. Serum BUN is 25 mg/dL.", "15. Serum Glucose is 99 mg/dL.", "16. Serum Creatinine is 1.4 mg/dL.", "17. Serum Ca2+ is 10.2 mg/dL." ]

[ "1. The patient is acutely altered.", "2. The patient is covered in urine, stool, and vomit.", "3. The patient's temperature is 97.6°F (36.4°C).", "4. The patient's blood pressure is 104/64 mmHg.", "5. The patient's pulse is 130/min.", "6. The patient's respirations are 19/min.", "7. The patient's oxygen saturation is 98% on room air.", "8. The patient is aroused with pain and begins answering basic questions.", "9. The patient states his vision is blurry and he can't see anything.", "10. Laboratory values are ordered as seen below.", "11. Serum Na+ level is 141 mEq/L.", "12. Serum Cl- level is 102 mEq/L.", "13. Serum K+ level is 4.4 mEq/L.", "14. Serum HCO3- level is 14 mEq/L.", "15. Serum BUN level is 25 mg/dL.", "16. Serum glucose level is 99 mg/dL.", "17. Serum creatinine level is 1.4 mg/dL.", "18. Serum Ca2+ level is 10.2 mg/dL." ]

[ "A 32-year-old construction worker is brought to the Emergency Department after a block of concrete crushed his right leg.", "His coworkers tried to remove the block, but it was not possible until firemen arrived on the scene 30 minutes after the incident.", "His personal medical history is unremarkable.", "Upon admission his vitals were stable.", "On physical examination the man is unconscious.", "His right leg is deformed with lacerations and hematomas.", "There are at least two fractures and several areas of the muscle appear pulpified.", "Distal right pulses are absent.", "An X-ray of the right leg reveals several displaced fractures of the tibia and fibula.", "Blood samples and a urine specimens are sent to the lab for analysis." ]

[ "1. A 32-year-old construction worker is brought to the Emergency Department.", "2. A block of concrete crushed his right leg.", "3. His coworkers tried to remove the block, but it was not possible until firemen arrived on the scene 30 minutes after the incident.", "4. His personal medical history is unremarkable.", "5. Upon admission his vitals were stable.", "6. On physical examination the man is unconscious.", "7. His right leg is deformed with lacerations and hematomas.", "8. There are at least two fractures and several areas of the muscle appear pulpified.", "9. Distal right pulses are absent.", "10. An X-ray of the right leg reveals several displaced fractures of the tibia and fibula.", "11. Blood samples and a urine specimens are sent to the lab for analysis." ]

[ "1. His coworkers tried to remove the block", "2. It was not possible until firemen arrived on the scene 30 minutes after the incident", "3. His personal medical history is unremarkable", "4. Upon admission his vitals were stable", "5. On physical examination the man is unconscious", "6. His right leg is deformed with lacerations and hematomas", "7. There are at least two fractures and several areas of the muscle appear pulpified", "8. Distal right pulses are absent", "9. An X-ray of the right leg reveals several displaced fractures of the tibia and fibula", "10. Blood samples and a urine specimens are sent to the lab for analysis" ]

[ "A 42-year-old primigravida woman goes into labor at 37 weeks.", "After several hours of labor, a boy is born with multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.", "Imaging reveals an absence of the thymic shadow." ]

[ "1. A 42-year-old primigravida woman goes into labor.", "2. The woman goes into labor at 37 weeks.", "3. After several hours of labor, a boy is born.", "4. The boy has multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.", "5. Imaging reveals an absence of the thymic shadow." ]

[ "1. A boy is born after several hours of labor.", "2. The boy has multiple physical abnormalities, including cleft palate, micrognathia, and low-set ears.", "3. Imaging reveals an absence of the thymic shadow." ]

[ "A 20-year-old woman presents following a seizure 2 hours ago.", "The patient's roommate describes seeing the patient suddenly 'freeze', collapse, and start having jerky movements involving her entire body.", "The patient says she can not recall the episode but does remember 'seeing stars' before losing consciousness.", "She remembers being confused about where she was soon after the seizure and had urinated in her clothes when she regained consciousness.", "A persistent headache has troubled her since the seizure for which she took acetaminophen before coming to the hospital.", "Her past medical history is unremarkable.", "She denies alcohol and drug use.", "The physician starts her on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels and is also used in status epilepticus." ]

[ "1. Patient is a 20-year-old woman.", "2. Patient presented 2 hours after a seizure.", "3. Roommate described patient suddenly 'freezing', collapsing, and having jerky movements involving her entire body.", "4. Patient cannot recall the episode but remembers 'seeing stars' before losing consciousness.", "5. Patient was confused about where she was soon after the seizure.", "6. Patient had urinated in her clothes when she regained consciousness.", "7. Patient has had a persistent headache since the seizure.", "8. Patient took acetaminophen before coming to the hospital.", "9. Patient's past medical history is unremarkable.", "10. Patient denies alcohol and drug use.", "11. Physician started patient on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels.", "12. Antiepileptic drug is also used in status epilepticus." ]

[ "1. The patient's roommate describes seeing the patient suddenly 'freeze', collapse, and start having jerky movements involving her entire body.", "2. The patient says she can not recall the episode but does remember 'seeing stars' before losing consciousness.", "3. She remembers being confused about where she was soon after the seizure and had urinated in her clothes when she regained consciousness.", "4. A persistent headache has troubled her since the seizure for which she took acetaminophen before coming to the hospital.", "5. Her past medical history is unremarkable.", "6. She denies alcohol and drug use.", "7. The physician starts her on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels and is also used in status epilepticus." ]

[ "A 68-year-old man presents to his primary care physician for pain in his feet.", "The patient states that it is very painful for him to walk around, and he has significant pain in his right and left toes.", "The patient has a past medical history of obesity, type II diabetes mellitus, anxiety, depression, COPD, and a 30 pack-year smoking history.", "The patient’s current medications include lisinopril, hydrochlorothiazide, insulin, metformin, fluoxetine, clonazepam, albuterol, home oxygen, varenicline, and fish oil and he is compliant with all medications.", "On physical exam, the patient’s toes appear pale and dirty.", "When inspecting his toes, shallow wounds with a pale base devoid of granulation tissue can be appreciated.", "The patient has decreased pinprick sensation in his lower extremities bilaterally.", "Pulmonary exam is notable for a prolonged expiratory phase." ]

[ "1. A 68-year-old man presents to his primary care physician for pain in his feet.", "2. The patient states that it is very painful for him to walk around.", "3. The patient has significant pain in his right and left toes.", "4. The patient has a past medical history of obesity.", "5. The patient has a past medical history of type II diabetes mellitus.", "6. The patient has a past medical history of anxiety.", "7. The patient has a past medical history of depression.", "8. The patient has a past medical history of COPD.", "9. The patient has a 30 pack-year smoking history.", "10. The patient's current medications include lisinopril.", "11. The patient's current medications include hydrochlorothiazide.", "12. The patient's current medications include insulin.", "13. The patient's current medications include metformin.", "14. The patient's current medications include fluoxetine.", "15. The patient's current medications include clonazepam.", "16. The patient's current medications include albuterol.", "17. The patient's current medications include home oxygen.", "18. The patient's current medications include varenicline.", "19. The patient's current medications include fish oil.", "20. The patient is compliant with all medications.", "21. On physical exam, the patient's toes appear pale and dirty.", "22. When inspecting his toes, shallow wounds with a pale base devoid of granulation tissue can be appreciated.", "23. The patient has decreased pinprick sensation in his lower extremities bilaterally.", "24. Pulmonary exam is notable for a prolonged expiratory phase." ]

[ "1. The patient experiences significant pain in his right and left toes.", "2. The patient has a past medical history of obesity, type II diabetes mellitus, anxiety, depression, COPD, and a 30 pack-year smoking history.", "3. The patient's current medications include lisinopril, hydrochlorothiazide, insulin, metformin, fluoxetine, clonazepam, albuterol, home oxygen, varenicline, and fish oil, and he is compliant with all medications.", "4. On physical exam, the patient's toes appear pale and dirty.", "5. Shallow wounds with a pale base devoid of granulation tissue can be appreciated when inspecting the patient's toes.", "6. The patient has decreased pinprick sensation in his lower extremities bilaterally.", "7. Pulmonary exam is notable for a prolonged expiratory phase." ]

[ "A 16-year-old man is brought to the emergency department for left arm pain.", "Per the patient, he was playing at his high-school football game when a member of the opposing team tackled him from behind, which resulted in him landing on his left arm.", "He felt a “popping” sensation and immediate, sharp pain at his left shoulder.", "The patient is in mild distress and holds his arm against his abdomen.", "Physical examination demonstrates limited abduction secondary to pain and reduced muscle tone over the shoulder." ]

[ "1. A 16-year-old man is brought to the emergency department for left arm pain.", "2. The patient was playing at his high-school football game when a member of the opposing team tackled him from behind.", "3. The patient landed on his left arm.", "4. He felt a “popping” sensation and immediate, sharp pain at his left shoulder.", "5. The patient is in mild distress and holds his arm against his abdomen.", "6. Physical examination demonstrates limited abduction secondary to pain.", "7. Physical examination demonstrates reduced muscle tone over the shoulder." ]

[ "1. The patient was playing at his high-school football game.", "2. A member of the opposing team tackled him from behind.", "3. The tackle resulted in him landing on his left arm.", "4. He felt a “popping” sensation in his left shoulder.", "5. He experienced immediate, sharp pain in his left shoulder.", "6. The patient is in mild distress.", "7. He holds his arm against his abdomen.", "8. Physical examination demonstrates limited abduction secondary to pain.", "9. Reduced muscle tone is observed over the shoulder." ]

[ "A 68-year-old woman is brought to the emergency room because of pain in her right shoulder after falling down the stairs in her apartment.", "She has a history of postmenopausal osteoporosis.", "Her current medications are alendronate, vitamin D, and calcium supplementation.", "Physical examination shows shortening of the right arm as well as tenderness and swelling over the right shoulder.", "The range of motion of the right arm is limited by pain.", "An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus." ]

[ "1. A 68-year-old woman is brought to the emergency room.", "2. She fell down the stairs in her apartment.", "3. She has a history of postmenopausal osteoporosis.", "4. Her current medications are alendronate, vitamin D, and calcium supplementation.", "5. She has pain in her right shoulder.", "6. Physical examination shows shortening of the right arm.", "7. Physical examination shows tenderness and swelling over the right shoulder.", "8. The range of motion of the right arm is limited by pain.", "9. An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus." ]

[ "1. She has a history of postmenopausal osteoporosis.", "2. Her current medications are alendronate, vitamin D, and calcium supplementation.", "3. Physical examination shows shortening of the right arm.", "4. Physical examination shows tenderness and swelling over the right shoulder.", "5. The range of motion of the right arm is limited by pain.", "6. An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus." ]

[ "A hematologist has found a historical hemocytometer used during the 1960s.", "Out of curiosity, he decides to obtain platelet counts from his brother, who has idiopathic thrombocytopenic purpura (ITP), with both the historical hemocytometer and a modern automated CBC analyzer." ]

[ "1. A hematologist has found a historical hemocytometer.", "2. The historical hemocytometer was used during the 1960s.", "3. The hematologist decides to obtain platelet counts from his brother.", "4. His brother has idiopathic thrombocytopenic purpura (ITP).", "5. The platelet counts will be obtained with both the historical hemocytometer and a modern automated CBC analyzer." ]

[ "1. The man is curious about platelet counts.", "2. The man's brother has idiopathic thrombocytopenic purpura (ITP).", "3. The platelet counts are obtained from the man's brother.", "4. The platelet counts are obtained using a historical hemocytometer.", "5. The platelet counts are obtained using a modern automated CBC analyzer." ]

[ "A 9-year-old female child whose family recently emigrated from Afghanistan presents to the county hospital with difficulty swallowing and generalized muscle rigidity.", "Her parents note that although she is in severe pain she always appears to be smiling.", "After getting a detailed history from the parents, the residents comes to the conclusion that the child's clinical presentation is due to a lack of immunizations and a deep wound on her knee resulting from a fall six days ago." ]

[ "1. A 9-year-old female child presents to the county hospital.", "2. Her family recently emigrated from Afghanistan.", "3. She has difficulty swallowing and generalized muscle rigidity.", "4. Her parents note that she is in severe pain but always appears to be smiling.", "5. The residents get a detailed history from the parents.", "6. The residents come to the conclusion that the child's clinical presentation is due to a lack of immunizations.", "7. The child has a deep wound on her knee resulting from a fall six days ago." ]

[ "1. The child is in severe pain.", "2. The child always appears to be smiling.", "3. The child has a lack of immunizations.", "4. The child has a deep wound on her knee.", "5. The wound resulted from a fall six days ago." ]

[ "A 49-year-old obese man presents to the emergency department with a fever and a cough productive of bloody sputum.", "He has also been waking up at night frequently, which he attributes to sweating while asleep.", "He is also proud of recently losing some weight but denies actively trying to do so.", "He says that he has had these symptoms intermittently for the last several years but has not consistently sought treatment because his housing has been transient with periods of homelessness.", "He is started on a course of therapy and leaves against medical advice before his physician is able to explain the medications.", "He returns two days later because he is concerned that his eyes are bleeding." ]

[ "1. A 49-year-old man presented to the emergency department.", "2. He was obese.", "3. He had a fever and a cough productive of bloody sputum.", "4. He was waking up at night frequently and attributed it to sweating while asleep.", "5. He was proud of recently losing some weight but denied actively trying to do so.", "6. He had these symptoms intermittently for the last several years.", "7. He had not consistently sought treatment due to periods of homelessness.", "8. He was started on a course of therapy.", "9. He left against medical advice before his physician was able to explain the medications.", "10. He returned two days later because he was concerned his eyes were bleeding." ]

[ "1. He has been waking up at night frequently.", "2. He attributes the waking up at night to sweating while asleep.", "3. He is proud of recently losing some weight.", "4. He denies actively trying to lose weight.", "5. He has had symptoms intermittently for the last several years.", "6. He has not consistently sought treatment for his symptoms.", "7. His housing has been transient with periods of homelessness.", "8. He started on a course of therapy.", "9. He left against medical advice before his physician could explain the medications.", "10. He returned two days later.", "11. He was concerned that his eyes are bleeding." ]

[ "A 66-year-old male presents to clinic for a blood glucose level of 169 mg/dL taken at a local pharmacy.", "He is a farmer in rural Alabama and has not seen a doctor for decades.", "He wants to be in excellent shape prior to his trip to visit his daughter at college.", "His past medical history and family history are unknown, and he does not take any medications.", "His diet consists of pork products and he does not smoke.", "His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 169/90 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air.", "The patient is started on metformin, lisinopril, and a guided exercise program.", "Lab results are below: | | Serum: | Na+: 145 mEq/L | Cl-: 100 mEq/L | K+: 4.9 mEq/L | HCO3-: 24 mEq/L | BUN: 18 mg/dL | Glucose: 211 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.0 mg/dL | | He returns from his trip, complaining of cough.", "He denies any other symptoms.", "His temperature is 99.5°F (37.5°C), pulse is 101/min, blood pressure is 160/85 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air.", "Repeat lab results are below: | | Serum: | Na+: 145 mEq/L | Cl-: 100 mEq/L | K+: 5.3 mEq/L | HCO3-: 24 mEq/L | BUN: 22 mg/dL | Glucose: 169 mg/dL | Creatinine: 1.2 mg/dL | Ca2+: 10.1 mg/dL | | ." ]

[ "1. Patient is 66 years old.", "2. Blood glucose level is 169 mg/dL.", "3. Patient is a farmer in rural Alabama.", "4. Patient has not seen a doctor for decades.", "5. Patient wants to be in excellent shape prior to trip to visit daughter at college.", "6. Patient's past medical history and family history are unknown.", "7. Patient does not take any medications.", "8. Patient's diet consists of pork products.", "9. Patient does not smoke.", "10. Patient's temperature is 99.5°F (37.5°C).", "11. Patient's pulse is 100/min.", "12. Patient's blood pressure is 169/90 mmHg.", "13. Patient's respirations are 18/min.", "14. Patient's oxygen saturation is 97% on room air.", "15. Patient is started on metformin, lisinopril, and a guided exercise program.", "16. Patient's serum Na+ is 145 mEq/L.", "17. Patient's serum Cl- is 100 mEq/L.", "18. Patient's serum K+ is 4.9 mEq/L.", "19. Patient's serum HCO3- is 24 mEq/L.", "20. Patient's serum BUN is 18 mg/dL.", "21. Patient's serum glucose is 211 mg/dL.", "22. Patient's serum creatinine is 1.0 mg/dL.", "23. Patient's serum Ca2+ is 10.0 mg/dL.", "24. Patient returns from trip complaining of cough.", "25. Patient denies any other symptoms.", "26. Patient's temperature is 99.5°F (37.5°C).", "27. Patient's pulse is 101/min.", "28. Patient's blood pressure is 160/85 mmHg.", "29. Patient's respirations are 18/min.", "30. Patient's oxygen saturation is 98% on room air.", "31. Patient's serum Na+ is 145 mEq/L.", "32. Patient's serum Cl- is 100 mEq/L.", "33. Patient's serum K+ is 5.3 mEq/L.", "34. Patient's serum HCO3- is 24 mEq/L.", "35. Patient's serum BUN is 22 mg/" ]

[ "1. The patient is a farmer in rural Alabama.", "2. The patient has not seen a doctor for decades.", "3. The patient wants to be in excellent shape prior to his trip to visit his daughter at college.", "4. The patient's past medical history and family history are unknown.", "5. The patient does not take any medications.", "6. The patient's diet consists of pork products and he does not smoke.", "7. The patient's temperature is 99.5°F (37.5°C).", "8. The patient's pulse is 100/min.", "9. The patient's blood pressure is 169/90 mmHg.", "10. The patient's respirations are 18/min.", "11. The patient's oxygen saturation is 97% on room air.", "12. The patient is started on metformin, lisinopril, and a guided exercise program.", "13. Lab results show: Na+: 145 mEq/L, Cl-: 100 mEq/L, K+: 4.9 mEq/L, HCO3-: 24 mEq/L, BUN: 18 mg/dL, Glucose: 211 mg/dL, Creatinine: 1.0 mg/dL, Ca2+: 10.0 mg/dL.", "14. The patient returns from his trip, complaining of cough.", "15. The patient denies any other symptoms.", "16. The patient's temperature is 99.5°F (37.5°C).", "17. The patient's pulse is 101/min.", "18. The patient's blood pressure is 160/85 mmHg.", "19. The patient's respirations are 18/min.", "20. The patient's oxygen saturation is 98% on room air.", "21. Repeat lab results show: Na+: 145 mEq/L, Cl-: 100 mEq/L, K+: 5.3 mEq/L, HCO3-: 24 mEq/L, BUN: 22 mg/dL, Glucose: 169 mg/dL, Creatinine: 1.2 mg/dL, Ca2+: 10.1 mg/dL." ]

[ "A 25-year-old woman presents to her primary care physician for her annual physical exam.", "Her prior medical history is significant for seasonal allergies and a broken arm at age 12 that was treated in a long arm cast.", "She has not had any major illnesses in the previous year and does not currently have any major complaints.", "On physical exam her blood pressure is found to be 152/95 mmHg.", "Laboratory findings reveal elevated levels of renin and aldosterone.", "Given her elevated blood pressure, she is prescribed captopril; however, 1 week later she presents to the emergency department with hypertensive urgency.", "At that point captopril is immediately stopped." ]

[ "1. A 25-year-old woman presents to her primary care physician for her annual physical exam.", "2. Her prior medical history is significant for seasonal allergies.", "3. She had a broken arm at age 12 that was treated in a long arm cast.", "4. She has not had any major illnesses in the previous year.", "5. She does not currently have any major complaints.", "6. On physical exam her blood pressure is found to be 152/95 mmHg.", "7. Laboratory findings reveal elevated levels of renin and aldosterone.", "8. Given her elevated blood pressure, she is prescribed captopril.", "9. 1 week later she presents to the emergency department with hypertensive urgency.", "10. At that point captopril is immediately stopped." ]

[ "1. Prior medical history includes seasonal allergies and a broken arm at age 12.", "2. Broken arm at age 12 was treated in a long arm cast.", "3. No major illnesses in the previous year.", "4. No major complaints at present.", "5. Blood pressure on physical exam is 152/95 mmHg.", "6. Laboratory findings reveal elevated levels of renin.", "7. Laboratory findings reveal elevated levels of aldosterone.", "8. Prescribed captopril due to elevated blood pressure.", "9. Presented to the emergency department with hypertensive urgency 1 week after starting captopril.", "10. Captopril was immediately stopped at that point." ]

[ "An investigator is analyzing the serum calcium and parathyroid hormone levels of 100 patients.", "A scatter plot of the findings is shown." ]

[ "1. An investigator is analyzing the serum calcium and parathyroid hormone levels of 100 patients.", "2. A scatter plot of the findings is shown." ]

[ "1. A scatter plot", "2. The findings are shown" ]

[ "A 56-year-old male is admitted to the emergency department with sudden onset of pain, left-sided scrotal swelling, and nausea.", "The patient states that the symptoms started three hours ago after he lifted up a heavy pack.", "He says that the swelling had been intermittently present for several years already and was most prominent when physically straining or coughing, but it had never been painful.", "Past medical history is unremarkable.", "Patient reports a 26-pack-year history of smoking.", "Vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 14/min, and temperature 37.8℃ (100℉).", "BMI is 32.9 kg/m2.", "Patient’s respiratory and cardiovascular exams are within normal limits.", "The abdomen is moderately distended.", "There is a tender erythematous scrotal swelling on the left, which cannot be manually reduced." ]

[ "1. A 56-year-old male is admitted to the emergency department.", "2. Patient has sudden onset of pain, left-sided scrotal swelling, and nausea.", "3. Symptoms started three hours ago after he lifted up a heavy pack.", "4. Swelling had been intermittently present for several years already.", "5. Swelling was most prominent when physically straining or coughing, but it had never been painful.", "6. Patient's past medical history is unremarkable.", "7. Patient has a 26-pack-year history of smoking.", "8. Blood pressure is 150/90 mm Hg.", "9. Heart rate is 85/min.", "10. Respiratory rate is 14/min.", "11. Temperature is 37.8℃ (100℉).", "12. BMI is 32.9 kg/m2.", "13. Patient's respiratory and cardiovascular exams are within normal limits.", "14. Abdomen is moderately distended.", "15. There is a tender erythematous scrotal swelling on the left.", "16. Swelling cannot be manually reduced." ]

[ "1. The patient's symptoms started three hours ago after lifting a heavy pack.", "2. The swelling had been intermittently present for several years and was most prominent when physically straining or coughing, but it had never been painful.", "3. The patient's past medical history is unremarkable.", "4. The patient reports a 26-pack-year history of smoking.", "5. Vital signs: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 14/min, temperature 37.8℃ (100℉).", "6. BMI is 32.9 kg/m2.", "7. Patient's respiratory and cardiovascular exams are within normal limits.", "8. The abdomen is moderately distended.", "9. There is a tender erythematous scrotal swelling on the left, which cannot be manually reduced." ]

[ "A 6-year-old boy presents to a pediatrician for initial evaluation.", "He was recently adopted from abroad and his parents want to establish care in the United States.", "His medical history is unclear and there are no records on any family history.", "On presentation, he is found to fall below the 5th percentile in height for his age with shortened 4th and 5th digits.", "Physical exam reveals wrist spasms when his blood pressure is taken.", "Radiographs reveal decreased bone mineral density and several healing fractures." ]

[ "1. A 6-year-old boy presents to a pediatrician for initial evaluation.", "2. He was recently adopted from abroad.", "3. His parents want to establish care in the United States.", "4. His medical history is unclear.", "5. There are no records on any family history.", "6. On presentation, he is found to fall below the 5th percentile in height for his age.", "7. He has shortened 4th and 5th digits.", "8. Physical exam reveals wrist spasms when his blood pressure is taken.", "9. Radiographs reveal decreased bone mineral density.", "10. Radiographs reveal several healing fractures." ]

[ "1. He was recently adopted from abroad.", "2. His parents want to establish care in the United States.", "3. His medical history is unclear.", "4. There are no records on any family history.", "5. On presentation, he is found to fall below the 5th percentile in height for his age.", "6. He has shortened 4th and 5th digits.", "7. Physical exam reveals wrist spasms when his blood pressure is taken.", "8. Radiographs reveal decreased bone mineral density.", "9. Radiographs also reveal several healing fractures." ]

[ "A 12-year-old boy is brought to the emergency department with a 2-month history of increasing difficulty with physical activity.", "Specifically, he says that he gets short of breath quickly with exertion even though he used to participate in all activities without a problem.", "When asked, he endorses sometimes coughing up flecks of blood.", "His past medical history is unclear because he was recently adopted from abroad and has not yet established care.", "Physical exam reveals blue discoloration of his lips and fingernails as well as a holosystolic murmur best heard at the lower left sternal border." ]

[ "1. A 12-year-old boy is brought to the emergency department.", "2. He has a 2-month history of increasing difficulty with physical activity.", "3. He used to participate in all activities without a problem.", "4. He endorses sometimes coughing up flecks of blood.", "5. His past medical history is unclear.", "6. He was recently adopted from abroad and has not yet established care.", "7. Physical exam reveals blue discoloration of his lips and fingernails.", "8. Physical exam reveals a holosystolic murmur best heard at the lower left sternal border." ]

[ "1. He gets short of breath quickly with exertion.", "2. He used to participate in all activities without a problem.", "3. He sometimes coughs up flecks of blood.", "4. His past medical history is unclear.", "5. He was recently adopted from abroad.", "6. He has not yet established care.", "7. Physical exam reveals blue discoloration of his lips and fingernails.", "8. Physical exam reveals a holosystolic murmur best heard at the lower left sternal border." ]

[ "A scientist isolates the rough endoplasmic reticulum from HeLa cells.", "He performs a northern blot to isolate nucleic acid sequences of interest." ]

[ "1. A scientist isolates the rough endoplasmic reticulum from HeLa cells.", "2. He performs a northern blot.", "3. He isolates nucleic acid sequences of interest." ]

[ "1. A northern blot is performed.", "2. The purpose is to isolate nucleic acid sequences of interest." ]

[ "A 14-month-old girl is brought to the pediatrician after her parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.", "Parents deny any history of fever.", "They recently immigrated to the country and, unfortunately, the mother did not receive prenatal care during pregnancy due to a lack of health insurance.", "Physical examination is unremarkable except for a head circumference over 2 standard deviations larger than the mean for her age, and delay in meeting motor developmental milestones.", "A magnetic resonance imaging (MRI) of her brain shows an enlargement of the posterior fossa, cystic dilation of the 4th ventricle, and hypoplasia of the cerebellar vermis (see image)." ]

[ "1. Patient is a 14-month-old girl.", "2. Parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.", "3. Parents deny any history of fever.", "4. Parents recently immigrated to the country.", "5. Mother did not receive prenatal care during pregnancy due to a lack of health insurance.", "6. Physical examination is unremarkable except for a head circumference over 2 standard deviations larger than the mean for her age, and delay in meeting motor developmental milestones.", "7. MRI of her brain shows an enlargement of the posterior fossa.", "8. MRI of her brain shows cystic dilation of the 4th ventricle.", "9. MRI of her brain shows hypoplasia of the cerebellar vermis." ]

[ "1. Parents deny any history of fever.", "2. They recently immigrated to the country.", "3. The mother did not receive prenatal care during pregnancy due to a lack of health insurance.", "4. Physical examination is unremarkable.", "5. Head circumference is over 2 standard deviations larger than the mean for her age.", "6. Delay in meeting motor developmental milestones.", "7. MRI of her brain shows an enlargement of the posterior fossa.", "8. MRI shows cystic dilation of the 4th ventricle.", "9. MRI shows hypoplasia of the cerebellar vermis." ]

[ "A 28-year-old woman presents with a 3-year history of recurrent headaches.", "She says the episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep, although many times the trigger is not known.", "She describes her headaches as unilateral, severe, throbbing, and aggravated by movement.", "The patient says that each episode usually lasts for 6–24 hours and is often accompanied by nausea, vomiting, and intolerance to light." ]

[ "1. A 28-year-old woman presents with a 3-year history of recurrent headaches.", "2. The episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep.", "3. Many times the trigger is not known.", "4. She describes her headaches as unilateral, severe, throbbing, and aggravated by movement.", "5. Each episode usually lasts for 6–24 hours.", "6. The episodes are often accompanied by nausea, vomiting, and intolerance to light." ]

[ "1. Episodes are typically triggered by hunger.", "2. Episodes are typically triggered by mental stress.", "3. Episodes are typically triggered by physical exertion.", "4. Episodes are typically triggered by lack of sleep.", "5. Many times the trigger is not known.", "6. Headaches are described as unilateral.", "7. Headaches are described as severe.", "8. Headaches are described as throbbing.", "9. Headaches are aggravated by movement.", "10. Each episode usually lasts for 6–24 hours.", "11. Episodes are often accompanied by nausea.", "12. Episodes are often accompanied by vomiting.", "13. Episodes are often accompanied by intolerance to light." ]